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Disparities in Adherence to Pediatric Sepsis Guidelines across a Spectrum of Emergency Departments: A Multicenter, Cross-Sectional Observational In Situ Simulation Study

  • David O. Kessler
    Correspondence
    Reprint Address: David O. Kessler, md, msci, faap, Department of Pediatrics, Columbia University Medical Center, 3959 Broadway, CHN-1-116, New York, NY 10032
    Affiliations
    Department of Pediatrics, Columbia University Medical Center, New York Presbyterian Morgan Stanley Children's Hospital of New York, New York, New York
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  • Barbara Walsh
    Affiliations
    Department of Pediatrics, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
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  • Travis Whitfill
    Affiliations
    Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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  • Sandeep Gangadharan
    Affiliations
    Department of Pediatrics, Long Island Jewish Medical Center, New Hyde Park, New York
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  • Marcie Gawel
    Affiliations
    Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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  • Linda Brown
    Affiliations
    Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island

    Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
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  • Marc Auerbach
    Affiliations
    Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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  • for theINSPIRE ImPACTS investigators
    Author Footnotes
    1 Study Group Authorship: INSPIRE stands for International Network for Simulation-Based Pediatric Innovation, Research and Education; ImPACTS stands for Improving Pediatric Acute Care Through Simulation. INSPIRE ImPACTS investigators (Group By-line authors): Akira Nishisaki, MD, MSCE,** Vinay Nadkarni, MD,** Jessica Katznelson, MD,†† Megan Lavoie, MD,‡‡ Khoon-Yen Tay, MD,‡‡ Janette Baird PhD,§§ and Melinda Hamilton MD, MSc‖‖.
  • Author Footnotes
    1 Study Group Authorship: INSPIRE stands for International Network for Simulation-Based Pediatric Innovation, Research and Education; ImPACTS stands for Improving Pediatric Acute Care Through Simulation. INSPIRE ImPACTS investigators (Group By-line authors): Akira Nishisaki, MD, MSCE,** Vinay Nadkarni, MD,** Jessica Katznelson, MD,†† Megan Lavoie, MD,‡‡ Khoon-Yen Tay, MD,‡‡ Janette Baird PhD,§§ and Melinda Hamilton MD, MSc‖‖.

      Abstract

      Background

      Each year in the United States, 72,000 pediatric patients develop septic shock, at a cost of $4.8 billion. Adherence to practice guidelines can significantly reduce mortality; however, few methods to compare performance across a spectrum of emergency departments (EDs) have been described.

      Objectives

      We employed standardized, in situ simulations to measure and compare adherence to pediatric sepsis guidelines across a spectrum of EDs. We hypothesized that pediatric EDs (PEDs) would have greater adherence to the guidelines than general EDs (GEDs). We also explored factors associated with improved performance.

      Methods

      This multi-center observational study examined in situ teams caring for a simulated infant in septic shock. The primary outcome was overall adherence to the pediatric sepsis guideline as measured by six subcomponent metrics. Characteristics of teams were compared using multivariable logistic regression to describe factors associated with improved performance.

      Results

      We enrolled 47 interprofessional teams from 24 EDs. Overall, 21/47 teams adhered to all six sepsis metrics (45%). PEDs adhered to all six metrics more than GEDs (93% vs. 22%; difference 71%, 95% confidence interval [CI] 43–84). Adherent teams had significantly higher Emergency Medical Services for Children readiness scores, MD composition of physicians to total team members, teamwork scores, provider perceptions of pediatric preparedness, and provider perceptions of sepsis preparedness. In a multivariable regression model, only greater composite team experience had greater adjusted odds of achieving an adherent sepsis score (adjusted odds ratio 1.38, 95% CI 1.01–1.88).

      Conclusions

      Using standardized in situ scenarios, we revealed high variability in adherence to the pediatric sepsis guideline across a spectrum of EDs. PEDs demonstrated greater adherence to the guideline than GEDs; however, in adjusted analysis, only composite team experience level of the providers was associated with improved guideline adherence.

      Keywords

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      References

        • Watson R.S.
        • Carcillo J.A.
        Scope and epidemiology of pediatric sepsis.
        Pediatr Crit Care Med. 2005; 6: S3-S5
        • Mangia C.M.F.
        • Kissoon N.
        • Carcillo J.A.
        Sepsis and septic shock: a global overview.
        J Pediatr Infect Dis. 2009; 4: 71-76
        • Hartman M.E.
        • Linde-Zwirble W.T.
        • Angus D.C.
        • Watson R.S.
        Trends in the epidemiology of pediatric severe sepsis.
        Pediatr Crit Care Med. 2013; 14: 686-693
        • Ruth A.
        • McCracken C.E.
        • Fortenberry J.D.
        • Hall M.
        • Simon H.K.
        • Hebbar K.B.
        Pediatric severe sepsis: current trends and outcomes from the Pediatric Health Information Systems database.
        Pediatr Crit Care Med. 2014; 15: 828-838
        • Balamuth F.
        • Weiss S.L.
        • Neuman M.I.
        • et al.
        Pediatric severe sepsis in U.S. children's hospitals.
        Pediatr Crit Care Med. 2014; 15: 798-805
        • Weiss S.L.
        • Fitzgerald J.C.
        • Pappachan J.
        • et al.
        Global epidemiology of pediatric severe sepsis: the sepsis prevalence, outcomes, and therapies study.
        Am J Respir Crit Care Med. 2015; 191: 1147-1157
        • Sullivan A.F.
        • Rudders S.A.
        • Gonsalves A.L.
        • Steptoe A.P.
        • Espinola J.A.
        • Camargo Jr., C.A.
        National survey of pediatric services available in US emergency departments.
        Int J Emerg Med. 2013; 6: 13
        • Committee on the future of emergency care in the United States health system
        Emergency care for children: growing pains.
        The National Academies Press, Washington, DC2007
        • Chamberlain J.M.
        • Krug S.
        • Shaw K.N.
        Emergency care for children in the United States.
        Health Aff (Millwood). 2013; 32: 2109-2115
      1. National Pediatric Readiness Project. Pediatric readiness assessment. Available at: http://www.pedsready.org. Accessed September 29, 2014.

        • Weiss S.L.
        • Fitzgerald J.C.
        • Balamuth F.
        • et al.
        Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis.
        Crit Care Med. 2014; 42: 2409-2417
        • Beck V.
        • Chateau D.
        • Bryson G.L.
        • et al.
        Timing of vasopressor initiation and mortality in septic shock: a cohort study.
        Crit Care. 2014; 18: R97
        • Han Y.Y.
        • Carcillo J.A.
        • Dragotta M.A.
        • et al.
        Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome.
        Pediatrics. 2003; 112: 793-799
        • Cruz A.T.
        • Perry A.M.
        • Williams E.A.
        • Graf J.M.
        • Wuestner E.R.
        • Patel B.
        Implementation of goal-directed therapy for children with suspected sepsis in the emergency department.
        Pediatrics. 2011; 127: e758-e766
        • Larsen G.Y.
        • Mecham N.
        • Greenberg R.
        An emergency department septic shock protocol and care guideline for children initiated at triage.
        Pediatrics. 2011; 127: e1585-e1592
        • Paul R.
        • Neuman M.I.
        • Monuteaux M.C.
        • Melendez E.
        Adherence to PALS sepsis guidelines and hospital length of stay.
        Pediatrics. 2012; 130: e273-e280
        • Inwald D.P.
        • Tasker R.C.
        • Peters M.J.
        • Nadel S.
        Emergency management of children with severe sepsis in the United Kingdom: the results of the Paediatric Intensive Care Society sepsis audit.
        Arch Dis Child. 2009; 94: 348-353
        • Weinger M.B.
        The pharmacology of simulation: a conceptual framework to inform progress in simulation research.
        Simul Healthc. 2010; 5: 8-15
        • Cheng A.
        • Auerbach M.
        • Hunt E.A.
        • et al.
        Designing and conducting simulation-based research.
        Pediatrics. 2014; 133: 1091-1101
        • Hunt E.A.
        • Hohenhaus S.M.
        • Luo X.
        • Frush K.S.
        Simulation of pediatric trauma stabilization in 35 North Carolina emergency departments: identification of targets for performance improvement.
        Pediatrics. 2006; 117: 641-648
        • Patterson M.D.
        • Blike G.T.
        • Nadkarni V.M.
        In situ simulation: challenges and results.
        in: Advances in patient safety: new directions and alternative approaches. 3. Agency for Healthcare Research and Quality, Rockville, MD2008 (performance and tools, 1–18)
        • Nishisaki A.
        • Keren R.
        • Nadkarni V.
        Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety.
        Anesthesiol Clin. 2007; 25: 225-236
        • Gordon J.A.
        • Alexander E.K.
        • Lockley S.W.
        • et al.
        Does simulator-based clinical performance correlate with actual hospital behavior? The effect of extended work hours on patient care provided by medical interns.
        Acad Med. 2010; 85: 1583-1588
        • Boulet J.R.
        • Murray D.
        • Kras J.
        • Woodhouse J.
        • McAllister J.
        • Ziv A.
        Reliability and validity of a simulation-based acute care skills assessment for medical students and residents.
        Anesthesiology. 2003; 99: 1270-1280
        • Bond W.F.
        • Spillane L.
        The use of simulation for emergency medicine resident assessment.
        Acad Emerg Med. 2002; 9: 1295-1299
        • Brydges R.
        • Hatala R.
        • Zendejas B.
        • Erwin P.J.
        • Cook D.A.
        Linking simulation-based educational assessments and patient-related outcomes: a systematic review and meta-analysis.
        Acad Med. 2015; 90: 246-256
      2. International Network for Simulation-Based Pediatric Innovation, Research and Education (INSPIRE). Available at: http://www.InspireSim.com. Accessed July 7, 2015.

        • Dellinger R.P.
        • Levy M.M.
        • Rhodes A.
        • et al.
        Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012.
        Intensive Care Med. 2013; 39: 165-228
        • Reid J.
        • Stone K.
        • Brown J.
        • et al.
        The Simulation Team Assessment Tool (STAT): development, reliability and validation.
        Resuscitation. 2012; 83: 879-886
        • American Academy of Pediatrics Committee on Pediatric Emergency Medicine; American College of Emergency Physicians Pediatric Committee; Emergency Nurses Association Pediatric Committee
        Joint policy statement—guidelines for care of children in the emergency department.
        Ann Emerg Med. 2009; 54: 543-552
        • Brierley J.
        • Carcillo J.A.
        • Choong K.
        • et al.
        Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine.
        Crit Care Med. 2009; 37: 666-688
        • American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians, Pediatric Committee; Emergency Nurses Association, Pediatric Committee
        Joint policy statement—guidelines for care of children in the emergency department.
        J Emerg Nurs. 2013; 39: 116-131
        • Fleiss J.L.
        • Cohen J.
        The equivalence of weighted kappa and the intraclass correlation coefficient as measures of reliability.
        Educ Psychol Meas. 1973; 33: 613-619
        • Enders C.K.
        • Tofighi D.
        Centering predictor variables in cross-sectional multilevel models: a new look at an old issue.
        Psychol Methods. 2007; 12: 121-138
        • Bond W.F.
        • Lammers R.L.
        • Spillane L.L.
        • et al.
        The use of simulation in emergency medicine: a research agenda.
        Acad Emerg Med. 2007; 14: 353-363
        • Small S.D.
        • Wuerz R.C.
        • Simon R.
        • Shapiro N.
        • Conn A.
        • Setnik G.
        Demonstration of high-fidelity simulation team training for emergency medicine.
        Acad Emerg Med. 1999; 6: 312-323
        • Issenberg S.B.
        • McGaghie W.C.
        • Petrusa E.R.
        • Lee Gordon D.
        • Scalese R.J.
        Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review.
        Med Teach. 2005; 27: 10-28
        • Kobayashi L.
        • Dunbar-Viveiros J.A.
        • Devine J.
        • et al.
        Pilot-phase findings from high-fidelity In Situ medical simulation investigation of emergency department procedural sedation.
        Simul Healthc. 2012; 7: 81-94
        • Ventre K.M.
        • Barry J.S.
        • Davis D.
        • et al.
        Using in situ simulation to evaluate operational readiness of a children's hospital-based obstetrics unit.
        Simul Healthc. 2014; 9: 102-111
        • O'Leary F.
        • McGarvey K.
        • Christoff A.
        • et al.
        Identifying incidents of suboptimal care during paediatric emergencies-an observational study utilising in situ and simulation centre scenarios.
        Resuscitation. 2014; 85: 431-436
        • Wetzel E.A.
        • Lang T.R.
        • Pendergrass T.L.
        • Taylor R.G.
        • Geis G.L.
        Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary neonatology teams.
        Jt Comm J Qual Patient Saf. 2013; 39: 268-273
        • Marshall N.E.
        • Vanderhoeven J.
        • Eden K.B.
        • Segel S.Y.
        • Guise J.M.
        Impact of simulation and team training on postpartum hemorrhage management in non-academic centers.
        J Matern Fetal Neonatal Med. 2015; 28: 495-499
        • Lighthall G.K.
        • Poon T.
        • Harrison T.K.
        Using in situ simulation to improve in-hospital cardiopulmonary resuscitation.
        Jt Comm J Qual Patient Saf. 2010; 36: 209-216
        • Ottestad E.
        • Boulet J.R.
        • Lighthall G.K.
        Evaluating the management of septic shock using patient simulation.
        Crit Care Med. 2007; 35: 769-775
        • Walkey A.J.
        • Wiener R.S.
        Hospital case volume and outcomes among patients hospitalized with severe sepsis.
        Am J Respir Crit Care Med. 2014; 189: 548-555
        • Halm E.A.
        • Lee C.
        • Chassin M.R.
        Is volume related to outcome in health care? A systematic review and methodologic critique of the literature.
        Ann Intern Med. 2002; 137: 511-520
        • Welch S.J.
        • Augustine J.J.
        • Dong L.
        • Savitz L.A.
        • Snow G.
        • James B.C.
        Volume-related differences in emergency department performance.
        Jt Comm J Qual Patient Saf. 2012; 38: 395-402
        • Kocher K.E.
        • Haggins A.N.
        • Sabbatini A.K.
        • Sauser K.
        • Sharp A.L.
        Emergency department hospitalization volume and mortality in the United States.
        Ann Emerg Med. 2014; 64: 446-457.e6
        • Phibbs C.S.
        • Baker L.C.
        • Caughey A.B.
        • Danielsen B.
        • Schmitt S.K.
        • Phibbs R.H.
        Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants.
        N Engl J Med. 2007; 356: 2165-2175
        • Welke K.F.
        • O'Brien S.M.
        • Peterson E.D.
        • Ungerleider R.M.
        • Jacobs M.L.
        • Jacobs J.P.
        The complex relationship between pediatric cardiac surgical case volumes and mortality rates in a national clinical database.
        J Thorac Cardiovasc Surg. 2009; 137: 1133-1140
        • Chang R.-K.R.
        • Klitzner T.S.
        Non-medical variables affecting outcomes of children with heart disease.
        Prog Pediatr Cardiol. 2003; 18: 163-167
        • Glatz A.C.
        • Shah S.S.
        • McCarthy A.L.
        • et al.
        Prevalence of and risk factors for acute occlusive arterial injury following pediatric cardiac catheterization: a large single-center cohort study.
        Catheter Cardiovasc Interv. 2013; 82: 454-462
        • Smink D.S.
        • Finkelstein J.A.
        • Kleinman K.
        • Fishman S.J.
        The effect of hospital volume of pediatric appendectomies on the misdiagnosis of appendicitis in children.
        Pediatrics. 2004; 113: 18-23
        • Knops R.R.
        • van Dalen E.C.
        • Mulder R.L.
        • et al.
        The volume effect in paediatric oncology: a systematic review.
        Ann Oncol. 2013; 24: 1749-1753
        • Tracy E.T.
        • Bennett K.M.
        • Danko M.E.
        • et al.
        Low volume is associated with worse patient outcomes for pediatric liver transplant centers.
        J Pediatr Surg. 2010; 45: 108-113
        • Tilford J.M.
        • Simpson P.M.
        • Green J.W.
        • Lensing S.
        • Fiser D.H.
        Volume-outcome relationships in pediatric intensive care units.
        Pediatrics. 2000; 106: 289-294
        • Chen Y.C.
        • Jeng M.J.
        • Lee Y.S.
        • et al.
        The relationship between physician case volume and in-hospital mortality of critically ill children with a diagnosis of pneumonia: a cross-sectional observational analytical study.
        J Crit Care. 2014; 29: 1046-1051
        • Gaieski D.F.
        • Edwards J.M.
        • Kallan M.J.
        • Mikkelsen M.E.
        • Goyal M.
        • Carr B.G.
        The relationship between hospital volume and mortality in severe sepsis.
        Am J Respir Crit Care Med. 2014; 190: 665-674
        • Powell E.S.
        • Khare R.K.
        • Courtney D.M.
        • Feinglass J.
        Volume of emergency department admissions for sepsis is related to inpatient mortality: results of a nationwide cross-sectional analysis.
        Crit Care Med. 2010; 38: 2161-2168
        • Berg G.M.
        • Vasquez D.G.
        • Hale L.S.
        • Nyberg S.M.
        • Moran D.A.
        Evaluation of process variations in noncompliance in the implementation of evidence-based sepsis care.
        J Healthc Qual. 2013; 35: 60-69
        • Siassakos D.
        • Bristowe K.
        • Draycott T.J.
        • et al.
        Clinical efficiency in a simulated emergency and relationship to team behaviours: a multisite cross-sectional study.
        BJOG. 2011; 118: 596-607
        • Kilner E.
        • Sheppard L.A.
        The role of teamwork and communication in the emergency department: a systematic review.
        Int Emerg Nurs. 2010; 18: 127-137
        • Coiera E.W.
        • Jayasuriya R.A.
        • Hardy J.
        • Bannan A.
        • Thorpe M.E.
        Communication loads on clinical staff in the emergency department.
        Med J Aust. 2002; 176: 415-418
        • Morey J.C.
        • Simon R.
        • Jay G.D.
        • et al.
        Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project.
        Health Serv Res. 2002; 37: 1553-1581
        • Alessandrini E.
        • Varadarajan K.
        • Alpern E.R.
        • et al.
        Emergency department quality: an analysis of existing pediatric measures.
        Acad Emerg Med. 2011; 18: 519-526
        • de Oliveira C.F.
        • de Oliveira D.S.
        • Gottschald A.F.
        • et al.
        ACCM/PALS haemodynamic support guidelines for paediatric septic shock: an outcomes comparison with and without monitoring central venous oxygen saturation.
        Intensive Care Med. 2008; 34: 1065-1075
        • Ross J.S.
        • Normand S.L.
        • Wang Y.
        • et al.
        Hospital volume and 30-day mortality for three common medical conditions.
        N Engl J Med. 2010; 362: 1110-1118

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        Journal of Emergency MedicineVol. 51Issue 2
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          Kessler DO, Walsh B, Whitfill T, Gangadharan S, Gawel M, Brown L, Auerbach M, and Dudas RA, for the INSPIRE ImPACTSinvestigators. Disparities in Adherence to Pediatric Sepsis Guidelines Across a Spectrum of Emergency Departments: a Multicenter, Cross-Sectional Observational in Situ Simulation Study. J Emerg Med.2016;50(3):403–15.
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