How a sepsis bundle significantly reduced mortality

Idris Evans, MD, MSc

More than 170,000 pediatric patients were hospitalized with sepsis from 2004 to 2012, and 8% died before discharge, but it was one particular death of a young patient in New York in 2013 that inspired a new mandate for a 1-hour sepsis bundle in an effort to reduce mortality from this sometimes-fatal infection, according to a new report.

The study, published in the Journal of the American Medical Association, assessed the efficacy of this 1-hour bundle.¹ The bundle, modeled after current clinical practice guidelines for quickly recognizing and treating sepsis, includes blood culture collection before antibiotic administration, administration of broad-spectrum antibiotics, and the completion of a 20-mL/kg fluid bolus all within 1 hour. Researchers reviewed all pediatric sepsis cases in the New York State Department of Health database between April 2014 and December 2016 to determine whether the bundle was effective in reducing in-hospital mortality of pediatric sepsis.

Idris Evans, MD, MSc, assistant professor at the University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Department of Critical Care Medicine, and lead author of the report, says the study highlights the efficacy of the pediatric sepsis bundle, which resulted in a 40% reduction in mortality among pediatric patients with sepsis and septic shock.

“Treating sepsis in pediatric patients can be challenging. Many aspects of recognition and care vary with a patient’s age. For example, normal vital signs, the pathogens commonly associated with sepsis, and vaccination rates all vary from infancy to teenage years,” Evans says. “Further, intravenous access can be more difficult in young patients while some pediatric antibiotic doses may be challenging to create quickly at some pharmacies.”

Throughout the study period, hospitals were tasked with collecting data on sepsis cases, documenting sepsis protocol initiation and completion. Of the 1669 cases studied across 59 hospitals, 17.8% did not initiate a sepsis protocol. Other cases were excluded from the study because of contraindications or other reasons, including hospital transfer after a sepsis diagnosis. Of the 1179 eligible cases across 54 hospitals, the sepsis bundle was completed within 1 hour in 24.9% of the cases, according to the report.

Looking at individual elements of bundle completion, blood cultures were obtained within 1 hour in 62.8% of the cases; antibiotics were given within an hour in 67.7% of cases; and fluid boluses were completed within an hour for 46.5% of patients. The report notes that the entire bundle was completed within an hour most often among patients in the emergency department (ED) over other units and among previously healthy patients, and least often in patients who had been transferred from another facility.

Overall, researchers found that the incidence of septic shock was similar in patients who received the bundle-70.4%-to those who did not-68.3%-but that mortality rates were lower in patients who received the complete bundle within an hour compared with those who did not-13.2% versus 7.5%, respectively.

“The completion of the 1-hour bundle within 1 hour was associated with lower in-hospital mortality and shorter hospital length of stay,” the report notes. “However, individual bundle elements were not significantly associated with decreased mortality, and hospitals were widely variable in completing the bundle for comparable patients.”

The findings of the report support an association between utilization of the pediatric sepsis bundle and improved outcomes, according to the report.

For clinicians who don’t often encounter sepsis patients, Evans recommends they educate themselves on the early warning signs.

“The first step is to have a heightened suspicion for sepsis. So many children who present with fever and a fast heart rate will have a self-limited viral illness that does not progress to sepsis. However, some patients with fever and a fast heart rate will have a pneumonia or a bloodstream infection and become septic,” Evans explains. “While sometimes it can be challenging to differentiate between these 2 types of patients when providing early care, keeping sepsis on the initial diagnostic differential will allow providers to optimize care.”

Evans says early warning signs for pediatric sepsis include tachycardia or tachypnea that is not entirely caused by fever, as well as an abnormal white blood cell count. Hypotension is a later symptom of pediatric sepsis, so a “normal” blood pressure reading should not reduce a clinician’s suspicion for sepsis, he says. Other late signs of sepsis in children include altered mental status and poor perfusion.

Although UPMC Children’s Hospital of Pittsburgh doesn’t have a mandated bundle, Evans says he has seen improvement in antibiotic administration times for pediatric sepsis by using electronic health record alerts in the ED. The UPMC Children’s Hospital of Pittsburgh has also been involved for the last 2 years in the Children’s Hospital Association’s Improving Pediatric Sepsis Outcomes (IPSO) collaborative, which is focused on reducing sepsis mortality by 75% and addresses all stages of sepsis care. Still, he says, the mandate in New York is a great example of how a bundle can work in pediatric care, and he hopes other organizations and providers will take note.

“The New York State Department of Health did an amazing job in implementing a statewide public policy initiative that involved sepsis protocol development, accurate data reporting, data auditing, protocol refinement, and data analysis. The amount of effort this took cannot be overstated,” Evans says. “We hope that healthcare providers and organizations will develop practices that promote timely recognition and care for pediatric patients with sepsis.”