Implementation of Goal-Directed Therapy for Children

With Suspected Sepsis in the Emergency Department

abstract
BACKGROUND: Suboptimal care for children with septic shock in-
cludes delayed recognition and inadequate fluid resuscitation.
AUTHORS: Andrea T. Cruz, MD, MPH,a,b Andrew M. Perry,
MD,a Eric A. Williams, MD, MS,c Jeanine M. Graf, MD,c
Elizabeth R. Wuestner, MSN, RN,d and Binita Patel, MDa
Sections of aEmergency Medicine, bInfectious Diseases, and
cCritical Care Medicine, Department of Pediatrics, Baylor College

OBJECTIVE: To describe the implementation of an emergency depart- of Medicine, Houston, Texas; and dEmergency Department, Texas
Children’s Hospital, Houston, Texas
ment (ED) protocol for the recognition of septic shock and facilitate
adherence to national treatment guidelines. KEY WORDS
goal-directed therapy, pediatric, sepsis
PATIENTS AND METHODS: Root-cause analyses and morbidity and ABBREVIATIONS
mortality conferences identified system problems with sepsis recog- ED—emergency department
nition and management. A group of ED and critical care physicians met QI—quality improvement
to identify barriers and create solutions. Drs Cruz and Perry contributed equally to this work.

RESULTS: To facilitate sepsis recognition, a computerized triage sys- www.pediatrics.org/cgi/doi/10.1542/peds.2010-2895

tem alarmed on abnormal vital signs, and then toxic-appearing chil- doi:10.1542/peds.2010-2895
dren or children at high risk for invasive infection were placed in a Accepted for publication Dec 6, 2010
resuscitation room. To facilitate timely delivery of interventions, addi- Address correspondence to Andrea T. Cruz, MD, MPH,
tional nursing, respiratory therapy, and pharmacy personnel were re- Department of Pediatrics, Sections of Emergency Medicine and
Infectious Diseases, Baylor College of Medicine, 6621 Fannin St,
cruited. Fluids were administered via syringe delivery; standardized Suite A210, MC 1-1481, Houston, TX 77030. E-mail: acruz@bcm.edu
laboratory studies and antibiotics were ordered and prioritized. Fre-
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
quent vital-sign measurements and interventions were documented on
Copyright © 2011 by the American Academy of Pediatrics
a graphical flow sheet to facilitate interpretation of physiologic re-
FINANCIAL DISCLOSURE: The authors have indicated they have
sponse to therapy. After protocol initiation, there were 191 encounters no financial relationships relevant to this article to disclose.
in 167 patients with suspected sepsis. When compared with children
seen before the protocol, time from triage to first bolus decreased
from a median of 56 to 22 minutes (P ⬍ .001) and triage to first anti-
biotics decreased from a median of 130 to 38 minutes (P ⬍ .001).
CONCLUSIONS: The protocol resulted in earlier recognition of suspected
sepsis and substantial reductions in both time to receipt of time-sensitive
interventions and a decrement in treatment variation. Pediatrics 2011;127:
e758–e766

e758 CRUZ et al
Downloaded from pediatrics.aappublications.org by guest on September 12, 2015

Between 20 000 and 40 000 US children
develop septic shock annually1,2;
chronically ill children are overrepre-
sented in incidence and mortality
rates.2,3 Despite evidence-based guide-
lines,4 a minority of children receive
the standard of care.5 Although delays
in fluid resuscitation have been
associated with increased mortality
rates,5,6 many barriers to timely resus-
citation exist in busy emergency de-
partments (EDs).7,8
We hypothesized that process barriers
resulted in delays in shock recognition
and management in our ED and that
system changes would result in im-
proved outcomes. We designed a
quality-improvement (QI) intervention
to maximize the recognition of patients
at risk for septic shock and facilitate
the ED implementation of preexisting
national guidelines in 3 ways. First, we
created an automated triage tool to
recognize vital-sign abnormalities.
Second, we harnessed resources for
the more intensive nursing care
needed to implement national guide-
lines. Third, we designed a physiologic
flow sheet to characterize temporal
changes in vital signs that could assist
in patient handoffs and maintain
awareness of the guideline.
METHODS
Root-cause analyses and morbidity
and mortality conferences revealed
areas for improvements in sepsis
management. With support from hos-
pital leadership, a multidisciplinary
team (ED and ICU physicians and
nurses and ancillary services) identi-
fied several obstacles including varia-
tion in experience of staff in perform-
ing initial evaluations; lack of adequate
nursing staff for resource-intensive
patients; difficulty obtaining frequent
vital-sign measurements; lack of stan-
dardization of empiric antibiotics and
diagnostic tests; lack of medication
PEDIATRICS Volume 127, Number 3, March 2011
Downloaded from pediatrics.aappublications.org by guest on September 12, 2015
prioritization; and barriers to patient
flow through the institution.
Subsequently, a prospective QI project
was designed to measure the impact
of early recognition and intensive
nursing resources on the ability to de-
liver fluids and antibiotics more rap-
idly to children in shock; the project
was termed the “shock protocol.” This
project was conducted in the Texas
Children’s Hospital ED, where ⬎200
practitioners and 170 nurses care for
⬃85 000 children annually. All children
for whom the shock protocol was im-
plemented were included. Children
were clinically diagnosed as septic;
case definitions9 were not used as in-
clusion criteria. Patients included in
the protocol were identified from a
shock protocol order set. Patients in
shock who did not receive the protocol
(missed patients) were identified from
several sources: records of triage
tool alerts; admission/discharge diag-
noses of PICU admissions; and inpa-
tient rapid-response team calls ⬍24
hours after admission. For patients in
shock for whom the triage tool was
triggered but the protocol was not
used, chart review and discussion with
the individual clinician(s) were per-
formed to determine obstacles to pro-
tocol use.
Resuscitation timeliness was mea-
sured by documentation of time from
triage to initiation of first fluid and sub-
sequent boluses, bolus volume/dura-
tion, and timing of vasoactive agent
use. Antibiotic use and timing were
measured. Both included and missed
patients were evaluated for ED and
hospital length of stay, and rapid-
response teams called within 24 hours
of admission to a non-PICU bed. These
admissions were compared with PICU
admissions for sepsis in 2009. Data
were analyzed by using MiniTab (State
College, PA). Statistical process con-
trol charts were used to compare out-
come measures in time order in con-
QUALITY-IMPROVEMENT REPORTS
secutive patients from 2009 to the
study period (February to August
2010). Control limits define 3 SDs
around the mean; outliers signify
causes not inherent to the process.
Data points within the control limits
signify variability in the process that
requires system changes. Retrospec-
tive anecdotal discussions helped us
to document institutional protocol-
related cultural changes. Institutional
review board approval was obtained.
RESULTS
Our first priority was improving shock
recognition, specifically easily identify-
ing patients with abnormal vital signs.
We needed to create a system that
would minimize variation in ED pro-
vider experience and the fluctuations
in ED patient arrivals that contributed
to delayed recognition of abnormal
vital signs. Information technology
helped create a computerized triage
tool that corrected heart rate for pyr-
exia.10 If vital signs were outside of age-
appropriate norms,4,9,11 an electronic
alert forced the triage nurse to con-
sider the shock protocol. If the patient
was at high risk (Table 1) or appeared
ill, the triage nurse was empowered to
call the charge nurse and activate the
protocol. With activation, the transport
team and PICU charge nurse were also
alerted of a potential admission. The
patient was immediately taken to a
designated room, and an attending
physician was called to evaluate the
patient and initiate treatment appro-
priately. Although intended to be acti-
vated from triage, the shock protocol
could be initiated by nurses or physi-
cians for any patient at any point in the
ED stay, and children could be taken off
the protocol by an attending physician
at any time.
In addition, nurses on the QI team
pointed out that the existing nurse/pa-
tient ratio was impractical given the
urgency and resource intensity of
e759
TABLE 1 Triage Algorithm
Characteristic
Temperature abnormality
High-risk patient (any of the conditions listed)
and
Abnormal pulse beyond temperature
correctionb
and/or
Abnormal mental status or capillary refill
time of ⬎3 s
orc
Patient in shock without meeting criteria
listed above
a Fever or hypothermia may have been documented at home or in the ED.
b
Five beats/1°F above 100°F.
c This category requires no vital-sign or risk-factor criterion.
shock treatment. With protocol activa-
tion, our pediatric transport team
(nurse, respiratory therapist, emer-
gency medical technician) now served
as ad hoc shock-team responders
when available. They assisted in ob-
taining vascular access, administering
medications and fluids, and documen-
tation and transported the patient to
the PICU. The additional support for the
bedside ED nurse allowed patients in
the protocol and their other assigned
patients to continue receiving timely
care. Also, trends in vital signs are es-
sential for monitoring response to
therapy but were obtained infre-
quently before the protocol because of
the lack of resources and standardiza-
tion. A graphical flow sheet (Fig 1) was
created by the team to assist in ongo-
ing assessments and facilitate hand-
offs across the continuum of care.
A major tenet of goal-directed therapy
is the early reversal of volume deple-
tion in the face of a compromised vas-
cular bed.4 Accomplishing this goal re-
quired a change in nursing culture, in
which isotonic fluid boluses were gen-
erally administered over an hour on a
pump. All boluses for patients in the
protocol were administered via rapid in-
fuser system or using a manual syringe-
delivery system. Physicians were noti-
fied if vascular access was not obtained
e760 CRUZ et al
Downloaded from pediatrics.aappublications.org by guest on September 12, 2015
Criteria
ⱖ100.4°F/38°Ca ⱕ96°F/35.5°Ca
Malignancy Solid-organ transplant
Bone marrow transplant Central venous catheter
Asplenia Immunodeficiency
— —
— —
— —
in 5 minutes. The goal of this protocol
was not to dictate therapy but, rather, to
facilitate rapid fluid administration once
the decision was made.
The team also identified wide variation
in laboratory evaluations and antibi-
otic therapy. After consultation with
subspecialty services, preprinted or-
der sheets (Table 2) were created by
the team to standardize therapy and
laboratory evaluation. The order-set
sequence reflected a stepwise ap-
proach to the treatment of shock. Be-
fore protocol implementation, ED
pharmacists had no acuity-based med-
ication prioritization and filled orders
on first-come basis. The preprinted or-
der sets served as a prioritization tool
for pharmacists, who hand-delivered
medications to the room. In addition,
the laboratory prioritized shock proto-
col tests and made them available
within 10 minutes via telephone calls
to physicians.
Finally, variation in disposition of pa-
tients in the protocol needed to be ad-
dressed. The team decided that chil-
dren who required ⱖ60 mL/kg of fluid
resuscitation would be admitted to the
PICU for continued monitoring regard-
less of their postresuscitation condi-
tion. This determination was made be-
cause of the lack of data regarding risk
stratification of septic children and to
avoid boarding ill patients for long pe-
riods in the ED until their clinical
course was more evident. Well-
appearing children who required fluid
resuscitation ⬍60 mL/kg were admit-
ted to other hospital units.
After creation of the protocol, a com-
munication strategy was developed.
The month before protocol initiation,
2-hour education sessions were con-
ducted with all ED nurses and the
transport team to explain inclusion
criteria and changes from existing
procedures. This education was re-
peated 4 months later. E-mail commu-
nications were sent to ED and PICU
staff, and leadership was available to
answer questions. Subspecialty ser-
vices were involved in protocol design
to verify acceptable fluid volumes, em-
piric antibiotics, and pertinent labora-
tory evaluation. As a continuous QI
project, it was recognized that modifi-
cations would be necessary and com-
municated. With feedback, the order
set was revised to include additional
medications that were commonly used
in patients with shock, add laboratory
measures, and change empiric antibi-
otics for previously healthy children.
These changes and interval outcome
measures were posted in the ED and
e-mailed to providers and stakehold-
ers every 2 months.
Of the 191 discrete encounters in 167
unique patients with suspected sepsis,
158 were enrolled at triage and 33
were enrolled after triage (Table 3). Of
the encounters enrolled after triage,
21% should have been enrolled at tri-
age. The remainder of the patients
were enrolled after physician evalua-
tion; 64% were previously healthy, and
15% had underlying medical problems
but did not trigger the screening alert.
In addition, through review of all PICU
admissions, a diagnosis consistent
with systemic inflammatory response
syndrome/sepsis was identified in 25
 QUALITY-IMPROVEMENT REPORTS

FIGURE 1
Shock flow sheet.

PEDIATRICS Volume 127, Number 3, March 2011 e761

Downloaded from pediatrics.aappublications.org by guest on September 12, 2015
TABLE 2 Preprinted Order Set for Shock Protocol
Category Intervention Expected Time Frame From Notes
Protocol Initiation
Nursing
Vital-sign measurement Supplemental oxygen; pulse oximetry; 5 min Measure vital signs every 15 min
cardiopulmonary monitoring
Vascular access No anesthetic creams used; freezing 5–10 min Physician notified if no access after 5 min
sprays can be used
Strict monitoring of UOP, fluids Foley catheter if not neutropenic From onset Vital-sign flow sheet (Fig 1)
administered
Blood pressure support
Fluid resuscitation 20 mL/kg (maximum: 1 L) IV up to 3 15 min (to start of first 10 mL/kg boluses for patients with cardiac
boluses; all boluses were given bolus) conditions, BMT patients, and patients
push-pull or via rapid infuser immediately after lung transplant
Vasoactive agents Warm shock: norepinephrine; cold Order with completion of Low doses given via peripheral IV line
shock: dopamine ⫾ epinephrine third bolus
Antibiotic therapy
High risk (except asplenia) Piperacillin-tazobactam, 30 min Piperacillin-tazobactam and
aminoglycoside, vancomycin aminoglycoside given first, at same time
via the same line
Asplenia and immunologically Ceftriaxone, vancomycin, nafcillin 30 min Ceftriaxone given first over 3 min, then
normal hosts vancomycin
Other medications
Stress-dose steroids Hydrocortisone 100 mg/m2 30 min No ACTH-stimulation testing performed
Laboratory, radiographic evaluation
Screening laboratory tests CBC; chemistries; liver panel; DIC 10 min after received by Sent via life-threatening laboratory system
panel; CRP; VBG with lactate; laboratory
consider type and screen
Microbiology Blood culture: peripheral and central — All lumens of central lines cultured
(if applicable); urine culture, rapid
RSV and influenza assays
Radiology Portable chest radiograph — Able to be viewed in resuscitation room
Other
Page primary services; page ICU — At time of protocol initiation; ICU charge nurse receives page with each
with completion of third shock-protocol initiation
bolus
UOP indicates urine output; IV, intravenous; BMT, bone marrow transplant; ACTH, adrenocorticotropic hormone; CBC, complete blood count; DIC, disseminated intravascular coagulation; CRP,
C-reactive protein; VBG, venous blood gas; RSV, respiratory syncytial virus.

patients for whom the protocol was
not used. Of these children, 12% had
high-risk conditions; however, none
was tachycardic at triage. The nonen-
rolled patients were more acutely ill
and required immediate interventions
and initial airway management (Table
4). Statistical process control charts
that presented time to interventions in
chronological order showed that chil-
dren on the shock protocol received
interventions more rapidly and with
less variation than the patients with
sepsis in 2009 (Fig 2). There were no
rapid-response teams called for pa-
tients admitted to non-PICU settings af-
ter the shock protocol.
Several changes occurred at a sys-
tems level. First, the triage tool was
developed with information technol-
ogy as electronic medical records
were introduced. Second, project suc-
cess led to the protocol being priori-
tized for integration into electronic
algorithms. Third, the protocol was
integrated into hospital evidence-
based guidelines for shock. Fourth,
the decision of where to admit poten-
tially septic children was critically
evaluated.
Changes also occurred at the nursing
level. The most significant change was
that nurses were empowered to initi-
ate the protocol from triage, and the
team encouraged physicians to com-
municate with nurses when the deci-
sion was made to stop the protocol.
The nurses became protocol advo-
cates. Within 1 month, nurses were
asking if fluid boluses for children who
were not in shock could be given more
rapidly. The nurses were instrumental
in redesigning order sets and the flow
sheet. There was concern that there
would be territorial issues or blurring
of responsibilities between the ED
nurses and transport team. The ED
nurses appreciated the skills and
workforce provided by the transport
team.
Before project roll-out, we recognized
that frequent measurement of vital
signs was of minimal utility without
creating a documentation system that
was easy to complete and read. Multi-
tasking ED physicians were given in-
stantly readable graphical vital-sign

e762 CRUZ et al
Downloaded from pediatrics.aappublications.org by guest on September 12, 2015
 QUALITY-IMPROVEMENT REPORTS

TABLE 3 Demographic Features of the Study Population The main changes for physicians were
Characteristic Enrolled at Enrolled After Not Used No. of Patient the ability to intervene earlier and har-
Triage Triage Encounters ness resources for very ill children. ED
No. of patients 139 28 25 192 physicians and nurses immediately
No. (%) of patient encountersa 158 (73) 33 (15) 25 (12) 216
Age group, %b,c recognized that this ability would be
0–23 mo 70 12 19 43 beneficial even for patients who were
2–5 y 71 20 9 55 not in shock but needed more intense
6–12 y 78 15 6 65
⬎12 y 72 13 15 53 evaluation and treatment. In addition,
Triage acuity, median, 5-point scaled 2 3 2 — earlier communication with the PICU
Male gender, %b,c 72 14 14 115 led to shorter ED stays. Physicians who
Medical comorbidities, %b,c
Hematologic malignancy 91 7 1 70
treated children off-protocol were ap-
Nonhematologic malignancy 85 7 7 27 proached by the team to explore the
Bone marrow transplantation 94 6 0 16 reasons why; data were shared with
Solid-organ transplantation 90 10 0 21
Asplenia 100 0 0 6
the group on outcomes of children
Short gut 100 0 0 4 treated on and off the protocol. Like-
Other 76 24 0 21 wise, subspecialty services shared
None 27 29 43 51
Indwelling vascular catheter, %b,c 94 4 3 109
concerns or suggestions. The protocol
Presence of neutropenia (absolute neutrophil 76 16 8 49 did not decrease physician autonomy
count ⬍ 500), %b,d but did standardize and facilitate care.
Disease location, %b,d,e
There was collaboration between ED
Pneumonia 54 17 29 35
Skin/soft-tissue infection 33 22 44 9 and PICU physicians with a similar
Bacteremia 65 17 17 23 goal, which was attained by education
Fungemia 100 0 0 2 and reeducation of caregivers across
Urinary tract infection 55 27 18 11
Meningitis 33 0 67 3 the hospital by the team.
Otherf 81 14 5 139 Pharmacy culture changed by priori-
Etiologies, %b,d,e
Streptococcus pneumoniae 25 0 75 4 tizing and streamlining antibiotics. On
Staphylococcus aureus 43 14 43 7 the basis of the medications pre-
Other Gram-positives 100 0 0 9 scribed that were not on the initial or-
Escherichia coli 33 33 33 12
Other Gram-negatives 50 29 21 14
der sheet, preprinted orders were re-
Parainfluenza viruses 60 30 10 10 vised. A bundled laboratory package
H1N1 influenza 83 17 0 6 was created by the team in conjunc-
Other viruses 50 25 25 12
Candida species 100 0 0 3
tion with the laboratory to decrease
Anaerobes 0 50 50 2 variation in diagnostic evaluation.
No organism identified 82 12 6 142
Disposition from ED, %b,d DISCUSSION
ICU 54 23 24 106
Intermediate care floor 80 20 0 10 The Surviving Sepsis Campaign12 has
Inpatient floor 93 7 0 87 made great inroads in delivery of
Discharge home 92 8 0 12
Died in ED 100 0 0 1 timely care for septic adults, and
a Eighteen patients had 2 encounters; 3 patients had 3 encounters. “shock” teams exist in many adult EDs.
b Percentages within rows may not sum to 100% as a result of rounding.
c Numbers given for unique patients.
These teams have led to decreased
d Numbers given for individual patient encounters. mortality rates,13 a decreased need for
e Seven children had ⬎1 site of disease, and 11 had ⬎1 infectious agent identified.
invasive monitoring in the ICU,14 and an
f “Other” includes no identifiable disease location and viral respiratory infections.
increased proportion of patients who
receive goal-directed therapy per na-
trends with specific times and quanti- created. It should be noted that al- tional guidelines.15,16 The few published
ties of fluid and medications given; though the triage alert did require an pediatric series have focused on the
thus, flow-sheet results could help electronic medical record (EMR), use logistic difficulties with meeting Pedi-
guide therapy. A graphical, imminently of the flow sheet, although it could be atric Advanced Life Support/American
useful handoff tool for the receiving incorporated into an EMR, was not con- College of Critical Care Medicine
PICU or other admitting physician was tingent on it. (PALS/ACCCM) guidelines. These barri-

PEDIATRICS Volume 127, Number 3, March 2011 e763

Downloaded from pediatrics.aappublications.org by guest on September 12, 2015
TABLE 4 Comparison of Interventions in Children Used at Triage and not Used in the Shock
Protocol
Characteristic
Triage to first bolus, mina
Triage to third bolus, mina
Total volume of fluid given, mL/kg
Triage to first antibiotic, mina
Intubated in ED, %
Vasoactive medications given in ED, %
Death during that admission, %
Patients for whom the protocol was used after triage were not included in these analyses.
a The time to intervention had a nonnormal distribution, and the result is presented as a medians.
ers primarily fall into 2 categories:
delays in recognition and delays in im-
plementation of resuscitative mea-
sures.7,8,17 Our protocol was con-
structed with these barriers in mind.
In our ED, the problem was a delay in
recognition of the child in compen-
sated, not decompensated, shock. The
triage tool identified vital-sign abnor-
malities and enabled more timely
recognition of patients at risk. The pro-
tocol then harnessed additional re-
sources to allow for more timely and
ongoing interventions.
The protocol followed Institute of Med-
icine domains.18 It was safe: preprinted
order sets offered correct dosage pa-
rameters and empiric medications. It
was effective: the protocol enabled the
ED to implement evidence-based rec-
ommendations. It was equitable: all
children who met the physiologic crite-
ria could be enrolled. It was patient-
centered: parent and patient concerns
were addressed at the time of protocol
initiation. It was efficient: energy was
expended in improving the process
rather than reinventing the process
with each patient, and there was de-
creased time in the ED and decreased
PICU length of stay. And, it was timely:
time to resuscitation was reduced.
We think our approach was successful
because of the recognition of a need
for improvement by all stakeholders,
collaboration, flexibility in responding
to feedback, and a culture receptive to
e764 CRUZ et al
Downloaded from pediatrics.aappublications.org by guest on September 12, 2015
Protocol Used at Triage Protocol not Used
(n ⫽ 158 Encounters) (n ⫽ 25 Encounters)
22
61
38.9
38
3.2
10.1
1.9 (PICU)
0.6 (ED)
change. Care of septic patients was
recognized by hospital administration
and staff as an improvement opportu-
nity. With leadership support, front-
line workers were given the opportu-
nity to make the necessary changes to
facilitate flow and dismantle barriers.
There was a common vested interest
that crossed service lines. Collabora-
tion between the ED and the ICU, and
between subspecialty services, was
established in the nascent stages.
Practitioners provided content exper-
tise and enabled identification and re-
moval of barriers. In turn, the smooth
operation of the protocol garnered
support from staff. Feedback was elic-
ited from participants and given back
to participants individually. The proto-
col underwent serial reviews and revi-
sions to incorporate suggested modifi-
cations, which increased efficiency
and empowered staff. Results were
shared with the group via posting of
interim results in work areas and col-
laborative conferences. Sharing our
successes reinforced interest and be-
lief in protocol efficacy. We evaluated
balance measures to make sure that
resources for patients who received
the shock protocol did not divert care
from other children. During the study
period, we did not notice weakening in
observed gains; delays for our pediatric
transport team were not observed. We
feel that this was because of nursing co-
ownership of the program, repeated ed-
ucational interventions, and a strong
collaborative relationship established
between the ED and PICU. Finally, this
project came at a time when our hospital
72
279.9 had both a culture amenable to change
58.8 and an ability to analyze processes.
143
20 Our experience may not be generaliz-
16 able for several reasons. First, diag-
4 (PICU) noses were clinically based; case defi-
—
nitions were not used. Second, given
our barriers, we wanted to take a step-
wise approach to optimize adoption.
Specifically, our target was implemen-
tation of the international guidelines.
At present, our protocol time frames
fall short of this target, but we have a
system in place to continuously im-
prove to achieve our goal. This proto-
col has been an important milestone
for our institution. We do not view this
as successful completion of a single QI
project but, rather, continuous refine-
ment of our QI process as we evolve
into a learning organization. From that
perspective, we will continue to at-
tempt to reach our target. Third, it was
not possible to query physicians re-
garding clinical decision-making; the
purpose of the protocol was not to
change decision-making but to make
the interventions on the basis of those
decisions occur more rapidly and their
effects measured more consistently
with data presented in more useful
ways. Fourth, external validity may be
decreased in centers that see lower
proportions of high-risk patients and
for centers in which existing infra-
structure does not allow for increas-
ing caregiver resources. Although this
study addressed the obstacles found
in our center, each hospital has to ad-
dress its own obstacles and culture to
design a protocol suitable to its indi-
vidual needs.
We have plans to continue improving.
First, the triage tool can be modified to
increase sensitivity (eg, modify tem-
perature correction for tachycardia).
Increased sensitivity will result in
 QUALITY-IMPROVEMENT REPORTS

A quire change. Third, the use of the

B these acutely ill patients because of
C pediatric study revealed that warm
FIGURE 2
A, Statistical process control charts of time to first bolus for children identified at triage. B, Statistical
process control charts of time to third bolus for children identified at triage. C, Statistical process
control charts of time to first antibiotic for children identified at triage.
overtreatment of a minority of chil-
dren. However, given the risk of miss-
ing a child in compensated shock,
some false-positives are acceptable.
Second, criteria for ICU admission can
be modified. If children receive 60
mL/kg of fluid but are then appear well
in the ED, they may be candidates to go
to non-ICU beds. This protocol change
will require frequent vital-sign moni-
toring, which may be beyond the ca-
pacity of acute-care floors and may re-
protocol can be extended to outpatient
clinics and initiated before ED arrival
and on transport. The protocol has
been adopted already by the outpa-
tient oncology clinic. In addition, ef-
forts to use the protocol for decom-
pensated, acutely ill patients, with and
without high risk factors, need to be
made. Tables 3 and 4 highlight differ-
ences between patients enrolled in the
protocol and those who were not. The
protocol was not used for many of
the rapid need for airway manage-
ment, not initially recognized because
of the lack of risk factors, or because
additional staff were already at the
bedside. However, a structured, stan-
dardized method may improve their
care. Finally, sonographic measure-
ment of hemodynamic parameters
may be incorporated. Differentiating
between warm and cold shock is not
always straightforward, but it does af-
fect selection of vasoactive agents; 1
shock was more common in children
with central venous catheter infec-
tions and cold shock in those with
community-acquired sepsis.19 Bedside
ultrasonography may provide real-
time quantitative measurements of
vascular resistance and cardiac index,
which would provide more objective
data to optimize therapy.
This protocol allowed earlier recog-
nition of children in shock, identified
barriers to effective management,
and instituted mechanisms to har-
ness additional resources to im-
prove care. Standardization of fluids,
antibiotics, laboratory studies, and
patient disposition was emphasized,
which led to substantial reductions
in both time to receipt of time-
sensitive interventions and a reduc-
tion in variation in how children in
shock were treated.

PEDIATRICS Volume 127, Number 3, March 2011 e765

Downloaded from pediatrics.aappublications.org by guest on September 12, 2015
ACKNOWLEDGMENTS
We thank Joan Shook, MD, MBA, Paul
Sirbaugh, DO, Charles Macias, MD,
REFERENCES
1. Watson RS, Carcillo JA, Linde-Zwirble WT,
Clermont G, Lidicker J, Angus DC. The epide-
miology of severe sepsis in children in the
United States. Am J Respir Crit Care Med.
2003;167(5):695–701
2. Odetola FO, Gebremariam A, Freed GL. Pa-
tient and hospital correlates of clinical sep-
sis and resource utilization in severe pedi-
atric sepsis. Pediatrics. 2007;119(3):
487– 494
3. Fiser RT, West NK, Bush AJ, Sillos EM,
Schmidt JE, Tamburro RF. Outcome of se-
vere sepsis in pediatric oncology patients.
Pediatr Crit Care Med. 2005;6(5):531–536
4. Brierley J, Carcillo JA, Choong K, et al. Clin-
ical practice parameters for hemodynamic
support of pediatric and neonatal septic
shock: 2007 update from the American Col-
lege of Critical Care Medicine [published
correction appears in Crit Care Med. 2009;
37(4):1536]. Crit Care Med. 2009;37(2):
666 – 688
5. Han YY, Carcillo JA, Dragotta MA, et al. Early
reversal of pediatric-neonatal septic shock
by community physicians is associated with
improved outcome. Pediatrics. 2003;112(4):
793–799
6. Carcillo JA, Davis AL, Zaritsky A. Role of early
fluid resuscitation in pediatric septic
shock. JAMA. 1991;266(9):1242–1245
7. Launay E, Gras-Le Guen C, Martinot A, et al.
Suboptimal care in the initial management
of children who died from severe bacterial
infection: a population-based confidential
e766 CRUZ et al
Downloaded from pediatrics.aappublications.org by guest on September 12, 2015
MPH, Trung Nguyen, MD, Elizabeth Fre-
deboelling, RN, Gail Parazynski, RN, and
Carol Miller, RN, for their support. Fi-
inquiry. Pediatr Crit Care Med. 2010;11(4):
469 – 474
8. Inwald DP, Peters MJ, Nadel S; Paediatric
Intensive Care Society Study Group. Emer-
gency 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(5):348 –353
9. Goldstein B, Giroir B, Randolph A. Interna-
tional pediatric sepsis consensus confer-
ence: definitions for sepsis and organ sys-
tem dysfunction in pediatrics. Pediatr Crit
Care Med. 2005;6(1):2– 8
10. Hanna CM, Greenes DS. How much tachycar-
dia in infants can be attributed to fever? Ann
Emerg Med. 2004;43(6):699 –705
11. Custer JW, Rau RE. The Harriet Lane Hand-
book. 18th ed. Philadelphia, PA: Elsevier
Mosby; 2009
12. Dellinger RP, Levy MM, Carlet JM, et al. Sur-
viving sepsis campaign: international
guidelines for the management of severe
sepsis and septic shock: 2008 [published
correction appears in Crit Care Med. 2008;
36(4):1394 –1396]. Crit Care Med. 2008;
36(1):296 –327
13. Puskarich MA, Marchick MR, Kline JA,
Steuerwald MT, Jones AE. One year mortal-
ity of patients treated with an emergency
department based early goal-directed ther-
apy protocol for severe sepsis and septic
shock: a before and after study. Crit Care.
2009;13(5):R167
14. Trzeciak S, Dellinger RP, Abate NL, et al.
Translating research to clinical practice: a
nally, we thank the clinicians and
staffs of the ED and PICU for making
this project a success.
1-year experience with implementing early
goal-directed therapy for septic shock in
the emergency department. Chest. 2006;
129(2):225–232
15. Crowe CA, Mistry CD, Rzechula K, Kulstand
CE. Evaluation of a modified early goal-
directed therapy protocol. Am J Emerg Med.
2010;28(6):689 – 693
16. Jones AE, Focht A, Horton JM, Kline JA. Pro-
spective external validation of the clinical
effectiveness of an emergency department-
based early goal-directed therapy protocol
for severe sepsis and septic shock. Chest.
2007;132(2):425– 432
17. Oliveira CF, Nogueira de Sá FR, Oliveira DSF,
et al. Time- and fluid-sensitive resuscitation
for hemodynamic support of children in
septic shock: barriers to the implementa-
tion of the American College of Critical Care
Medicine/Pediatric Advanced Life Support
Guidelines in a pediatric intensive care unit
in the developing world. Pediatr Emerg
Care. 2008;24(12):810 – 815
18. Institute of Medicine, Committee on Health
Care Quality in America. Crossing the Qual-
ity Chasm: A New Health System for the 21st
Century. Washington, DC: National Academy
Press; 2001. Available at: www.nap.edu/
html/quality_chasm/reportbrief.pdf. Ac-
cessed July 21, 2010
19. Brierley J, Peters MJ. Distinct hemodynamic
patterns of septic shock at presentation to
pediatric intensive care. Pediatrics. 2008;
122(4):752–759
Implementation of Goal-Directed Therapy for Children With Suspected Sepsis in
the Emergency Department
Andrea T. Cruz, Andrew M. Perry, Eric A. Williams, Jeanine M. Graf, Elizabeth R.
Wuestner and Binita Patel
Pediatrics 2011;127;e758; originally published online February 21, 2011;
DOI: 10.1542/peds.2010-2895
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/127/3/e758.full.h
tml

References This article cites 17 articles, 4 of which can be accessed free

at:
http://pediatrics.aappublications.org/content/127/3/e758.full.h
tml#ref-list-1
Citations This article has been cited by 2 HighWire-hosted articles:
http://pediatrics.aappublications.org/content/127/3/e758.full.h
tml#related-urls
Subspecialty Collections This article, along with others on similar topics, appears in
the following collection(s):
Emergency Medicine
http://pediatrics.aappublications.org/cgi/collection/emergency
_medicine_sub
Permissions & Licensing Information about reproducing this article in parts (figures,
tables) or in its entirety can be found online at:
http://pediatrics.aappublications.org/site/misc/Permissions.xht
ml
Reprints Information about ordering reprints can be found online:
http://pediatrics.aappublications.org/site/misc/reprints.xhtml

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org by guest on September 12, 2015

Implementation of Goal-Directed Therapy for Children With Suspected Sepsis in
the Emergency Department
Andrea T. Cruz, Andrew M. Perry, Eric A. Williams, Jeanine M. Graf, Elizabeth R.
Wuestner and Binita Patel
Pediatrics 2011;127;e758; originally published online February 21, 2011;
DOI: 10.1542/peds.2010-2895

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/127/3/e758.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org by guest on September 12, 2015