Jacob Hemberger
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania
Disclosure information not submitted.
Rachel Rempell, MD
Associate Professor of Clinical Pediatrics
Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Brandon Ku, MD
Assistant Professor of Clinical Pediatrics
Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Fran Balamuth, MD, PhD, MSCE, MD, PhD, MSCE
Associate Director of Research in the Emergency Department
Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Title: Integrating Cardiac Point-of-Care Ultrasound into a Pediatric Emergency Sepsis Bundle
Introduction: Cardiac point-of-care ultrasound (C-POCUS) is an emerging diagnostic tool in pediatric sepsis. Recent Surviving Sepsis Guidelines advocate for the use advanced hemodynamic monitoring including C-POCUS to guide vasoactive medication choice in children with fluid refractory shock. C-POCUS is a novel tool in pediatric critical care, and feasibility of its use in sepsis in a pediatric ED is currently poorly described. We hypothesized we could integrate C-POCUS into our sepsis bundle workflow in a high-volume quaternary pediatric ED.
Methods: A team of key stakeholders convened to define aims and identify key drivers. The project aim was to increase C-POCUS utilization in suspected sepsis cases in the ED from a baseline of 2% to 50% within 12 months of project initiation. PDSA cycles included: 1) education on C-POCUS indications through division conferences and ongoing training of faculty and fellows in C-POCUS, 2) directed text alerts to C-POCUS trained providers working in the ED when a suspected sepsis patient was present, and 3) integrated clinical decision support that incorporated C-POCUS into the sepsis order set. 20 faculty and fellows performed C-POCUS exams during the project period, and POCUS experts reviewed all ultrasound images for quality assurance. Progress was monitored using p-charts to measure the proportion of suspected sepsis patients undergoing C-POCUS in the ED. Balancing metrics of time to fluid and antibiotic administration were tracked.
Results: There were 214 suspected sepsis cases during the project period. After our interventions, the proportion of suspected sepsis patients who received a C-POCUS exam increased from a baseline of 2% to 37%, with demonstration of special cause variation. The intervention showing the greatest increase in C-POCUS utilization was text alerts. Time to fluid and antibiotic administration remained unaffected.
Conclusions: Quality improvement interventions were effective at increasing C-POCUS utilization in suspected sepsis cases in a pediatric ED. Directed text alerts to providers was the most effective intervention. Next steps include identifying barriers to C-POCUS use and determining the impact of C-POCUS utilization on fluid and vasoactive medication decisions in sepsis.