Nurses play a central role on pediatric sepsis response teams, where collaboration between providers is critical to timely recognition and treatment of sepsis. Here, two nurses share their award-winning efforts to change practice.
Becca* was a 13-year-old who came into Boston Children's Hospital's emergency department (ED) for foot pain from a bug bite. After her initial assessment in triage, she was given Tylenol and sent to the waiting room. Three hours and another assessment later, Becca was receiving treatment for septic shock.
Fortunately, Becca survived, and her story had a good outcome. But it points to one problem facing health care providers: delays in recognizing sepsis can increase mortality and ICU length of stay. In children, sepsis is difficult to recognize in the early stages, and it's hard to treat once it advances to severe sepsis or septic shock.
Despite the challenges, hospitals are making strides to improve. The webinar, "Nursing at the Forefront of the Battle Against Sepsis," was the first event in CHA's 2017 Sepsis Webinar Series, and it put a spotlight on such efforts. The event kicked off with the story of how one father's experience with sepsis inspired an award program that would bring forward outstanding improvement work in pediatric sepsis.
Carl Flatley is the father of Erin Kay Flatley, who died in 2007 from septic shock. As founder of the Sepsis Alliance, he has spent years working to bring awareness to sepsis. In 2016, the Alliance awarded the first Erin Kay Flatley Pediatric Sepsis Nursing Awards to Julie Albright Gottfried and Carolyn Nightingale Riker, pediatric nurses focused on improving sepsis outcomes in children's hospitals. "I started this award to protect other children," Flatley says. "When I saw what these nurses were doing, I wish they'd been around for Erin. They're helping other children survive sepsis."
Raising the red flag for sepsis interventions
To improve care and outcomes for patients with severe sepsis and septic shock, Riker explained how her team at Boston Children's used—and eventually applied throughout the whole ED—a paper trigger tool that could identify potential sepsis in 20 seconds.
Riker cared for Becca after she was brought back from the waiting room. "Being a new nurse right out of school, Becca's case challenged me," Riker says. "Those of us in pediatrics know recognizing sepsis in children can be difficult. How do you determine who's sick and who's not?"
But this tool, which is now in the electronic medical record, provides scoring criteria that help providers find signs compatible with septic shock. A score of 0 to 2 means continue with standard care, while a score of 3 or greater initiates the septic shock protocol. And because sepsis is an evolving process, it's important to repeat the scoring for any patient presenting with a fever or concern for infection in the ED.
The scoring now plays an important role in identification of sepsis at Boston Children's. And because ED providers are already assessing patients, it's easy to implement, takes little time, and it flags the need for sepsis interventions more quickly.
"Looking back at Becca's case and applying the scoring system we have now, she would've initially been scored a 3. It would've been a 5 when she came back for treatment after waiting," Riker says. "Had this tool been used when she initially presented to the ED, she would have had an expedited evaluation by a physician and earlier treatment."
Improving sepsis care through simulation training
Miscommunication between members of the health care team is a leading factor in 80 percent of serious medical errors. For sepsis, those errors can look like missed cases and inadequate interventions. At Golisano Children's Hospital at The University of Rochester Medical Center, Gottfried began testing simulation training to prepare interprofessional teams to treat children with sepsis and septic shock in the ED.
"Mortality associated with septic shock is 50 percent," she says. "That makes it critical for ED staff to be familiar with the sepsis continuum and to adequately resuscitate patients that are progressing on that continuum toward septic shock."
In Gottfried's pilot project, four, 30-minute simulation sessions ran two different scenarios focused on communication and teamwork. From this research, Gottfried discovered that what professionals achieved in a simulation setting, they were more likely to demonstrate in a clinical setting.
The effort showed improvement in teamwork and communication behavior between scenarios, including an increase in areas like closed-loop communication, knowledge sharing and mutual respect. Participants also scored higher on individual knowledge of pediatric sepsis protocols after attending the training, pointing to a better understanding of the team skills necessary for optimal sepsis care.
"Early successes indicated staff readiness for ongoing learning as it relates to children with sepsis," Gottfried says. "Staff was requesting more training like this to further their critical thinking skills. And we were able to do it with no disruption to the care of patients."
To learn more about how these hospitals made these changes, listen to the webinar on demand.
*Patient name has been changed for confidentiality.
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