An Emergency Department Septic Shock Protocol and Care Guideline for Children Initiated at Triage

Abstract

BACKGROUND: Unrecognized and undertreated septic shock increases morbidity and mortality. Septic shock in children is defined as sepsis and cardiovascular organ dysfunction, not necessarily with hypotension. OBJECTIVE: Cases of unrecognized and undertreated septic shock in our emergency department (ED) were reviewed with a focus on (1) increased recognition at triage and (2) more aggressive treatment once recognized. We hypothesized that septic shock protocol and care guideline would expedite identification of septic shock, increase compliance with recommended therapy, and improve outcomes. METHODS: We developed an ED septic shock protocol and care guideline to improve recognition beginning at triage and evaluated all eligible ED patients from January 2005 to December 2009. RESULTS: We identified 345 pediatric ED patients (49% male, median age: 5.6 years), and 297 (86.1%) met septic shock criteria at triage. One hundred ninety-six (56.8%) had ≥1 chronic complex condition. Hypotension was present in 34% (n = 120); the most common findings were tachycardia (n = 251 [73%]) and skin-color changes (n = 269 [78%]). The median hospital length of stay declined over the study period (median: 181–140 hours; P < .05); there was no change in mortality rate, which averaged 6.3% (22 of 345). The greatest gains in care included more complete recording of triage vital signs, timely fluid resuscitation and antibiotic administration, and serum lactate determination. CONCLUSIONS: Implementation of an ED septic shock protocol and care guideline improved compliance in delivery of rapid, aggressive fluid resuscitation and early antibiotic and oxygen administration and was associated with decreased length of stay.