Kessler David O, Walsh Barbara, Whitfill Travis, Dudas Robert A, Gangadharan Sandeep, Gawel Marcie, Brown Linda, Auerbach Marc
Department of Pediatrics, Columbia University Medical Center, New York Presbyterian Morgan Stanley Children's Hospital of New York, New York, New York.
Department of Pediatrics, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts.
J Emerg Med. 2016 Mar;50(3):403-15.e1-3. doi: 10.1016/j.jemermed.2015.08.004. Epub 2015 Oct 20.
Each year in the United States, 72,000 pediatric patients develop septic shock, at a cost of $4.8 billion. Adherence to practice guidelines can significantly reduce mortality; however, few methods to compare performance across a spectrum of emergency departments (EDs) have been described.
We employed standardized, in situ simulations to measure and compare adherence to pediatric sepsis guidelines across a spectrum of EDs. We hypothesized that pediatric EDs (PEDs) would have greater adherence to the guidelines than general EDs (GEDs). We also explored factors associated with improved performance.
This multi-center observational study examined in situ teams caring for a simulated infant in septic shock. The primary outcome was overall adherence to the pediatric sepsis guideline as measured by six subcomponent metrics. Characteristics of teams were compared using multivariable logistic regression to describe factors associated with improved performance.
We enrolled 47 interprofessional teams from 24 EDs. Overall, 21/47 teams adhered to all six sepsis metrics (45%). PEDs adhered to all six metrics more than GEDs (93% vs. 22%; difference 71%, 95% confidence interval [CI] 43-84). Adherent teams had significantly higher Emergency Medical Services for Children readiness scores, MD composition of physicians to total team members, teamwork scores, provider perceptions of pediatric preparedness, and provider perceptions of sepsis preparedness. In a multivariable regression model, only greater composite team experience had greater adjusted odds of achieving an adherent sepsis score (adjusted odds ratio 1.38, 95% CI 1.01-1.88).
Using standardized in situ scenarios, we revealed high variability in adherence to the pediatric sepsis guideline across a spectrum of EDs. PEDs demonstrated greater adherence to the guideline than GEDs; however, in adjusted analysis, only composite team experience level of the providers was associated with improved guideline adherence.
在美国，每年有72000名儿科患者发生感染性休克，花费达48亿美元。遵循实践指南可显著降低死亡率；然而，很少有方法可用于比较不同急诊科（ED）的表现。
我们采用标准化的现场模拟来测量和比较不同急诊科对儿童脓毒症指南的遵循情况。我们假设儿科急诊科（PED）比综合急诊科（GED）对指南的遵循程度更高。我们还探讨了与表现改善相关的因素。
这项多中心观察性研究考察了现场团队对一名模拟感染性休克婴儿的护理情况。主要结局是通过六个子指标衡量的对儿童脓毒症指南的总体遵循情况。使用多变量逻辑回归比较团队特征，以描述与表现改善相关的因素。
我们纳入了来自24个急诊科的47个跨专业团队。总体而言，21/47个团队遵循了所有六项脓毒症指标（45%）。PED比GED更常遵循所有六项指标（93%对22%；差异71%，95%置信区间[CI]43 - 84）。遵循指南的团队在儿童急救服务准备得分、医生占团队成员总数的比例、团队协作得分、提供者对儿科准备情况的认知以及提供者对脓毒症准备情况的认知方面显著更高。在多变量回归模型中，只有团队综合经验更丰富才更有可能获得遵循指南的脓毒症评分（调整后的优势比为1.38，95%CI 1.01 - 1.88）。
通过标准化的现场情景，我们发现不同急诊科对儿童脓毒症指南的遵循情况存在很大差异。PED比GED对指南的遵循程度更高；然而，在调整分析中，只有提供者的团队综合经验水平与更高的指南遵循率相关。
