Phumeetham Suwannee, Limprayoon Kawewan, Law Suvikrom, Preeprem Nutnicha, Kriengsoontornkij Worapant
Division of Intensive Care, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
Division of Ambulatory Pediatrics, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
J Pediatr Clin Pract. 2025 Jul 25;17:200170. doi: 10.1016/j.jpedcp.2025.200170. eCollection 2025 Sep.
To evaluate the effectiveness of a quality improvement protocol-driven bundle care approach in reducing 28-day mortality among children with septic shock in a resource-limited setting.
We conducted a retrospective-prospective observational study in a pediatric intensive care unit from January 2013 to August 2023. Clinical data were collected during the preprotocol and postprotocol periods. The primary outcome was 28-day mortality. The impact of a protocol-driven bundle care approach on 28-day mortality was assessed using multivariate logistic regression analysis.
We studied 163 patients: 94 in the preprotocol period and 69 in the postprotocol period. The median age was 8.5 years (IQR 1.9-13.5), and the median Pediatric Risk of Mortality, version III (PRISM-III) score was 11 (IQR 5-18). After protocol implementation, 28-day mortality significantly decreased from 32.9% to 11.6% ( = .002). There was no difference in illness severity between the groups. Multivariate logistic regression analysis revealed that patients cared for in the postintervention period had a significantly decreased risk of 28-day mortality (aOR 0.258, 95% CI 0.086-0.770, = .015). However, higher PRISM-III scores were independently associated with increased mortality (aOR 1.193, 95% CI 1.115-1.277, < .001).
Implementing a quality improvement protocol-driven bundle care approach in a resource-limited pediatric setting was independently associated with a reduction in 28-day mortality among children with septic shock. These findings support the adoption of evidence-based protocols to improve outcomes in environments with limited resources. The strong correlation between PRISM-III scores and mortality highlights the importance of early recognition and planning for effective, timely intervention, and resource allocation.
评估在资源有限的环境中，以质量改进方案驱动的集束化护理方法在降低脓毒性休克患儿28天死亡率方面的有效性。
我们于2013年1月至2023年8月在一家儿科重症监护病房进行了一项回顾性-前瞻性观察性研究。在方案实施前和实施后阶段收集临床数据。主要结局是28天死亡率。使用多因素逻辑回归分析评估方案驱动的集束化护理方法对28天死亡率的影响。
我们研究了163例患者：方案实施前阶段94例，方案实施后阶段69例。中位年龄为8.5岁（四分位间距1.9 - 13.5），中位小儿死亡风险评分第三版（PRISM - III）为11分（四分位间距5 - 18）。方案实施后，28天死亡率从32.9%显著降至11.6%（P = .002）。两组间疾病严重程度无差异。多因素逻辑回归分析显示，干预后阶段接受护理的患者28天死亡风险显著降低（校正比值比0.258，95%置信区间0.086 - 0.770，P = .015）。然而，较高的PRISM - III评分与死亡率增加独立相关（校正比值比1.193，95%置信区间1.115 - 1.277，P < .001）。
在资源有限的儿科环境中实施以质量改进方案驱动的集束化护理方法与降低脓毒性休克患儿28天死亡率独立相关。这些发现支持采用循证方案以改善资源有限环境中的结局。PRISM - III评分与死亡率之间的强相关性凸显了早期识别以及规划有效、及时干预和资源分配的重要性。
