376 - Pediatric Sepsis Case Volume is not Associated with Guideline-Concordant Care in a General ED System

Poster Number: 376
Publication Number: 376.312

Halden F. Scott, University of Colorado, Children's Hospital Colorado, Aurora, CO, United States; allison kempe, University of Colorado School of Medicine, denver, CO, United States; Lalit Bajaj, University of Colorado Denver, Denver, CO, United States; Savannah Brackman, Children's Hospital Colorado, Denver, CO, United States; Erin McGonagle, Children's Hospital Colorado, Denver, CO, United States; Jan Leonard, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Daniel Lindberg, University of Colorado School of Medicine, Denver, CO, United States

Background: Up to 80% of children with sepsis first receive emergency care in general Emergency Departments (EDs), which treat adults and children. Studies have suggested that pediatric sepsis care is less-likely to be guideline-concordant and mortality is higher in EDs with low pediatric sepsis volume, but have been limited by non-standardized or administrative code case definitions, problematic when patients transfer. We sought to address these limitations with a standardized, previously-described definition, IPSO Sepsis, that identifies cases on ICD-10 code and additional criteria including ED treatments. IPSO Sepsis has been used in pediatric EDs, in this study we applied it in general EDs.

Objective: To test whether children with sepsis in general EDs with low pediatric sepsis volumes have lower relative risk of guideline-concordant pediatric sepsis care compared to higher pediatric sepsis volume EDs

Design/Methods: This retrospective cohort study was set in 32 Colorado general EDs, with combined annual pediatric/total visits of 53,000/487,000, and a shared EHR, from 1/2015-9/2021. Inclusion criteria were IPSO Sepsis, age 31 days-18 years; acute appendicitis was excluded. The primary outcome was concordance with 4 pediatric Surviving Sepsis Campaign (SSC) guideline elements: Blood culture, IV antibiotics within 3 hours, IV fluid bolus within 3 hours, lactate measured. Subgroup analysis of septic shock was performed.

Results: 1624 ED visits were included; only 4.6% were identified by ICD-10 code [Tab 1]. SSC concordance was 41.5%, and significantly improved from 23.8% in 2015 to 53.7% in 2021 (Cochran-Armitage trend p < 0.001) [Fig 1]. The risk of receiving concordant care did not differ in low vs. high-volume EDs (RR=1.04, 95% CI: 0.84-1.29), or in free-standing vs. hospital-based EDs (RR=1.08, 95% CI: 0.84-1.40) [Tab 2]. Lactate and antibiotic guideline elements were most often missed. In patients with septic shock, concordance with the 3-hour bundle was higher, 61.0%, but only 16.3% met the stricter SSC 1-hour goals for shock.Conclusion(s): This study ascertained pediatric sepsis cases in general EDs using a standardized definition, identifying cases missed by sepsis ICD-10 codes. Pediatric sepsis case volume was not associated with concordant care, a novel finding that would benefit from study in other regions. Pediatric sepsis care improved over time, but it was non-concordant in most cases, especially in septic shock. Future pediatric sepsis research in general EDs should focus particular attention on septic shock, and seek to understand and leverage existing drivers of improvement in general settings.
Table 1Patient and Emergency Department (ED) Care Characteristics of Study Subjects
Figure 1Proportion of pediatric sepsis patients who received Surviving Sepsis Ccampaign-concordant care, with 95% confidence intervals, and total pediatric sepsis patients treated per year. Volume was influenced by: new children’s hospital opening in 2019, Covid-19 pandemic in 2020-21, 2021 includes 9 months only.