354 - Integrating Cardiac Point-of-Care Ultrasound Into a Pediatric Emergency Sepsis Bundle

Poster Number: 354
Publication Number: 354.205

Jacob Hemberger, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Ethan S. Vorel, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Rachel Rempell, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Brandon Ku, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Fran Balamuth, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States

Background:
Cardiac point-of-care ultrasound (C-POCUS) is an emerging diagnostic tool in pediatric sepsis and is recommended by the recent Surviving Sepsis Guidelines to guide vasoactive medication choice in children with fluid refractory shock. The feasibility of integrating C-POCUS into early sepsis care in a pediatric ED is not known.

Objective:
To increase C-POCUS utilization in suspected sepsis cases in a large pediatric ED from a baseline of 3% to 50% within 12 months of project initiation.

Design/Methods:
We convened key stakeholders to define aims and identify key drivers. PDSA cycles included: 1) education on C-POCUS through division conferences and bedside training, 2) directed text alerts to C-POCUS trained providers working in the ED when a patient was being treated for sepsis, and 3) clinical decision support incorporating C-POCUS into the sepsis order set. 22 faculty and fellows credentialed in C-POCUS performed exams during the project period, and POCUS experts reviewed all ultrasound images for quality assurance. We used p-charts to track proportion of suspected sepsis cases utilizing C-POCUS and x-bar charts to track balancing metrics of time to fluid, antibiotic, and vasopressor administration. Finally, we explored univariate factors influencing rates of C-POCUS completion using chi-square testing.

Results: We identified 214 suspected sepsis cases during the project period. The proportion of patients with suspected sepsis who received a C-POCUS exam increased from 3% to 35%, with special cause variation (Figure 1). Balancing metrics were unchanged.
We reviewed 174 charts to identify factors impacting rates of C-POCUS completion (Table 1). We observed higher rates of C-POCUS completion with fellow presence in the ED, discharge diagnosis of multisystem inflammatory syndrome in children, and patients requiring hemodynamic support with at least two fluid boluses or a vasoactive medication. We saw a trend towards fewer C-POCUS exams performed for the sickest patients treated in the resuscitation bay or intubated, but this trend did not reach statistical significance.Conclusion(s):
We successfully increased C-POCUS utilization in patients with suspected sepsis from 3% to 35% in a large pediatric ED. Providers more often used C-POCUS for patients receiving hemodynamic support with high-volume fluid resuscitation or a vasoactive medication. Upcoming QI interventions include involving residents to obtain C-POCUS images and embedding text alerts into an EMR-based messaging platform. Next steps include determining the impact of C-POCUS on ED fluid and vasopressor decisions in pediatric sepsis.

CV (Jacob Hemberger)CV (Jake Hemberger).pdf
Table 1: Factors Influencing Rates of Cardiac POCUS CompletionPatient and provider factors influencing likelihood of C-POCUS completion. MIS-C = multisystem inflammatory syndrome in children.