Sepsis Plans in Hospitals Can Save Children’s Lives
Kids are more likely to survive when clinicians quickly follow three crucial steps.
by Lisa Esposito, Staff Writer.
First Published U.S. News, Wednesday, July 25, 2018
Take blood cultures. Start antibiotics. Give intravenous fluid. Following these three standard hospital procedures within an hour can save the life of a child with sepsis, a new study suggests.
Researchers analyzed how kids with severe sepsis fared in hospitals in New York state, where “Rory’s Regulations” – named after a boy who died of sepsis when the health care system failed him – are now mandated. The study, released Tuesday in JAMA, found that children who had received recommended treatment within 60 minutes were more likely to survive the life-shattering complication of sepsis.
Sepsis is a body-wide complication resulting from an infection. In an effort to combat the infection, the body overreacts by releasing chemicals into the bloodstream that provoke widespread inflammation. The cascade of resulting changes can lead to multiple organ failure, plunging blood pressure and death if sepsis advances to severe sepsis and septic shock. Among people who survive advanced sepsis, some require amputations of their fingers, toes or limbs.
Behind every sepsis mortality statistic is a child whose death might have been prevented and parents who will forever agonize over what could have been done differently.
Pediatric protocols in New York hospitals statewide spell out the three evidence-based steps that clinicians must promptly take for a child with possible sepsis. After the protocols were put in place, the researchers evaluated findings from pediatric patients treated in emergency rooms, hospital inpatient units and intensive care units statewide, from mid-2014 through 2016. The study included nearly 1,200 patients younger than 18 who were placed on the sepsis protocol.
The key point of comparison was whether children completed the sepsis “bundle” of treatments within one hour or not. With the bundle, clinicians take blood cultures, start kids on broad-spectrum antibiotics and infuse a weight-based dose of intravenous fluids in that period.
Kids with sepsis who received all three treatment measures were more likely to survive than those who received a single bundle element in the one-hour window. Completing the sepsis bundle within 60 minutes was tied to 40 percent lower odds of children dying of sepsis.
“These were children that were being cared for both at specialty children’s hospitals as well as adult hospitals that take care of kids,” says Dr. Christopher Seymour, the senior study author. “The clinicians in the study, the nurses and doctors, were challenged to deliver care for patients that they might not see as much as others,” says Seymour, who is an associate professor of critical care and emergency medicine at the University of Pittsburgh School of Medicine.
Awareness of sepsis in both adults and children, and understanding how sepsis might show up differently in kids, is the first step toward improving these results, Seymour says. “Once clinicians are aware of the signs and symptoms, having a structured set of steps for those first few hours is one way to get guideline-recommended treatments given to patients as often as possible.”
Ciaran and Orlaith Staunton are gratified by the new study findings. The couple’s tireless efforts were instrumental in the effort to mandate pediatric sepsis protocols in New York hospitals. It was their son, Rory Staunton, who inspired the pioneering regulations.
“It’s incredibly encouraging,” Ciaran Staunton says. “It comes too late for our son but it means someone else’s son will be spared this horrendous tragedy.”
Hospitalized patients in intensive care have a higher risk for developing sepsis. However, community-acquired sepsis accounts for the majority of severe sepsis hospitalizations – nearly 63 percent – compared with 26 percent health care-associated cases (such as in nursing homes) and 12 percent hospital-acquired cases, researchers found in a nationally representative analysis of 2012 hospital discharge figures.
Overall, more than 1.5 million people develop sepsis each year, according to U.S. figures. Among children, premature babies and infants are most vulnerable, according to the Sepsis Alliance. Nationwide, more than 75,000 children develop severe sepsis yearly, and nearly 7,000 of these kids die.
Sepsis can occur in a healthy child or adult starting even with a skin infection. That’s what happened to 12-year-old Rory, who cut his arm while diving for a ball during gym class at his New York school. The seemingly minor mishap turned into a systemic blood infection. A few days later, on April 1, 2012, Rory died in a tragic set of circumstances.
Rory’s devastating story is a chronicle of sepsis symptoms missed by health care providers and lost opportunities to start lifesaving treatment. Since then, the Rory Staunton Foundation’s mission has been working to raise sepsis awareness and improve pediatric medical procedures around sepsis in hospital emergency rooms.
In January 2013, Gov. Andrew Cuomo announced the adoption of “Rory’s Regulations” in New York hospitals statewide. “The first hour is critical,” Ciaran Staunton says. “When we see how many children can be saved, it should be compulsory in every state.” In 2016, Illinois also mandated that sepsis protocols be implemented in hospitals statewide. In January, New Jersey adopted a similar rule.
The Rory Staunton Foundation keeps working to beat sepsis. That includes promoting K-12 sepsis education and launching the National Family Council on Sepsis. Orlaith Staunton has contributed to the Safe Healthcare blog hosted by the Centers for Disease Control and Prevention.
Along with advocacy, the Stauntons stay busy with family matters. “Kathleen, our daughter, is entering her last year of high school,” Ciaran Staunton says. “And Rory; well, he would be 19 years old and at college. He would have graduated high school last year.”
According to health agencies like the CDC, symptoms such as these, alone or in combination, should trigger doctors and nurses to consider sepsis:
- Fever and shivering occur as the body reacts to the infection. Patients may complain of feeling cold.
- Pale or mottled skin is another sepsis indication.
- Patients can become confused and their mental status may change as sepsis affects the brain.
- Rapid breathing can be a result of lactic acid levels rising in the blood due to sepsis.
- Quickened heart rate or falling blood pressure are other vital sign changes related to sepsis. Patients may feel dizzy or lightheaded, and even pass out.
- Low urine output and changes in urine lab tests may indicate failing kidneys from sepsis.
- Abdominal pain is another sign that severe sepsis is affecting organ function.
“The [study] data suggests to parents to be mindful of the signs of severe infection. In particular, this is about thinking about keeping simple cuts and bruises clean,” Seymour says. When a child is not acting like his or her usual self; when there’s high fever, confusion or the child’s not eating, he says, “these are warning signs in which parents should use the words ‘severe infection’ or sepsis when talking to the doctor.”
Sepsis is much more common in adults, notes Dr. Martin Doerfler, the associate chief medical officer at Northwell Health, a large hospital system based in Hyde Park, New York. More research is available for adult sepsis, including a study he did with about 15,000 patients, published in the March 2017 issue of Critical Care Medicine.
With adult sepsis bundles, the target is for treatment within three hours. “When you look at the timing of antibiotics, in particular, every hour that you delay, you statistically get an increase in mortality for the population you have in that group,” Doerfler says. By adhering to sepsis protocols, he says, the health system reduced death rates for severe sepsis in adults by almost two-thirds.
Age-specific pediatric sepsis protocols are embedded at Cohen Children’s Medical Center, part of the Northwell system, Doerfler says. “Sepsis in a 6-month-old is very different than sepsis in a 16-year-old, both in its presentation and in some of the elements in how you treat it,” says Doerfler, who serves on the Rory Staunton Foundation’s medical advisory board.
Awareness is growing, Doerfler says, with clinicians more likely to quickly recognize signs and symptoms of sepsis in patients coming into the emergency room. However, he adds, it might still behoove family members to speak up.
“If you look at the Stauntons’ own circumstance, the pediatrician that they were with in the community did not think of [sepsis],” Doerfler says. “And when they went to a busy, highly regarded academic emergency department, that individual looked at the referral from the pediatrician who thought Rory had a viral enteritis and all of his symptoms were related to a different problem, and gave him fluid but didn’t think to give the antibiotics.”
In some cases, Doerfler suggests, a family member coming in and saying, “I’m concerned about sepsis,” could trigger a clinician to consider the possibility sooner and begin more aggressive treatment, and in doing so, cut through the dangerous delay.
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