Many children at high risk for septic shock: Follow these steps

Identify immunocompromised children at triage

If an infant or toddler presented with symptoms of an ear infection or the flu, would you ask about chronic medical conditions? This information is important, since immunocompromised children are at high risk for sepsis, says Rebecca Steinmann, RN, MS, CEN, CCRN, CCNS, clinical educator for the ED at Children's Memorial Hospital in Chicago.

ED nurses are caring for increased numbers of children at potential risk for sepsis, says Steinmann. "This is in large part because of our medical successes in managing children with chronic life-limiting conditions," she says. "This increases the pool of likely candidates."

Children living with HIV, sickle cell disease, steroid dependent-children, transplant patients, and children receiving chemotherapy or radiation therapy are some examples, says Steinmann. "In our ED, we are evaluating neonates and children with possible sepsis on a daily basis," she adds.

Failing to follow current recommendations for sepsis increase liability risks for emergency nurses, warns Sue Dill, RN, MSN, JD, director of hospital risk management at OHIC Insurance Co. in Columbus, OH. "If a physician orders something that is not according to the standard of care, you should bring it to their attention and follow the chain of command, depending on the nature of the deviation," she recommends.

Identify, treat without delay

At Children's Hospital Los Angeles, neutropenic children with fever are triaged quickly and in most cases, receive antibiotics within the first hour of arrival, says Inge Morton, RN, CPN, manager of education for the ED.

"Streamline the initial diagnostic work-up and treatment by using multidisciplinary protocols or clinical pathways," recommends Morton.

ED nurses use a protocol for children with fever/ neutropenia and a treatment protocol for infants younger than 2 months old with fever to expedite diagnostic tests and antibiotic administration, she says. (See the ED's protocol.) The protocols allow nurses to get the work-up started, so by the time the ED physician evaluates the patient, the lumbar puncture can be done and antibiotics can be given, says Morton. "This is more of a parallel process, instead of a step-by-step process that can take hours on a busy day," she says. "It took some time to get all the team members on board with using the protocols, but we are finally seeing them used on a frequent basis."

Some physicians argued that not every patient is the same and medicine can't be reduced to "cookie-cutter" recipes, Morton explains. To obtain buy-in, she recommends the following:

  • Communicate a clear vision what the protocols are supposed to accomplish, such as expediting care and decreasing length of stay and treatment delays.
  • Give team members time to review and provide input.
  • Empower nurses to suggest initiation of the protocol.
  • Track use of the protocol and outcomes, and identify reasons why the protocol was not initiated in cases that met the criteria.

Identify immunocompromised patients upon arrival to the ED, and provide them with a mask, says Morton. "In addition, those patients should be isolated from the general ED waiting room," she notes.

To identify children at risk for sepsis, ask these questions at triage, says Morton:

— Does the child have any medical problems in addition to the current chief complaint?

— Has the child been hospitalized or had surgery previously? If so, what was the reason?

— Is the child taking any medications?

Often, parents will bring a child to the ED for a specific symptom, such as fever or vomiting. Unless they are asked, they will omit mentioning the chronic medical problems because the parents don't think the current symptom relates to the chronic condition, says Morton.

However, a child with a 38.5°C fever who otherwise looks well might be triaged at a low acuity rating, but the same complaint in a child with sickle cell disease would receive a high-acuity rating, Morton says. "Therefore, the patient would be seen much sooner by a physician, and established clinical pathways could be initiated right from or after triage," she explains.

Give antibiotics as soon as possible, and closely monitor the patient for signs of septic shock, says Morton. Common signs of sepsis in children are tachycardia, mottled skin, delayed capillary refill time, irritability, hypotension, and fever, she says. "Neonates may present with hypothermia instead of fever, due to their immature thermoregulatory system," says Morton.

If sepsis is suspected, initial broad-spectrum antibiotics are given in the ED, says Steinmann. Previously, nurses reconstituted antibiotics and did the drug calculations in the ED, with dosages checked by a second nurse, but this practice was changed to comply with requirements of the Joint Commission on Accreditation of Healthcare Organizations. The standards require a pharmacist to review all prescription or medication orders, except in urgent situations when the resulting delay would harm the patient, including situations in which the patient experiences a sudden change in clinical status.

"Our Joint Commission consultants informed us that the standard is now being interpreted as the physician who has taken responsibility for the first-dose review having to be at the patient's bedside, rather than in close proximity, when drugs are administered that have not been verified by pharmacy," says Steinmann.

At Children's Hospitals and Clinics in Minneapolis, ED nurses have a goal to give antibiotics within 90 minutes of arrival, as soon as all necessary lab work is completed, reports Julie Maas, RN, an ED nurse. "We have an experienced nurse at sign-in who notifies our triage nurse immediately if a possible septic baby signs in, especially an infant under 4 weeks of age," says Maas. "The sign in nurse immediately gives that chart to a triage nurse, who takes the patient directly to a room."

Next, the ED nurse assesses the patient, takes vital signs, and notifies the physician, who writes orders for labs and antibiotics and does a spinal tap. "The nurse should be able to do her lab work and start an IV and administer the antibiotics, all within 90 minutes," says Maas.

These steps occur if sepsis is suspected, at Minneapolis Children's ED:

Children four weeks and younger receive a full sepsis work-up, including blood, urine, and spinal tap. "Their immune system is the most immature, so they are not as able to fight infection as older infants," Maas explains. "Older babies will get blood and urine labs done if there is a history of fever. Then based on those results and how the infant 'looks,' the spinal tap will be done."

Infants 4 weeks and younger automatically are admitted for IV antibiotics for a minimum of 48 hours. "Our babies of 4 to 8 weeks may be able to go home on oral antibiotics," Maas says. Babies older than 8 weeks will follow the protocol of blood and urine labs done first, then continue with the same format as the 4- to 8-week-old babies: A spinal tap is done and the child is sent home on antibiotics if the lab work is normal, or they're admitted if IV therapy is needed.

The key is to identify a possible septic baby as quickly as possible, says Mass. "Nurses are then capable of advocating for a physician to see the infant immediately, obtain the labs needed, and begin an IV and antibiotics as soon as possible," she says.

Once antibiotics are given, you must watch closely for signs of blood pressure instability, says Morton. For infants, systolic blood pressure should be at least 75 mm/Hg, depending on age. For children 2 and older, the ideal systolic blood pressure is 90 plus two times the child's age, and the lowest acceptable normal systolic blood pressure is 70 plus two times the child's age, says Morton.

Once you give antibiotics, it triggers lysis of bacteria, she says. "This can release endotoxin, causing hypotension," Morton says. "Patients who receive antibiotics for suspected sepsis should be monitored for this possible effect of the antibiotic."

Sources/Resource

For more information about pediatric sepsis in the ED, contact:

  • Sue Dill, RN, MSN, JD, Director of Hospital Risk Management, OHIC Insurance Co., 155 E. Broad St., Fourth Floor, Columbus, OH 43215. Telephone: (614) 255-7163. Fax: (614) 242-9806. E-mail: sue.dill@ohic.com.
  • Julie Maas, RN, Emergency Department, Children's Hospitals and Clinics, 2525 Chicago Ave. S., Minneapolis, MN 55404. Telephone: (612) 813-6117. Fax: (612) 813-6484. E-mail: Julie.Maas@childrensmn.org.
  • Inge Morton, RN, CPN, Manager, Education, Emergency Department, MS 74, Children's Hospital, 4650 Sunset Blvd., Los Angeles, CA 90027. Telephone: (323) 660-2450, ext. 4455. E-mail: IMorton@chla.usc.edu.
  • Rebecca Steinmann, RN, MS, CEN, CCRN, CCNS, Clinical Educator, Emergency Department, Children's Memorial Hospital, Chicago. Telephone: (773) 975-8764. E-mail: RSteinmann@childrensmemorial.org.

The complete guidelines for sepsis can be downloaded at no cost on the Society of Critical Care Medicine's web site: www.sccm.org. Click on "Professional Resources," "Sepsis Information," and "Surviving Sepsis Campaign Guidelines." The Institute for Healthcare Improvement has developed interventions for severe sepsis. They can be accessed at no charge at www.qualityhealthcare.org. Click on "Topics," "Critical Care," and "Sepsis."