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EHR-Based Alert System Can Significantly Decrease Missed Pediatric Sepsis

Diagnosing a child with severe sepsis is a rare event, with a mortality rate as high as 20%; however, missing the complex clinical syndrome is not an option, even if recognizing it remains a challenge in children.

That’s according to a new report in Annals of Emergency Medicine, which points out that many pediatric patients with sepsis present initially with compensated shock without apparent hypotension, and their condition can be missed among the many children at the ED who have fever and tachycardia. That’s why study authors, led by researchers from Children’s Hospital of Philadelphia, say they consider an electronic sepsis alert such an important advancement. The alert, which pulls together vital signs, risk factors, and physician judgment to identify children in a pediatric emergency department with severe sepsis, drove down missed diagnoses by 76%, the study found.

“Sepsis is a killer and notoriously difficult to identify accurately in children, which is why this alert is so promising,” explains lead study author Fran Balamuth, MD, PhD, MSCE, of Children’s Hospital of Philadelphia. “Identifying the rare child with severe sepsis or septic shock among the many non-septic children with fever and tachycardia in a pediatric ER is truly akin to finding the proverbial ‘needle in a haystack.’ This alert, especially with the inclusion of physician judgment, gets us much closer to catching most of those very sick children and treating them quickly.”

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The alert consists of two stages and is part of the hospital’s electronic health record (EHR). Age-based elevated heart rate or hypotensive blood pressure sparks the first-stage alert when those are documented in the EHR at any time during emergency visits. The second stage alert comes into play with an affirmative answer to follow-up questions to patients who also have a fever or risk of infection. Those queries are related to underlying high-risk conditions, perfusion, and mental status.

If both first- and second-stage alerts are triggered, the care team gets together for a so-called sepsis huddle to discuss diagnosis and treatment options.

“Clinical identification remains critically important to making this protocol successful in identifying and treating these sick children,” Balamuth says.

Results indicate that of the 1.2% of the patients who set off sepsis alerts, 23.8% were placed on the sepsis protocol. Overall, only 4% of unidentified patients later developed severe sepsis, usually because of “patient complexity,” study authors say, and often involved patients with developmental delays.

The advantage to the EHR-based alert, notes an accompanying editorial by Andrea Cruz, MD, MPH, of the Baylor College of Medicine in Houston, is that it integrates “vital sign anomalies, comorbidities that increase a child’s risk for sepsis, and clinical judgment into a tool that is both more sensitive and specific than prior alerts as well as less prone to alert fatigue.”