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Original Investigation
July 24/31, 2018

Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis

Author Affiliations
  • 1Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 2The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
  • 3IPRO, Lake Success, New York
  • 4Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 5Associate Editor, JAMA, Chicago, Illinois
  • 6New York State Department of Health, Albany
  • 7Department of Pediatrics, Division of Critical Care, BC Children’s Hospital and Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
  • 8Division of Biostatistics, College of Public Health, The Ohio State University, Columbus
  • 9Department of Medicine, Division of Pulmonary Critical Care & Sleep, Alpert Medical School of Brown University, Providence, Rhode Island
  • 10Department of Pediatrics, Pediatric Critical Care Medicine, Stony Brook Children’s Hospital, Stony Brook, New York
  • 11Pediatric Critical Care Medicine, Seattle Children’s Hospital and Research Institute, Seattle, Washington
  • 12Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
JAMA. 2018;320(4):358-367. doi:10.1001/jama.2018.9071
Key Points

Question  Following statewide mandated care for pediatric sepsis, was the prompt completion of a 1-hour bundle associated with lower risk-adjusted in-hospital mortality?

Findings  Among 1179 pediatric patients with sepsis at 54 adult and pediatric specialty hospitals in New York State, the completion of a 1-hour sepsis bundle that included blood cultures, broad spectrum antibiotics, and a 20-mL/kg fluid bolus was significantly associated with lower risk-adjusted in-hospital mortality compared with not completing the bundle within 1 hour (odds ratio, 0.59).

Meaning  Timely completion of a 1-hour bundle of care may improve outcomes in pediatric sepsis.

Abstract

Importance  The death of a pediatric patient with sepsis motivated New York to mandate statewide sepsis treatment in 2013. The mandate included a 1-hour bundle of blood cultures, broad-spectrum antibiotics, and a 20-mL/kg intravenous fluid bolus. Whether completing the bundle elements within 1 hour improves outcomes is unclear.

Objective  To determine the risk-adjusted association between completing the 1-hour pediatric sepsis bundle and individual bundle elements with in-hospital mortality.

Design, Settings, and Participants  Statewide cohort study conducted from April 1, 2014, to December 31, 2016, in emergency departments, inpatient units, and intensive care units across New York State. A total of 1179 patients aged 18 years and younger with sepsis and septic shock reported to the New York State Department of Health who had a sepsis protocol initiated were included.

Exposures  Completion of a 1-hour sepsis bundle within 1 hour compared with not completing the 1-hour sepsis bundle within 1 hour.

Main Outcomes and Measures  Risk-adjusted in-hospital mortality.

Results  Of 1179 patients with sepsis reported at 54 hospitals (mean [SD] age, 7.2 [6.2] years; male, 54.2%; previously healthy, 44.5%; diagnosed as having shock, 68.8%), 139 (11.8%) died. The entire sepsis bundle was completed in 1 hour in 294 patients (24.9%). Antibiotics were administered to 798 patients (67.7%), blood cultures were obtained in 740 patients (62.8%), and the fluid bolus was completed in 548 patients (46.5%) within 1 hour. Completion of the entire bundle within 1 hour was associated with lower risk-adjusted odds of in-hospital mortality (odds ratio [OR], 0.59 [95% CI, 0.38 to 0.93], P = .02; predicted risk difference [RD], 4.0% [95% CI, 0.9% to 7.0%]). However, completion of each individual bundle element within 1 hour was not significantly associated with lower risk-adjusted mortality (blood culture: OR, 0.73 [95% CI, 0.51 to 1.06], P = .10; RD, 2.6% [95% CI, −0.5% to 5.7%]; antibiotics: OR, 0.78 [95% CI, 0.55 to 1.12], P = .18; RD, 2.1% [95% CI, −1.1% to 5.2%], and fluid bolus: OR, 0.88 [95% CI, 0.56 to 1.37], P = .56; RD, 1.1% [95% CI, −2.6% to 4.8%]).

Conclusions and Relevance  In New York State following a mandate for sepsis care, completion of a sepsis bundle within 1 hour compared with not completing the 1-hour sepsis bundle within 1 hour was associated with lower risk-adjusted in-hospital mortality among patients with pediatric sepsis and septic shock.

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