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

• Published in: JAMA : the journal of the American Medical Association Vol. 320; no. 4; pp. 358 - 367
• Main Authors: Evans, Idris V. R, Phillips, Gary S, Alpern, Elizabeth R, Angus, Derek C, Friedrich, Marcus E, Kissoon, Niranjan, Lemeshow, Stanley, Levy, Mitchell M, Parker, Margaret M, Terry, Kathleen M, Watson, R. Scott, Weiss, Scott L, Zimmerman, Jerry, Seymour, Christopher W
• Format: Journal Article
• Language: English
• Published: United States American Medical Association 24-07-2018
• Subjects: Adolescent; Antibiotics; Blood; Blood culture; Bundling; Child; Child, Preschool; Clinical medicine; Cohort Studies; Drug delivery systems; Emergency medical services; Emergency Service, Hospital; Emergency Treatment; Female; Guideline Adherence; Hospital Mortality; Hospitals; Humans; Infant; Infant, Newborn; Intensive care units; Intravenous administration; Male; Mandatory Programs; Medical treatment; Mortality; New York; Odds Ratio; Patient Care Bundles; Patients; Pediatrics; Practice Guidelines as Topic; Risk; Risk Adjustment; Sepsis; Sepsis - mortality; Sepsis - therapy; Septic shock; Time Factors; New York; United States > US
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.2018.9071

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.