UH Rainbow Expert Pivotal in Successful Pediatric Sepsis Collaborative

Innovations in Pediatrics | Summer 2024

Nearly one-fifth of deaths worldwide are attributable to sepsis – with half occurring in children and teens, a figure even higher than the lives lost to pediatric cancer. For those who do survive sepsis, one-third have complications that delay their return to a high quality of life.

Charles Macias, MD

Charles G. Macias, MD, MPH, Chief of Pediatric Emergency Medicine and Chief Quality Officer at UH Rainbow Babies & Children’s Hospital, has been tackling this issue from a quality improvement perspective for the last 15 years. In 2009, he started making inquiries to pediatric emergency departments at children’s hospitals about how they were achieving good sepsis outcomes. What he found, he says, was many were not.

“Many organizations were discovering that, in fact, they didn't have great outcomes, that they actually had significant mortality and morbidity,” Dr. Macias says.

These revelations led to the Pediatric Septic Shock Collaborative, an effort to understand practice patterns and try to establish sepsis guidelines and uniformity. Shortly after, the Children’s Hospital Association launched a similar program in 2012, with Dr. Macias doing some early work on how to establish a small sepsis bundle.

“This is a constellation of interventions that allowed us to standardize across different organizations, to better diagnose and better manage sepsis,” he says. “We found that we could create better structures. This allowed us to launch new processes, but we hadn't yet so entrenched the work that we were seeing better outcomes.”

A second phase of the Pediatric Septic Shock Collaborative followed, with results showing better compliance among caregivers to the sepsis bundle. But Dr. Macias and his colleagues were still not satisfied.

“It was inconsistent and we weren't seeing the kinds of improvements and outcomes in mortality and morbidity that we were hoping to achieve,” he says. “Each time we were getting better and better and better. But we were not hitting that threshold nationally.”

That has now changed.

The outgrowth of these earlier quality improvement efforts on the part of Dr. Macias and others, the Improving Pediatric Sepsis Outcomes (IPSO) collaborative of the Children’s Hospital Association, launched in 2016, has proven so successful in moving the needle on pediatric sepsis that the project was officially “transitioned to a Community of Practice.” Dr. Macias was entrenched in the role as one of three co- chair and co-developer of the quality improvement collaborative that at its peak had 66 children's hospitals participating.

IPSO expanded beyond emergency medicine to include three additional care settings: the pediatric intensive care unit (PICU), hematology/oncology floors and inpatient units. It relied on five key processes: an improved sepsis screening tool, a huddle to align all caregivers for a particular patient, a standardized order set, first bolus of fluids in 30 minutes and timely antibiotics.

“It's important to keep in mind that if you look at the successes in reducing mortality from pediatric sepsis over the last decade, probably even the last two decades, there's been no magic bullet,” Dr. Macias says. “There's been no significant new pharmacologic intervention. The improvements have been made through quality improvement strategies for better diagnosis and more timely management. That was the driver of what we were trying to do.”

The results speak for themselves: The IPSO collaborative has saved 570 pediatric lives so far, in addition to preventing over 72,000 hospital days, 44,000 ICU days, 24,000 ventilator days, 13,000 vasoactive medication days and 3,500 episodes of organ dysfunction among children and teens in participating children’s hospitals. Published results for interim analyses show a 47-80% decrease in 30-day sepsis-related mortality, a 10-16% decrease in hospital days per sepsis episode, a 5-14% decrease in antibiotic days and a 7% decrease in ICU days.

“The impact to healthcare across the nation is huge when you consider not just the reduction in the burden of sepsis, but more importantly, the relief that parents feel when their child doesn't have to be an intensive care unit.,” Dr. Macias says. “These are children for which early in their development we have altered the course of their well-being… forever. They will become members of society who are working and functioning with a normal quality of life.”

Dr. Macias says he’s also gratified that IPSO results show that caregiver compliance with a bundle generates the sepsis mortality and morbidity outcomes everyone wants.

“We were able to generate evidence for how to improve outcomes, and publish that evidence,” he says. “So much of what we’re doing is defining the science of care delivery. We created this benchmark or standard of care not only with impact locally, but on a global scale. We can look to a better future when it comes to pediatric sepsis worldwide.”

For more information about this project, please email Peds.Innovations@UHhospitals.org.

Contributing Expert:
Charles G. Macias, MD, MPH
Division Chief, Pediatric Emergency Medicine
Chief Quality Officer
UH Rainbow Babies & Children’s Hospital
Professor of Pediatrics
Case Western Reserve University School of Medicine