38 vs 38.5C? SIRS indicator for pediatric sepsis screening
Kerry A. Gold, BSN, CCRN, CEN, MICN; Carson Del Greco, BS; Ashley Trueblood, RN, BSN, CCRN; Summer Gupta, RN, MSN; Leah T. Nubla, MSN, RN, CPHQ
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Session D presented Monday, September 30, 2:30-3:30 pm
Purpose: Sepsis, severe sepsis, and septic shock (hereafter referred to collectively as sepsis) are significant contributors to pediatric morbidity and mortality. In 2005, international guidelines were developed recommending the upper-temperature threshold of 38.5C as a systemic inflammatory response syndrome (SIRS) criterion to screen for pediatric sepsis1. This review examined our institution’s more sensitive limit of 38.0C for pediatric sepsis screenings to determine if a more sensitive threshold was supported by clinical evidence as a positive predictor for the presence of sepsis.
Design: This quality assurance project was a retrospective analysis of patient data to determine if the adoption of international guidelines over our institution’s standard would influence the sensitivity and specificity of a nursing-administered pediatric sepsis screening tool.
Setting: The settings were a tertiary/quaternary academic medical center and a complex teaching hospital providing comprehensive pediatric care, ranging from routine services to highly-specialized treatment for acute and complex diagnoses.
Participants/Subjects: The population comprised pediatric patients (<18 years old) admitted in the calendar year 2017 from a dual-campus academic medical center who had a positive sepsis screen. For inclusion, a patient must have two or more SIRS criteria and suspected or confirmed infection. The first positive screen for any given encounter was examined. This dataset was cross-referenced with a secondary query of all patients with a positive blood culture(s), regardless of sepsis screening status. Patients in the Neonatal Intensive Care Unit and those lacking abnormal temperatures were excluded. All patient data were reviewed within the encrypted and HIPAA-compliant infrastructure of the health system.
Methods: This was a retrospective review of patient records meeting inclusion criteria queried from an Epic Clarity database. The temperature value captured concurrently with the sepsis screen was preferred. Median absolute time from screening to temperature capture was two minutes. Patients identified with abnormal temperatures and a positive screen were compared using the presence of sepsis ICD-10 codes, positive blood cultures, and physician clinical impressions to determine which patients had “true” sepsis incidents and whether patients would be missed with a different temperature threshold. Inter-rater reliability was maintained through the use of consistent abstractors.
Results/Outcomes: Nearly a third (135 of the 462) of patients with a positive screen had a temperature between 38.0–38.4C. Of the 135, 38 (28%) would have screened positive for sepsis based on other SIRS criteria. 97 (72%) patients would have screened negative with the higher temperature threshold. 8 of 28 (29%) patients with a positive blood culture(s) would have screened negative for sepsis using the 38.5C threshold instead of 38.0C. These findings are supported by assessments of sepsis presence, ICD-10 codes, blood cultures, and physician clinical impressions.
Implications: The data support the use of a temperature threshold less than 38.5C in pediatric sepsis screenings. Use of 38.0C demonstrated similar specificity to the 38.5 threshold, but greater sensitivity. Our investigation supports the use of a more sensitive temperature range. Further research into appropriate temperature values in the detection of pediatric sepsis cases may be warranted.
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