The mean (SD) duration of hospital stay was 12 days (5) in phase 1 patients while it was 6 (2) days in phase 2. This difference however was not statistically significant. Two children died in each phase of refractory septic shock (Table 2).
The strength of our study is that we used a quality improvement initiative to improve the process outcomes such as decreasing the time to antibiotic administration in children with severe sepsis and/or septic shock. After implementing a simple triage tool, sepsis protocol, and increasing the number of nurses, we observed a decrease in time to administration of the first dose of antibiotics to within one hour of sepsis recognition.
The important limitations of our study include the small number of patients and the short time frame that makes it difficult to draw conclusions related to the impact of early antibiotic administration on clinical outcomes in children with severe sepsis or septic shock. Another limitation is that it was conducted in a unit where patients are evaluated as soon as they walk into the ER and treatment is initiated without any delay even before formalities for admission can be completed. Also, antibiotics are readily available in the ER at any point of time or can be made available without any delay from the pharmacy of the hospital free of cost. Our processes may not be congruent with hospital ER throughout where treatment is initiated only after completing registration and admission.
In this quality improvement before and after initiative, after introduction of changes in the system using components of Quality Improvement, we observed that—(1) the median time to recognition of severe sepsis decreased from 10 to 5 minutes, (2) the median time to administration of antibiotics reduced to 20 minutes from a baseline of 50 minutes, and (3) the duration of hospital stay was only 6 days in phase 2 as compared to 12 days in phase 1.
The effect of time to appropriate antibiotic therapy has been shown to be an independent determinant of length of stay in the Intensive Care Unit and in-hospital.17 David et al observed that for every hour delay in initiating appropriate antibiotic therapy, the length of Intensive Care Unit stay and hospital stay increased by 0.095 days and 0.13 days, respectively. Similar to their study, we observed the length of hospital stay to be longer in phase 1 as compared to phase 2 following the Quality Improvement initiative even though the difference was not statistically significant. It appears that there has been a reduction in length of stay following the training and process changes. However, whether delay in administering antibiotics increased the duration of hospital stay will have to be evaluated in larger studies in resource restricted settings to confirm such association.
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Yash Mittal, MBBS, AIIMS, New Delhi, VI semester Medical Student involved in research projects on improving quality of care in patient care areas.
Jhuma Sankar, MD (Paed), AIIMS, New Delhi; Assistant Professor; Division of Paediatric Pulmonology and Critical Care; As a Pediatric Intensivist, she is involved in care of sick children admitted in intensive care unit at AIIMS, Delhi. She has conducted multiple studies exploring different aspects on management of septic shock in children and has published the results in major indexed journals on critical care.
Nitin Dhochak, MD (Paed), AIIMS, New Delhi; Senior Resident; Division of Pediatric Pulmonology and Critical Care; Currently pursuing DM course in pediatric pulmonology and critical care, Dr. Nitin is involved in care of critically ill children and children with chronic/acute respiratory illnesses. He is also involved in various quality improvement projects in the unit in patient care areas.
Samriti Gupta, MD (Paed), AIIMS, New Delhi; Senior Resident; Division of Pediatric Pulmonology and Critical Care; Currently pursuing DM course in pediatric pulmonology and critical care, Dr. Samriti is involved in care of critically ill children and children with chronic/acute respiratory illnesses. She is also involved in various quality improvement projects in the unit in patient care areas.
Rakesh Lodha, MD (Paed), AIIMS, New Delhi; Professor; Division of Paediatric Pulmonology and Critical Care; As chief of Division of Paediatric Intensive care unit at AIIMS, Dr. Lodha has been instrumental in revolutionizing Pediatric critical care in India alongside others. He is an expert in research methodology and has over 300 publications in reputed national and international journals. He has contributed to national and international health care policy and guidelines with his path breaking research on critical illnesses, infections, tuberculosis, and HIV.
S K Kabra, MD (Paed), AIIMS, New Delhi; Professor and Chief; Division of Paediatric Pulmonology and Critical Care; Known as the “Founder of pediatric pulmonology” in India and also well known abroad as an expert in pediatric pulmonology, Dr. Kabra as the head of division of pediatric pulmonology has revolutionized the care of children with pulmonary diseases in India. His research work has been practice changing for chronic lung diseases, cystic fibrosis, tuberculosis, and chest diseases. He cherishes the vision of improving healthcare for children in India and is a key member of national health care policy and guideline making bodies.