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  • Measure Summary
  • NQMC:009720
  • Aug 2014

Sepsis: proportion of hospitalized children younger than 19 years of age with severe sepsis or septic shock whose heart rate was documented at least every 15 minutes for the first hour of intravenous or intraosseous fluid resuscitation and then hourly thereafter until resolution of their condition, or for 24 readings.

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC). Basic measure information: documentation of heart rate during fluid resuscitation for children with severe sepsis or septic shock. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium; 2014 Aug. 50 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2016.

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Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the proportion of hospitalized children younger than 19 years of age with severe sepsis or septic shock whose heart rate was documented at least every 15 minutes for the first hour of intravenous or intraosseous fluid resuscitation and then hourly thereafter until resolution of their condition, or for 24 readings. A higher proportion indicates better performance.

Rationale

Sepsis is a potentially catastrophic condition that can escalate from infection to organ failure and death within hours. While mortality rates for pediatric sepsis have decreased over time, 4% to 10% of hospitalized children with sepsis in the United States die (Watson et al., 2003; Odetola, Gebremariam, & Freed, 2007). Also, annual hospital treatment costs are significant, at nearly $2 billion (Watson et al., 2003). Clinical practice parameters and clinical guidelines for the treatment of children with sepsis syndrome emphasize the critical importance of early recognition and aggressive treatment for all suspected cases (Dellinger et al., 2013; Carcillo et al., 2002). Improved survival has been associated with adherence to guidelines that emphasize prompt resuscitation of children with sepsis syndrome (Han et al., 2003). Whether a child presents to an academic medical center or to a community hospital, clinicians must be ready to rapidly deploy a set of time-sensitive, goal-directed, stepwise procedures to hinder or reverse the cascade of events in sepsis that lead to organ failure and death. Checking heart rate as part of fluid resuscitation is an essential element of timely and appropriate treatment for severe sepsis and septic shock. Prompt initiation of fluid resuscitation, ideally within the first hour of recognition of severe sepsis or septic shock, helps restore circulation, thus decreasing the risk of organ dysfunction (Brierley et al., 2009; Rivers & Ahrens, 2008) and mortality (Oliveira et al., 2008). Heart rates reported over time indicate whether resuscitation efforts are sufficient and help guide next steps for shock reversal, as age-specific heart rates are central to the definition of shock (Dellinger et al., 2013).

Evidence for Rationale

Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, Doctor A, Davis A, Duff J, Dugas MA, Duncan A, Evans B, Feldman J, Felmet K, Fisher G, Frankel L, Jeffries H, Greenwald B, Gutierrez J, Hall M, Han YY, Hanson J, Hazelzet J, Hernan L, Kiff J, Kissoon N, Kon A, Irazuzta J, Lin J, Lorts A, Mariscalco M, Mehta R, Nadel S, Nguyen T, Nicholson C, Peters M, Okhuysen-Cawley R, Poulton T, Relves M, Rodriguez A, Rozenfeld R, Schnitzler E, Shanley T, Kache S, Skippen P, Torres A, von Dessauer B, Weingarten J, Yeh T, Zaritsky A, Stojadinovic B, Zimmerman J, Zuckerberg A. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009 Feb;37(2):666-88. PubMed External Web Site Policy

Carcillo JA, Fields AI. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med. 2002 Jun;30(6):1365-78. [162 references] PubMed External Web Site Policy

Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R, Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013 Feb;41(2):580-637. [636 references] PubMed External Web Site Policy

Han YY, Carcillo JA, Dragotta MA, Bills DM, Watson RS, Westerman ME, Orr RA. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics. 2003 Oct;112(4):793-9. PubMed External Web Site Policy

Odetola FO, Gebremariam A, Freed GL. Patient and hospital correlates of clinical outcomes and resource utilization in severe pediatric sepsis. Pediatrics. 2007 Mar;119(3):487-94. PubMed External Web Site Policy

Oliveira CF, Nogueira de Sá FR, Oliveira DS, Gottschald AF, Moura JD, Shibata AR, Troster EJ, Vaz FA, Carcillo JA. Time- and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a pediatric intensive care unit in a developing world. Pediatr Emerg Care. 2008 Dec;24(12):810-5. PubMed External Web Site Policy

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC). Basic measure information: documentation of heart rate during fluid resuscitation for children with severe sepsis or septic shock. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium; 2014 Aug. 50 p.

Rivers EP, Ahrens T. Improving outcomes for severe sepsis and septic shock: tools for early identification of at-risk patients and treatment protocol implementation. Crit Care Clin. 2008 Jul;24(3 Suppl):S1-47. PubMed External Web Site Policy

Watson RS, Carcillo JA, Linde-Zwirble WT, Clermont G, Lidicker J, Angus DC. The epidemiology of severe sepsis in children in the United States. Am J Respir Crit Care Med. 2003 Mar 1;167(5):695-701. PubMed External Web Site Policy

Primary Health Components

Severe sepsis; septic shock; intravenous or intraosseous fluid resuscitation; heart rate; children

Denominator Description

The eligible population for the denominator is the number of hospitalized children younger than 19 years of age with severe sepsis or septic shock who received intravenous or intraosseous fluid resuscitation (see the related "Denominator Inclusions/Exclusions" field).

Numerator Description

The eligible population for the numerator is the number of hospitalized children younger than 19 years of age with severe sepsis or septic shock whose heart rate was documented at least every 15 minutes for the first hour of intravenous or intraosseous fluid resuscitation and then hourly thereafter until resolution of their condition or for 24 readings (see the related "Numerator Inclusions/Exclusions" field).

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Sepsis Prevalence and Incidence
While sepsis-associated mortality in children has declined in recent years, from 97% in infants in 1966 to 9% in the early 1990s, it remains a major cause of morbidity and mortality among children (Watson et al., 2003). Incidence of pediatric sepsis was estimated in 1995 to be 0.56/1000 children, with the highest prevalence in infancy at 5.6/1000 children; boys had a higher incidence compared with girls (0.6 vs. 0.52 per 1000 children) (Watson et al., 2003). Sepsis prevalence tends to have two peaks during childhood, corresponding to significant periods of time in the maturity of the immune system: first, during the neonatal stage, with an incidence of 4.3 per 1000 and second, at 2 years of age (Watson et al., 2003). Odetola et al. (2007) reported another age-specific peak in hospitalization rates: in 2003, children 15 to 19 years of age made up 18% of the pediatric population hospitalized nationally for sepsis.

Mortality among hospitalized children with severe sepsis has been reported to be between 4% and 10% (Watson et al., 2003; Odetola, Gebremariam, & Freed, 2007). Mortality is strongly associated with multiple organ dysfunction syndrome, occurring in 7% of children with one failing organ, increasing to 53% in those with at least four failing organs (Watson et al., 2003). Comorbid illness is also associated with mortality from sepsis, with mortality rates of 8% in children with comorbid illness versus 2% among previously healthy children (Odetola, Gebremariam, & Freed, 2007). There are also reports of age-specific differences in mortality from pediatric sepsis. Higher mortality rates among children over the age of 2 years may be attributable to the presence of chronic and severe underlying disease and to improved survival of immune‐compromised and immune‐suppressed children (Oliveira et al., 2008). Also, older pediatric patients have been sick longer than younger patients and may also have experienced more hospital admissions and treatments, such as transplantation or chemotherapy, making them more vulnerable to sepsis syndrome (Oliveira et al., 2008).

Sepsis Cost
Estimated annual total cost of pediatric sepsis in the United States is $1.97 billion (Watson et al., 2003). The average (mean) charge per hospitalization for sepsis is $47,126 (Odetola, Gebremariam, & Freed, 2007). Children who died from sepsis had total hospital charges that were 2.5-fold higher compared with those who survived. Higher charges were also associated with higher severity of illness. Longer length of stay for children hospitalized with sepsis was associated with multiple comorbidities, multiple organ dysfunction, and higher illness severity (Odetola, Gebremariam, & Freed, 2007).

Performance Gap
Despite the availability of evidence-based guidelines for the care of children with sepsis, only a minority of children receive the standard of care. Process barriers are a common problem leading to delay in the recognition and treatment of pediatric shock (Cruz et al., 2011). They include varying levels of experience among emergency department staff performing initial evaluations, lack of adequate nursing staff for resource‐intensive patients, difficulty in obtaining frequent vital signs, lack of standardization of empiric antibiotics and diagnostic tests, lack of prioritization of medications, and barriers to patient flow through the hospital (Cruz et al., 2011). Similarly, Oliveria et al. (2008) suggested reasons for delay may include inaccuracy in assessing the severity of a child's state of shock, shortage of health care providers, fatigue among medical teams, and difficulty in establishing adequate intravascular access.

Treatment of septic shock cannot start at arrival at the intensive care unit; it must begin when patients present to the emergency department (Larsen, Mecham, & Greenberg, 2011). Early recognition and treatment of septic shock right from presentation to the emergency department benefits all patients because it leads to more meticulous patient assessment (Larsen, Mecham, & Greenberg, 2011). The development of emergency department shock protocols for pediatric patients with sepsis syndrome standardizes and facilitates care by providing explicit instructions regarding interventions and timeframes (Cruz et al., 2011). This will allow earlier intervention and harness resources for very ill children. To mitigate delay in the recognition of sepsis, a triage tool could aid improved recognition of abnormal vital signs and lead to more timely identification and treatment of patients at risk (Cruz et al., 2011).

Several of the challenges involved in providing standard elements of care (such as regular documentation of heart rate as part of fluid resuscitation) to children with severe sepsis and septic shock have to do with hospital type and location. Many children live far from medical facilities that offer specialized pediatric care. For those presenting with septic shock to remote community hospitals, resuscitation efforts made by attending physicians are crucial to their survival and should be prioritized. Delay in resuscitation while waiting to transfer patients to a more advanced pediatric medical facility is unwise (Han et al., 2003). Han et al. (2003), in a 9 year retrospective study, reported that 29% of infants and children who presented with septic shock at community hospitals and required transport to a larger medical center, did not survive. In a separate report, Odetola et al. (2007) reported that pediatric patients with sepsis who were transferred incurred higher charges than those whose care did not entail transfer.

As clinical guidelines for the treatment of sepsis were developed at pediatric academic centers without accounting for use at community hospitals, barriers to use may exist (Han et al., 2003). For example, some community physicians may lack the specialized technical skills necessary for treating children with severe sepsis or septic shock. Educational barriers regarding the guidelines themselves may curtail implementation, if physicians are unaware of, or lack support to execute stepwise, goal-directed interventions in a timely manner. However, most of the procedures detailed in current guidelines are easily within the scope of a community-based practice (Han et al., 2003). Continued efforts to increase knowledge and comfort with sepsis guidelines among community physicians will likely improve outcomes. Odetola and colleagues (2007) also noted an urgent need for concerted clinical and educational efforts within the clinical care setting designed to limit the progression of sepsis severity, as multiple organ dysfunction portends poor outcomes including death.

At community hospitals, lack of familiarity with clinical guidelines for the specifics of fluid resuscitation, including such elements as regular documentation of heart rate, may lead to insufficient care. Han and colleagues (2003) found that practice at community hospitals tended to be conservative regarding fluid resuscitation. Physicians at these hospitals administered similar median volumes of fluid therapy (20 mL/kg) to pediatric patients with persistent shock and those in whom shock was reversed (Han et al., 2003). This finding suggests that community physicians tended not to administer additional fluid boluses to patients who remained in persistent shock after providing an initial fluid bolus. When faced with persistent septic shock, community physicians tended to escalate preferentially to inotropic/vasopressor support, rather than additional fluid therapy. While children in septic shock require inotropic/vasopressor support, the hemodynamic impact of catecholamine infusions may be undermined by inadequate fluid resuscitation. This practice may suggest unfamiliarity with clinical guidelines (Han et al., 2003).

Similarly, Oliveira et al. (2008) noted that the lack of local clinical protocols covering specific procedures and treatment goals limited the behavior of health care providers, even though the importance of time and fluid-sensitive treatment for patients with severe sepsis or septic shock is well known. These researchers found that while physicians were aware of existing guidelines, nurses were less familiar with them. Nurses often did not know why a patient was receiving a particular treatment, which might explain the failure noted by Oliveira et al. to consistently observe achievement of at least a 40-mL/kg dose of fluid resuscitation in the first hour of treatment of septic shock. Special attention should be given to nursing education, these researchers say, emphasizing the critical role of good vascular access and the importance of teamwork.

See the original measure documentation for additional evidence supporting the measure.

Evidence for Additional Information Supporting Need for the Measure

Cruz AT, Perry AM, Williams EA, Graf JM, Wuestner ER, Patel B. Implementation of goal-directed therapy for children with suspected sepsis in the emergency department. Pediatrics. 2011 Mar;127(3):e758-66. PubMed External Web Site Policy

Han YY, Carcillo JA, Dragotta MA, Bills DM, Watson RS, Westerman ME, Orr RA. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics. 2003 Oct;112(4):793-9. PubMed External Web Site Policy

Larsen GY, Mecham N, Greenberg R. An emergency department septic shock protocol and care guideline for children initiated at triage. Pediatrics. 2011 Jun;127(6):e1585-92. PubMed External Web Site Policy

Odetola FO, Gebremariam A, Freed GL. Patient and hospital correlates of clinical outcomes and resource utilization in severe pediatric sepsis. Pediatrics. 2007 Mar;119(3):487-94. PubMed External Web Site Policy

Oliveira CF, Nogueira de Sá FR, Oliveira DS, Gottschald AF, Moura JD, Shibata AR, Troster EJ, Vaz FA, Carcillo JA. Time- and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a pediatric intensive care unit in a developing world. Pediatr Emerg Care. 2008 Dec;24(12):810-5. PubMed External Web Site Policy

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC). Basic measure information: documentation of heart rate during fluid resuscitation for children with severe sepsis or septic shock. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium; 2014 Aug. 50 p.

Watson RS, Carcillo JA, Linde-Zwirble WT, Clermont G, Lidicker J, Angus DC. The epidemiology of severe sepsis in children in the United States. Am J Respir Crit Care Med. 2003 Mar 1;167(5):695-701. PubMed External Web Site Policy

Extent of Measure Testing

Reliability
Data and Methods. Measure testing involved an audit of medical records from three large hospitals serving children in Michigan: Children's Hospital of Michigan (CHM, Detroit), Hurley Medical Center (Hurley, Flint), and C.S. Mott Children's Hospital – University of Michigan Health System (UMHS, Ann Arbor). Medical records for all children with sepsis syndrome meeting the measure specification criteria during the measurement year were abstracted at each site. Note that at the University of Michigan, an 18-month measurement period was used (January 1, 2012 to June 30, 2013) to enable an adequate number of eligible records for review. Among the three sites, 300 unique and valid records for children with sepsis syndrome were abstracted and reviewed to test this measure.

Reliability of medical record data was determined through re-abstraction of patient record data by a second abstractor to calculate the inter-rater reliability (IRR) between abstractors. Broadly, IRR is the extent to which the abstracted information is collected in a consistent manner (Keyton et al., 2004). Low IRR may be a sign of poorly executed abstraction procedures, such as ambiguous wording in the data collection tool, inadequate abstractor training, or abstractor fatigue. For this measure, the medical record data collected by two nurse abstractors were compared.

Measuring IRR at the beginning of the abstraction process is imperative to identify and correct any misinterpretations early on. It is also important to assess IRR throughout the abstraction process to ensure that the collected data maintain high reliability standards. Therefore, IRR was evaluated at each site to address any reliability issues prior to completing data abstraction. Lessons learned were applied to work at other sites.

IRR was determined by calculating both percent agreement and Kappa statistics. While abstraction was still being conducted at each site, IRR assessments were conducted for 5% of the total set of unique patient records that were abstracted. Two abstractors reviewed the same medical records; findings from these abstractions were then compared, and a list of discrepancies was created.

Three separate IRR meetings were conducted, one in the early stages of abstraction for each center. All of the meetings included a review of multiple sepsis measures that were being evaluated. Because of eligibility criteria, not all patient records were eligible for all measures. Therefore, records for IRR were not chosen completely at random; rather, records were selected to maximize the number of measures assessed for IRR at each site.

Results. For the measure numerator, 7 of 300 unique patient records (2%) from the abstraction process were assessed for IRR across the three testing sites. In order for a record to be abstracted for this measure, the patient must also meet a specific treatment criterion (received fluid bolus) in addition to meeting diagnostic criteria (severe sepsis and septic shock). Therefore, IRR was also assessed for these eligibility criteria. For severe sepsis and septic shock, 15 of 300 unique patient records (5%) from the abstraction process were assessed for IRR across the three testing sites. For receiving a fluid bolus, 10 of 300 unique patient records (3%) were assessed for IRR across the three testing sites.

Table 7 of the original measure documentation shows the percent agreement and Kappa statistic for the numerator and the eligibility criteria of this measure for each site and across all sites. The overall agreement for the measure numerator, documentation of heart rate, was 57% and Kappa was -0.24. The overall agreement for timely fluid bolus was 80% and the Kappa was 0.38. The overall agreement for severe sepsis and septic shock diagnosis criteria were both 87%, with Kappa statistics of 0.72 and 0.58, respectively. Note that the Kappa value is affected by the prevalence of the finding under consideration, similar to positive predictive value being influenced by the prevalence of the condition. For rare findings, very low values of Kappa may not necessarily reflect low rates of overall agreement (Viera & Garrett, 2005).

This time-sensitive measure requires the documentation of heart rate at least every 15 minutes for the first hour of intravenous or intraosseous fluid resuscitation, and then hourly until severe sepsis or septic shock has resolved. It was sometimes difficult for abstractors to identify the time at which events actually occurred. In addition, there were physician's notes that stated that an event occurred on a specific day, but the time of day was not recorded.

Table 8 of the original measure documentation shows the percent agreement and Kappa statistic for assessing whether heart rate was assessed at appropriate time intervals for each site and across all sites. The overall agreement for heart rate at appropriate intervals was 100% with a Kappa statistic of 1.00. In addition, the reliability of determining the time at which key sepsis-related events took place was assessed. The overall agreement for identifying the time at which a severe sepsis diagnosis was made (±15 minutes) was 33% and for identifying the time of a septic shock diagnosis (±15 minutes) was 73%. Note that a Kappa statistic could not be calculated for the time of diagnoses measures since disagreement of times cannot be classified appropriately for statistical computation.

Validity
The validity of this measure was determined from two perspectives: face validity and validity of medical record data.

Face Validity. Face validity is the degree to which the measure construct characterizes the concept being assessed. The face validity of this measure was established by a national panel of experts and a parent representative for families of children with sepsis syndrome convened by the Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC). The Q-METRIC panel included nationally recognized experts in the identification and treatment of pediatric sepsis syndrome, representing neonatology, hematology/oncology, infectious diseases, emergency medicine, nursing, pediatric surgery, and pediatric intensive care. In addition, measure validity was considered by experts in state Medicaid program operations, health plan quality measurement, health informatics, and health care quality measurement. In total, the Q-METRIC sepsis panel included 15 experts, providing a comprehensive perspective on sepsis syndrome care and the measurement of quality metrics for states and health plans.

The Q-METRIC expert panel concluded that this measure has a high degree of face validity through a detailed review of concepts and metrics considered to be essential to effective sepsis syndrome identification and treatment. Concepts and draft measures were rated by this group for their relative importance. This measure was very highly rated, receiving an average score of 8.3 (with 9 as the highest possible score).

Validity of Abstracted Data. This measure was tested using medical record data. This source is considered the gold standard for clinical information; our findings indicate that these data have a high degree of face validity. This measure was tested among a total of 17 children younger than 19 years of age with severe sepsis or septic shock (Table 9 of the original measure documentation). Overall, 18% of children with severe sepsis or septic shock had documentation of heart rate at least every 15 minutes for the first hour of intravenous or intraosseous fluid resuscitation, and then hourly until severe sepsis or septic shock had resolved, or for 24 readings (range: 0% to 27%).

Evidence for Extent of Measure Testing

Keyton J, King T, Mabachi N, Manning J, Leonard L, Schill D. Content analysis procedure book. Lawrence (KS): University of Kansas; 2004.

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC). Basic measure information: documentation of heart rate during fluid resuscitation for children with severe sepsis or septic shock. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium; 2014 Aug. 50 p.

Viera AJ, Garrett JM. Understanding interobserver agreement: the kappa statistic. Fam Med. 2005 May;37(5):360-3. PubMed External Web Site Policy

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Emergency Department

Hospital Inpatient

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Nurses

Physician Assistants

Physicians

Least Aggregated Level of Services Delivery Addressed

Individual Clinicians or Public Health Professionals

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Age less than 19 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Timeliness

Case Finding Period

The measurement year

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Encounter

Institutionalization

Patient/Individual (Consumer) Characteristic

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
The eligible population for the denominator is the number of hospitalized children younger than 19 years of age with severe sepsis or septic shock who received intravenous or intraosseous fluid resuscitation.

Note:

  • Eligible children are all those admitted to the hospital, including the emergency department (ED).
  • Intake Period: January 1 through December 31 of the measurement year
  • Severe Sepsis: Sepsis plus one of the following: cardiovascular organ dysfunction OR acute respiratory distress syndrome OR two or more other organ dysfunctions
  • Septic Shock: Sepsis and cardiovascular organ dysfunction
  • International Classification of Diseases, Ninth Revision (ICD-9) codes to identify potential severe sepsis and septic shock cases using administrative data to identify medical records for review are documented in Table 2 of the original measure documentation. Refer to Table 1 of the original measure documentation for additional definitions.

Exclusions

  • Patients with advanced directives for comfort care
  • Patient or surrogate decision maker declined or is unwilling to consent to therapies

Exclusions/Exceptions

Patient factors addressed

Numerator Inclusions/Exclusions

Inclusions
The eligible population for the numerator is the number of hospitalized children younger than 19 years of age with severe sepsis or septic shock whose heart rate was documented at least every 15 minutes for the first hour of intravenous or intraosseous fluid resuscitation and then hourly thereafter until resolution of their condition or for 24 readings.

Note:

  • Fluid resuscitation is defined as greater than or equal to 20mL/kg of intravenous or intraosseous fluid administered over less than or equal to 15 minutes.
  • Resolution of severe sepsis or septic shock is defined in Table 3 of the original measure documentation.
  • Age-specific vital signs and laboratory variables are listed in Table 4 the original measure documentation.

Exclusions
None

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Electronic health/medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

Documentation of heart rate during fluid resuscitation for children with severe sepsis or septic shock.

Measure Collection Name

Sepsis Measures

Submitter

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) - Academic Affiliated Research Institute

Developer

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) - Academic Affiliated Research Institute

Funding Source(s)

This work was funded by the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) under the Children's Health Insurance Program Reauthorization Act (CHIPRA) Pediatric Quality Measures Program Centers of Excellence grant number U18 HS020516.

Composition of the Group that Developed the Measure

Sepsis Expert Panels

Representative Panel

  • Marjorie Arca, MD, Associate Professor and Clinical Director, Pediatric Surgical Critical Care, Medical College of Wisconsin, Milwaukee, WI
  • Joseph Carcillo, MD, Associate Professor, Department of Critical Care Medicine and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
  • Gretchen Cavanagh, RN, Registered Nurse, University of Michigan Health System, Ann Arbor, MI
  • Shannon Hamet, MEd, Parent Representative, Flat Rock, MI
  • James O'Callaghan, MD, Clinical Assistant Professor, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
  • Richard Polin, MD, Director, Division of Neonatology, Professor of Pediatrics, Attending Physician, Columbia University Medical Center, New York, NY
  • Richard Saladino, MD, Chief of Pediatric Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
  • Samir Shah, MD, MSCE, Director and Research Director, Hospital Medicine, Associate Professor, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
  • Lillian Sung, MD, PhD, Associate Professor, University of Toronto, Scientist and Pediatric Oncologist, The Hospital for Sick Children, Toronto, Ontario

Feasibility Panel

  • Christine Gall, DrPHc, MS, RN, Director, Quality and Client Relations, Virtual PICU Systems, LLC, Milwaukee, WI
  • Lakshmi Halasyamani, MD, Chief Medical Officer, Saint Joseph Mercy Health System, Ypsilanti, MI
  • Kevin Johnson, MD, MS, Professor and Vice Chair of Biomedical Informatics, Vanderbilt University, Nashville, TN
  • Sue Moran, BSN, MPH, Director of the Bureau of Medicaid Program Operations and Quality Assurance, Michigan Department of Community Health, Lansing, MI
  • Joseph Singer, MD, Vice President Clinical Affairs, HealthCore, Inc., Wilmington, DE
  • Marjorie Wilkins, CPC, CPC-H, CPAT, AHIMA, Approved International Classification of Diseases, Tenth Revision (ICD-10) Trainer, Altarum Institute, Alexandria, VA

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) Investigators

  • Folafoluwa Olutobi Odetola, MD, MPH, Assistant Professor, Department of Pediatrics and Communicable Diseases, School of Medicine, University of Michigan, Ann Arbor, MI
  • Gary L. Freed, MD, MPH, Professor of Pediatrics, School of Medicine and Professor of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI (principal investigator)
  • Kevin J. Dombkowski, DrPH, MS, Research Associate Professor of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, MI

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2014 Aug

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2016.

Source(s)

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC). Basic measure information: documentation of heart rate during fluid resuscitation for children with severe sepsis or septic shock. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium; 2014 Aug. 50 p.

Measure Availability

Source available from the Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) Web site External Web Site Policy. Support documents External Web Site Policy are also available.

For more information, contact Q-METRIC at 300 North Ingalls Street, Room 6C08, SPC 5456, Ann Arbor, MI 48109-5456; Phone: 734-232-0657; Fax: 734-764-2599.

NQMC Status

This NQMC summary was completed by ECRI Institute on April 16, 2015. The information was verified by the measure developer on May 19, 2015.

The information was reaffirmed by the measure developer on January 7, 2016.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

Inform Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) if users implement the measures in their health care settings.

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