Table 1.

Core Pediatric Sepsis QI Program Best Practices-critical elements in italics

Pediatric sepsis improvement team	1. Workgroup should include key stake holders and front-line providers (e.g., nurses, technicians, advanced practice providers, pharmacists, respiratory therapists, IV team), other key members (e.g., project manager, improvement specialist, unit specific educator, family advisory board member, data analysist, EHR specialist, administrative leadership representative). 2. Meet regularly to review program and analytics/metrics. 3. Establish evidence-based metrics for interventions. 4. Consider creating an evidence-based pediatric sepsis guideline. 5. Have a project manager.
Data and analytics	1. Team should include a dedicated analyst familiar with QI statistics/methodologies. 2. Though not required, a consistent data abstractor is highly recommended as part of the team. 3. Develop a case definition for cohort inclusion based on published, evidence-based recommendations [4,9,12,13]. 4. Build an algorithm for cohort identification leveraging elements extractable from the EHR. Utilize previously published methods [22], and modify for site-specific requirements. 5. If feasible, perform manual chart review of possible cohort candidates, particularly in the beginning, and for those who received non-compliant care. 6. Develop a case review algorithm that allows for consistent determination of cohort inclusion. Discuss ambiguous cases during regular team meetings. 7. Depending on patient volumes, perform EHR query for cohort candidates on a weekly or bi-monthly basis. 8. Establish data elements for analysis (leverage EHR) including process, outcome and balancing metrics, clinical parameters, laboratory results (e.g., lactate), demographics, disposition.
Recognition strategy	1. Pediatric specific early recognition screen should include age adjusted vital signs, incorporate high risk conditions, be actionable and forward facing to providers. 2. Consider adding a hard-stop to the screen alert that is actionable (e.g., requires providers to acknowledge the alert and select a management option). 3. Structure the screen to maximize sensitivity and positive predictive value (will likely require multiple rapid improvement cycles).
Escalation and management strategy	1. The notification system should alert key personnel to the bedside for patients with suspected sepsis (e.g., overhead broadcast, communication system alert such as Vocera®) 2. Following an alert, initiate a multi-disciplinary bedside huddle (minimum of nurse and attending physician) for all patients with a positive screen. 3. Standardized order set should be easily accessible and include key components of recommended sepsis care [4].
De-escalation strategy	1. Discontinue vasoactive medications as soon as allowable. 2. Discontinue lines and tubes as soon as allowable. 3. Tailor antibiotics utilizing available data including culture and/or susceptibility results. 4. Transfer from a critical care unit as soon as is feasible.