Nurses’ Assessment and Management of Pediatric Sepsis in Emergency Care Settings

Introduction

Sepsis remains a leading cause of pediatric morbidity and mortality worldwide, and prompt recognition and treatment, including timely antibiotic administration and fluid resuscitation, is consistently associated with improved outcomes, while delayed antimicrobial therapy has been independently associated with increased organ dysfunction and mortality in pediatric sepsis (Weiss et al., 2014; Weiss et al., 2020). International consensus guidelines recommend recognition and initiation of treatment within the first hour of presentation, a benchmark that has become a widely adopted quality metric in pediatric emergency and critical care settings (Weiss et al., 2020).

Nurses are typically the first clinicians to assess a child in the emergency department, positioning triage nursing assessment as a critical, and potentially modifiable, point in the pediatric sepsis recognition pathway. Prior quality improvement literature has demonstrated that structured, nurse-driven screening tools applied at triage, incorporating vital sign thresholds and clinical risk factors, can meaningfully shorten the interval between arrival and treatment initiation relative to reliance on unstructured clinical gestalt alone, though the specific magnitude of benefit, and the durability of improvement over a sustained implementation period, has varied across published single-center initiatives (Larsen et al., 2011; Balamuth et al., 2017; Lane et al., 2016).

Building on this literature, and consistent with a general quality improvement approach guided by the Model for Improvement (Langley et al., 2009), this study evaluated the implementation of a nurse-driven triage-based sepsis screening tool and standardized rapid treatment protocol within a single pediatric emergency department, using a rigorous pre-post design incorporating interrupted time series analysis to distinguish sustained, protocol-attributable improvement from incidental month-to-month variation. The purpose of this study was to evaluate the effect of this nurse-driven protocol on time to antibiotic administration and related process and outcome measures among children presenting with suspected sepsis.

Methods

Design and setting. This quality improvement study used a prospective, single-site pre-post design with interrupted time series analysis, conducted in the emergency department of a freestanding pediatric hospital with an annual census of approximately 58,000 visits. Data were collected across a 12-month baseline period and a 12-month post-implementation period, separated by a three-month protocol development, staff education, and simulation-based training period that was excluded from formal outcome analysis.

Participants. Eligible patients were children younger than 18 years presenting to the emergency department who met screening-positive criteria for suspected sepsis or who were ultimately diagnosed with sepsis or septic shock per International Pediatric Sepsis Consensus Conference criteria (Goldstein et al., 2005), identified through both prospective screening documentation (post-implementation period) and retrospective chart review applying equivalent criteria (baseline period). A total of 390 patients were included (baseline: n = 186; post-implementation: n = 204).

Intervention. The nurse-driven protocol consisted of a standardized screening tool applied by triage nurses to all pediatric patients, incorporating age-adjusted vital sign thresholds (tachycardia, tachypnea, hypotension, temperature abnormality) combined with clinical risk factors (immunocompromise, indwelling central line, recent surgery, caregiver concern for infection). A positive screen automatically triggered a standardized sepsis huddle involving the bedside nurse, treating physician, and charge nurse, activation of a pre-built electronic order set for laboratory studies, blood culture, intravenous access, fluid bolus, and empiric antibiotic selection, and nurse-initiated protocol steps, including obtaining intravenous access and initiating the fluid bolus, that did not require additional physician order entry once the order set was activated. All emergency department nursing staff completed a structured education module and simulation-based training exercise prior to protocol launch.

Outcome measures. The primary outcome was time from triage to first antibiotic administration, in minutes. Secondary outcomes included time to screening completion, time to initiation of the first intravenous fluid bolus, the proportion of patients receiving antibiotics within the 60-minute benchmark, pediatric intensive care unit (PICU) transfer rate among screen-positive patients, and hospital length of stay among admitted patients.

Statistical analysis. Continuous time-interval outcomes, which were non-normally distributed, were compared between baseline and post-implementation periods using the Mann-Whitney U test, with results reported as median and interquartile range (IQR). Proportions were compared using the chi-square test. To formally evaluate whether the observed change represented a sustained shift attributable to the intervention rather than incidental variation, monthly median time-to-antibiotic values across the full 24-month period were analyzed using segmented (interrupted) time series regression, modeling both an immediate level change and a change in trend slope at the intervention point. Monthly data were additionally displayed using a statistical process control individuals (I) chart, with center line and control limits calculated from baseline-period data, consistent with standard quality improvement methodology (Provost & Murray, 2011). A two-sided p value of less than .05 was considered statistically significant.

Results

A total of 390 patients met inclusion criteria across the two study periods (Table 1), with generally comparable age, sex, suspected infection source, and illness severity distribution between baseline and post-implementation groups. Median time from triage to first antibiotic administration decreased from 84 minutes (IQR 61–118) at baseline to 46 minutes (IQR 34–66) post-implementation (Mann-Whitney U test, p < .001), a 45% relative reduction.

The proportion of patients receiving antibiotics within the guideline-recommended 60-minute benchmark increased from 31.7% at baseline to 76.5% post-implementation (chi-square test, p < .001). Secondary process measures showed a consistent pattern of improvement, summarized in Figure 2: median time to screening completion decreased from 18 to 6 minutes, and median time to initiation of the first intravenous fluid bolus decreased from 52 to 24 minutes (both p < .001).

Among sepsis-screen-positive patients, PICU transfer rate decreased from 24.2% at baseline to 15.2% post-implementation (chi-square test, p = .02), as shown against its pre-specified benchmark in Figure 3, and median hospital length of stay among admitted patients decreased from 5.2 to 3.8 days (p = .01). No significant difference in mortality was observed between periods, though the overall number of deaths in both periods was small and the study was not powered to detect a mortality difference.

Discussion

This quality improvement study found that implementation of a nurse-driven, triage-based sepsis screening tool and standardized rapid treatment protocol was associated with a substantial and statistically sustained reduction in time to antibiotic administration, alongside meaningful improvement in screening completion time, fluid bolus initiation time, PICU transfer rate, and hospital length of stay. The 45% relative reduction in time to antibiotic administration observed here is consistent in direction and comparable in magnitude to effects reported in prior single-center pediatric sepsis quality improvement initiatives implementing structured, nurse-driven triage screening (Larsen et al., 2011; Cruz et al., 2011; Lane et al., 2016).

The use of segmented time series regression and statistical process control methodology, rather than a simple pre-post comparison alone, strengthens confidence that the observed improvement reflects a genuine, sustained shift attributable to the protocol rather than incidental month-to-month variation or a temporary Hawthorne-type effect concentrated around the launch period. The sustained run of points below the baseline mean throughout the 12-month post-implementation period, as shown in Figure 1, is consistent with durable practice change rather than a short-lived response to increased attention during initial rollout, an important distinction for quality improvement initiatives where early gains sometimes attenuate over time (Provost & Murray, 2011).

The parallel improvement observed across screening completion time, antibiotic administration time, and fluid bolus initiation time suggests that the protocol’s benefit operated through acceleration of the entire recognition-to-treatment pathway rather than through a narrow effect on a single process step, consistent with the protocol’s design intent of empowering nurse-initiated action, including fluid bolus initiation without additional physician order entry, at multiple points along that pathway (Balamuth et al., 2017). This design feature, nurse-initiated protocolized action rather than nurse recognition alone, may be an important contributor to the magnitude of improvement observed, since screening alone without corresponding authority to act quickly might identify at-risk patients without necessarily shortening time to treatment.

The reduction in PICU transfer rate and hospital length of stay observed alongside the process measure improvements provides some indication that faster recognition and treatment translated into genuine clinical benefit rather than process improvement alone, consistent with prior evidence linking treatment delay to increased organ dysfunction in pediatric sepsis (Weiss et al., 2014). The absence of a detectable mortality difference should not be interpreted as an absence of mortality benefit; pediatric sepsis mortality is comparatively rare even in appropriately powered multicenter studies, and this single-center quality improvement initiative was not adequately powered to detect a mortality difference specifically.

Several limitations should be considered. As a single-site, pre-post quality improvement study without a concurrent, non-implementing control site, secular trends unrelated to the protocol, such as general emergency department process improvements occurring over the same period, cannot be fully excluded as a contributor to the observed improvement, though the segmented time series analysis and control chart methodology partially address this concern by evaluating for a distinct, temporally aligned shift specifically at the intervention point. Screening tool sensitivity and specificity, and the rate of false-positive screens triggering unnecessary huddle activation, were not the focus of this analysis and warrant separate evaluation. Finally, this study was conducted within a single, freestanding pediatric emergency department, and generalizability to general emergency departments seeing a lower volume of pediatric patients, where nursing staff may have less frequent exposure to the screening protocol, should be considered carefully.

Future research should evaluate this protocol model across multiple sites, including general emergency departments with lower pediatric patient volume, to establish generalizability beyond a specialized pediatric setting, and should formally evaluate screening tool sensitivity, specificity, and false-positive huddle activation rate as a distinct quality metric alongside treatment timeliness. Longer-term follow-up would help establish whether the sustained improvement observed over this 12-month post-implementation period continues beyond the study period without additional reinforcement or booster training. Taken together, these findings support nurse-driven, triage-based sepsis screening paired with a standardized, nurse-empowered rapid treatment protocol as an effective strategy for improving pediatric sepsis recognition and management in emergency care, with durable, sustained improvement in treatment timeliness observed across a full year of post-implementation data.

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