Implementing Balanced Fluid Resuscitation for Sepsis Patients in a Tertiary Care Pediatric Emergency Department: A Quality Improvement Initiative.

INTRODUCTION: National data support the use of balanced fluid during volume resuscitation in the setting of sepsis, as it improves morbidity and mortality, particularly preventing acidosis and kidney injury. This single-center quality improvement project aimed to increase the percentage of patients with a positive sepsis screen treated in the tertiary care pediatric emergency department (ED) who received lactated Ringer's (LR) fluid resuscitation from 4.6% to 30% by June 2024. METHODS: A multidisciplinary team examined barriers using a fishbone diagram, process mapping, and failure mode and effects analysis (FMEA). Interventions included order set and clinical practice guideline changes with subsequent electronic medical record changes, huddle form reminders, increased accessibility to LR, as well as discussion forums. RESULTS: Data showed patients receiving at least one balanced fluid bolus in June 2023 increased from 4.6% to 35.4% with special cause variation detected. Completed sepsis huddle forms documented in the electronic medical record (EMR) improved from 42.8% to 54.2% with special cause variation detected. The time to antibiotics from arrival decreased from 97.7 to 65.6 minutes in December 2023 with special cause variation detected. CONCLUSIONS: Through multiple interventions, balanced fluid resuscitation was successfully implemented in the ED. Order set changes with prechecked LR fluids bolus that forced providers to "opt out" along with clinical pathway updates seemed to be the most influential changes. FMEA proved to be a helpful tool to ensure safe implementation. Future directions include expansion to the inpatient units in the hospital.