Halden Scott, MD, associate professor of pediatrics at the University of Colorado School of Medicine, has a career defined by her passion for sepsis research and improving the quality of emergency care for children.
The pediatric emergency physician investigates the processes and systems of emergency sepsis care, including diagnosis and treatment, and how they intersect with health systems to care for children.
Scott’s research projects include key collaborations with investigators across the CU Anschutz Medical Campus and in different areas of sepsis work nationally through her work with Children’s Hospital Colorado, the Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), and the Improving Pediatric Sepsis Outcomes (IPSO) Collaborative.
“When I started this work, I would have said that I do my research and then I also do some quality improvement. I think it’s important because I care about the quality of care we give at Children's Colorado, and I care about it nationally, too. As my career has progressed, I’ve realized that the quality improvement I was doing as a side project is really all part of the same care for children,” says Scott, an investigator at ACCORDS.
Improving pediatric sepsis outcomes
Scott has been working with the Children Hospital Association’s Improving Pediatric Sepsis Outcomes (ISPO) collaborative since its inception in 2015, when she was appointed to the Steering Committee and co-led the collaborative’s first Research Working Group.
“I set out to make policies and procedures for how we would handle the enormous amounts of data we were getting and how we would produce generalizable research from that,” Scott says.
From 2017 to 2023, the IPSO collaborative had more than 70,000 cases in the data set with more than 50 children’s hospitals involved. The IPSO participants led quality improvement efforts and evaluated data to drive long-term progress. There have been seven papers published by the collaborative so far.
Scott co-authored an IPSO article, published in JAMA Network Open in June, that was the largest analysis performed to date to study what length of delay in antibiotic delivery is associated with increased mortality in children with sepsis.
Timely antibiotics in sepsis research
Sepsis care involves prescribing antibiotics and fluids in a timely manner, but that exact timing has been a moving target. The long-held standard has been antibiotics within one hour, but there is little evidence to support this timeframe.
After years of data collection, the IPSO researchers began with a graphical analysis to determine if a natural inflection point for sepsis-attributable mortality emerged for the length of time antibiotics were administered.
Looking only at patients who had sepsis identified within the first hour after emergency department arrival, the researchers saw an inflection point that was later than they expected at 330 minutes. For children who received antibiotics before that 330-minute mark, the 30-day mortality was 0.9%. The 30-day mortality in patients who received antibiotics after the inflection point was doubled, at 2%.
“The median time to give antibiotics was 69 minutes. This tells us the Quality Improvement Collaborative was doing its work and was getting antibiotics in fast for most children,” Scott says. “What we also saw is it's unclear whether giving antibiotics super-fast is what makes a difference, but not giving it slow is incredibly important. We know there's harm if you're substantially delayed.”
Supporting emergency care
The IPSO study demonstrated the important work of the collaborative to improve quality care for pediatric sepsis that led to lower mortality rates. However, Scott acknowledges that children don’t usually start their emergency care at a children’s hospital, they often begin their care at their nearest emergency department.
The ability of general emergency room systems to give specialized pediatric care and recognize sepsis early has become another focus area for Scott’s research.
“I have been working with our teams at ACCORDS to find ways to take these findings from a pediatric hospital collaborative and make it meaningful and usable in most ER settings,” Scott says.
In a study Scott completed with Brooke Dorsey Holliman, PhD, associate professor of family medicine and ACCORDS Qualitative and Mixed Methods Research Core director, the researchers interviewed general emergency department physicians and nurses regarding their challenges in caring for pediatric sepsis.
A difficulty for general emergency departments is that they are treating both adults and children, with only a small percentage of those visits being children. A theme in Scott’s research has been early sepsis recognition. Particularly with children, they get fevers more than adults, which can make it difficult to distinguish between a normal viral fever and a child that will progress toward critical illness.
Scott hopes that her research in general EDs will influence guidelines to ensure that dissemination tools make evidence-based guidelines easily read and understood. She is currently participating in the latest round of guideline development as a member of the Surviving Sepsis Pediatric Guidelines Committee.
Refining definitions for easier recognition
Prior to January 2024 there were multiple pediatric sepsis definitions being used. Some medical professionals felt that these existing definitions were outdated and needed to be updated.
Scott, along with Tell Bennett, MD, professor of biomedical informatics, and their international colleagues, were part of a task force to modernize pediatric sepsis criteria.
The Phoenix sepsis criteria is now the standard to identify children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems.
“An ongoing area of research for me, as well as many others, is how we define the cohort of children who would also benefit from treatment somewhere between the broad definition of IPSO sepsis, and the very narrow Phoenix sepsis,” Scott says. “Where ER clinicians need to identify and start treating sepsis before it gets terribly severe.”
Clinician support for diagnosis
Scott is also working to provide diagnostic support for general emergency departments through her project, The Right Call.
Working with Caroline Tietbohl, PhD, assistant professor of family medicine and an ACCORDS methodologist, Scott analyzes phone conversations among physicians, emergency departments, and Children’s Hospital transfer center nurses to learn more about the symptoms discussed on those calls that ultimately provide support and lead to the correct diagnosis. The project also aims to identify opportunities to improve the process.
“As physicians, we're taught in medical school how to talk to patients and talk much less about how to talk to each other,” Scott says. “I think we'll have some interesting findings for how we can provide better pediatric expertise and support to our colleagues in our seven-state region that send us children from Montana, Wyoming, Nebraska, and all around the West.”
June 24, 2024