Biomarker-enhanced Artificial Intelligence Based Pediatric Sepsis Screening Tool

Sepsis Clinical Trial

Official title:

Biomarker-enhanced Artificial Intelligence Based Pediatric Sepsis Screening Tool Towards Early Recognition and Personalized Therapeutics

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT05311046
• Other study ID #: NIAID 1R41AI167224-01
• Status: Recruiting
• Start date: January 9, 2023
• Est. completion date: June 2024

Study information

• Verified date: February 2023
• Source: Computer Technology Associates, Inc.
• Contact: Ioannis Koutroulis, MD
• Phone: 202-476-4177
• Email: IKOUTROULI[@]childrensnational.org
• Is FDA regulated: No
• Study type: Observational

Clinical Trial Summary

The overall objective of this proposed research is the derivation of a biomarker-enhanced artificial intelligence (AI)-based pediatric sepsis screening tool (PSCT) (software) that can be used in combination with the hospital's electronic health record (EHR) system to monitor and assess real-time emergency department (ED) electronic health record (EHR) data towards the enhancement of early pediatric sepsis recognition and the initiation of timely, aggressive personalized sepsis therapy known to improve patient outcomes.

It is hypothesized that the screening performance (e.g., positive predictive value) of the envisioned screening tool will be significantly enhanced by the inclusion of a biomarker panel test results (PERSEVERE) that have been shown to be effective in prediction of clinical deterioration in non-critically ill immunocompromised pediatric patients evaluated for infection. It is also hypothesized that enhanced phenotypes can be derived by clustering PERSEVERE biomarkers combined with routinely collected EHR data towards improved personalized medicine.

Description:

Background and Rationale Existing automated pediatric sepsis screening tools (PSCT) based on consensus criteria currently used in emergency departments do not improve early recognition and/or inform personalized therapeutic decisions leading to improved outcomes. The Improving Pediatric Sepsis Outcomes (IPSO) initiative found that by including patients that receive treatment, the extended criteria captured not only patients who developed sepsis with organ dysfunction (OD), but also those in whom early sepsis was treated with OD potentially averted.

The objective of the proposed effort is to derive and retrospectively validate a biomarker-enhanced AI-based pediatric sepsis screening tool that can be used to screen ED EHR data to improve early recognition, severity stratification, and the timely initiation of personalized sepsis therapy. CTA and its 6 institutional partners jointly propose to establish two de-identified patient registries: 1) the "EHR-data only cohort" (N = 2000) and 2) the "EHR + biomarker data cohort" (N = 400) in support of this objective.

Encounter data elements to be abstracted from EHRs for inclusion in these registries include both structured (e.g., time-stamped physiological measurements, treatments, procedures, outcomes) as well as free text notes.

Data Analysis and biases All study data, including physiological data extracted from patient EHR and results of biomarker assays will be analyzed using a variety of machine learning algorithms and techniques towards producing a high precision sepsis screening predictive model. Analytic methods involve standard descriptive statistical analysis of predictive classification performance (e.g., AUC, sensitivity/specificity, PPV, etc.).

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 2400
• Est. completion date: June 2024
• Est. primary completion date: February 2024
• Accepts healthy volunteers: No
• Gender: All
• Age group: 3 Months to 17 Years

Eligibility

Inclusion Criteria:

Patients 3 months -17 years of age, inclusive

• Diagnosed with sepsis by a clinician or trigger a sepsis alert and a blood culture is ordered. Controls will be false positive patients.

• For those patients that will be prospectively enrolled for blood sample collection:

will require a venipuncture or intravenous line placement.

Exclusion Criteria:

• Patients participating in an investigational program with interventions outside of routine clinical practice

• Patients with parents or LARs that don't speak English or Spanish

• Pregnancy

Related Conditions & MeSH terms

• Sepsis
• Toxemia

Intervention

Diagnostic Test:
• Pediatric sepsis screening tool (either algorithmic or manual)
All participating institutions employ either an algorithmic, manual, or combined algorithmic/manual pediatric sepsis screening protocol for patients that present with fever and/or a concern for infection. While the specific parameters tested in screening tools differ, they generally consist of tests for a systemic inflammatory response (e.g. SIRS) and/or organ dysfunction (e.g. SOFA) and/or high susceptibility (e.g. immunocompromised) factors.

Locations

Country	Name	City	State
United States	Children's National Hospital	Washington	District of Columbia

Sponsors (6)

Lead Sponsor	Collaborator
Computer Technology Associates, Inc.	Children's Hospital Medical Center, Cincinnati, Emory University, Johns Hopkins All Children's Hospital, Johns Hopkins University, Rainbow Babies and Children's Hospital

Country where clinical trial is conducted

United States, 

References & Publications (42)

Beglinger B, Rohacek M, Ackermann S, Hertwig R, Karakoumis-Ilsemann J, Boutellier S, Geigy N, Nickel C, Bingisser R. Physician's first clinical impression of emergency department patients with nonspecific complaints is associated with morbidity and mortality. Medicine (Baltimore). 2015 Feb;94(7):e374. doi: 10.1097/MD.0000000000000374. — View Citation

Bodenreider O. The Unified Medical Language System (UMLS): integrating biomedical terminology. Nucleic Acids Res. 2004 Jan 1;32(Database issue):D267-70. doi: 10.1093/nar/gkh061. — View Citation

Brewer A, Helfgott MA, Novak J, Schanhals R. An application of cmaps in the description of clinical information structure and logic in electronic health records. Glob Adv Health Med. 2012 Sep;1(4):16-31. doi: 10.7453/gahmj.2012.1.4.003. — View Citation

Bujang MA, Adnan TH. Requirements for Minimum Sample Size for Sensitivity and Specificity Analysis. J Clin Diagn Res. 2016 Oct;10(10):YE01-YE06. doi: 10.7860/JCDR/2016/18129.8744. Epub 2016 Oct 1. — View Citation

C. D. Sutton, "Classification and Regression Trees, Bagging, and Boosting," Handb. Stat., vol. 24, pp. 303-329, 2005, doi: 10.1016/S0169-7161(04)24011-1.

Delucchi K, Famous KR, Ware LB, Parsons PE, Thompson BT, Calfee CS; ARDS Network. Stability of ARDS subphenotypes over time in two randomised controlled trials. Thorax. 2018 May;73(5):439-445. doi: 10.1136/thoraxjnl-2017-211090. Epub 2018 Feb 24. — View Citation

Eisenberg M, Madden K, Christianson JR, Melendez E, Harper MB. Performance of an Automated Screening Algorithm for Early Detection of Pediatric Severe Sepsis. Pediatr Crit Care Med. 2019 Dec;20(12):e516-e523. doi: 10.1097/PCC.0000000000002101. — View Citation

Eisenberg MA, Freiman E, Capraro A, Madden K, Monuteaux MC, Hudgins J, Harper M. Outcomes of Patients with Sepsis in a Pediatric Emergency Department after Automated Sepsis Screening. J Pediatr. 2021 Aug;235:239-245.e4. doi: 10.1016/j.jpeds.2021.03.053. Epub 2021 Mar 30. — View Citation

Feuillet F, Bellanger L, Hardouin JB, Victorri-Vigneau C, Sebille V. On Comparison of Clustering Methods for Pharmacoepidemiological Data. J Biopharm Stat. 2015;25(4):843-56. doi: 10.1080/10543406.2014.920855. — View Citation

Gardlund B, Dmitrieva NO, Pieper CF, Finfer S, Marshall JC, Taylor Thompson B. Six subphenotypes in septic shock: Latent class analysis of the PROWESS Shock study. J Crit Care. 2018 Oct;47:70-79. doi: 10.1016/j.jcrc.2018.06.012. Epub 2018 Jun 8. — View Citation

Ghassemi M, Naumann T, Schulam P, Beam AL, Chen IY, Ranganath R. A Review of Challenges and Opportunities in Machine Learning for Health. AMIA Jt Summits Transl Sci Proc. 2020 May 30;2020:191-200. eCollection 2020. — View Citation

Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005 Jan;6(1):2-8. doi: 10.1097/01.PCC.0000149131.72248.E6. — View Citation

Hajian-Tilaki K. Sample size estimation in diagnostic test studies of biomedical informatics. J Biomed Inform. 2014 Apr;48:193-204. doi: 10.1016/j.jbi.2014.02.013. Epub 2014 Feb 26. — View Citation

Iwashyna TJ, Odden A, Rohde J, Bonham C, Kuhn L, Malani P, Chen L, Flanders S. Identifying patients with severe sepsis using administrative claims: patient-level validation of the angus implementation of the international consensus conference definition of severe sepsis. Med Care. 2014 Jun;52(6):e39-43. doi: 10.1097/MLR.0b013e318268ac86. — View Citation

Jacobs L, Berrens Z, Stenson EK, Zackoff MW, Danziger LA, Lahni P, Wong HR. The Pediatric Sepsis Biomarker Risk Model (PERSEVERE) Biomarkers Predict Clinical Deterioration and Mortality in Immunocompromised Children Evaluated for Infection. Sci Rep. 2019 Jan 23;9(1):424. doi: 10.1038/s41598-018-36743-z. — View Citation

Kent P, Jensen RK, Kongsted A. A comparison of three clustering methods for finding subgroups in MRI, SMS or clinical data: SPSS TwoStep Cluster analysis, Latent Gold and SNOB. BMC Med Res Methodol. 2014 Oct 2;14:113. doi: 10.1186/1471-2288-14-113. — View Citation

L. Medsker, M. Tan, and E. Turban, "Knowledge acquisition from multiple experts: Problems and issues," Expert Syst. Appl., vol. 9, no. 1, pp. 35-40, Jan. 1995, doi: 10.1016/0957-4174(94)00046-X.

Lanziotti VS, Povoa P, Soares M, Silva JR, Barbosa AP, Salluh JI. Use of biomarkers in pediatric sepsis: literature review. Rev Bras Ter Intensiva. 2016 Oct-Dec;28(4):472-482. doi: 10.5935/0103-507X.20160080. — View Citation

Lippi G. Sepsis biomarkers: past, present and future. Clin Chem Lab Med. 2019 Aug 27;57(9):1281-1283. doi: 10.1515/cclm-2018-1347. No abstract available. — View Citation

Marshall JC, Reinhart K; International Sepsis Forum. Biomarkers of sepsis. Crit Care Med. 2009 Jul;37(7):2290-8. doi: 10.1097/CCM.0b013e3181a02afc. — View Citation

Mathias B, Mira JC, Larson SD. Pediatric sepsis. Curr Opin Pediatr. 2016 Jun;28(3):380-7. doi: 10.1097/MOP.0000000000000337. — View Citation

Patel K, McElvania E. Diagnostic Challenges and Laboratory Considerations for Pediatric Sepsis. J Appl Lab Med. 2019 Jan;3(4):587-600. doi: 10.1373/jalm.2017.025908. Epub 2018 Nov 21. — View Citation

Paxton C, Niculescu-Mizil A, Saria S. Developing predictive models using electronic medical records: challenges and pitfalls. AMIA Annu Symp Proc. 2013 Nov 16;2013:1109-15. eCollection 2013. — View Citation

R. Lachman, "Expert systems: A cognitive science perspective," Behav. Res. Methods, Instruments, Comput., 1989, doi: 10.3758/BF03205582.

R. M. RJ Rovetto, "Causality and the ontology of disease," Appl Ontol, vol. 10, no. 2, pp. 79-105, Sep. 2015, doi: 10.3233/ao-150147.

R. Matkar and A. Parab, "Ontology based expert systems - replication of human learning," Thinkquest~2010, pp. 43-47, 2011, doi: 10.1007/978-81-8489-989-4_7.

R. R. Starr and J. M. Parente De Oliveira, "Concept maps as the first step in an ontology construction method," Inf. Syst., 2013, doi: 10.1016/j.is.2012.05.010.

Rudin C. Stop Explaining Black Box Machine Learning Models for High Stakes Decisions and Use Interpretable Models Instead. Nat Mach Intell. 2019 May;1(5):206-215. doi: 10.1038/s42256-019-0048-x. Epub 2019 May 13. — View Citation

Scott HF, Brilli RJ, Paul R, Macias CG, Niedner M, Depinet H, Richardson T, Riggs R, Gruhler H, Larsen GY, Huskins WC, Balamuth F; Improving Pediatric Sepsis Outcomes (IPSO) Collaborative Investigators.. Evaluating Pediatric Sepsis Definitions Designed for Electronic Health Record Extraction and Multicenter Quality Improvement. Crit Care Med. 2020 Oct;48(10):e916-e926. doi: 10.1097/CCM.0000000000004505. — View Citation

Sepanski RJ, Godambe SA, Mangum CD, Bovat CS, Zaritsky AL, Shah SH. Designing a pediatric severe sepsis screening tool. Front Pediatr. 2014 Jun 16;2:56. doi: 10.3389/fped.2014.00056. eCollection 2014. — View Citation

Seymour CW, Kennedy JN, Wang S, Chang CH, Elliott CF, Xu Z, Berry S, Clermont G, Cooper G, Gomez H, Huang DT, Kellum JA, Mi Q, Opal SM, Talisa V, van der Poll T, Visweswaran S, Vodovotz Y, Weiss JC, Yealy DM, Yende S, Angus DC. Derivation, Validation, and Potential Treatment Implications of Novel Clinical Phenotypes for Sepsis. JAMA. 2019 May 28;321(20):2003-2017. doi: 10.1001/jama.2019.5791. — View Citation

Sinha P, Calfee CS, Delucchi KL. Practitioner's Guide to Latent Class Analysis: Methodological Considerations and Common Pitfalls. Crit Care Med. 2021 Jan 1;49(1):e63-e79. doi: 10.1097/CCM.0000000000004710. — View Citation

Sinha P, Delucchi KL, Thompson BT, McAuley DF, Matthay MA, Calfee CS; NHLBI ARDS Network. Latent class analysis of ARDS subphenotypes: a secondary analysis of the statins for acutely injured lungs from sepsis (SAILS) study. Intensive Care Med. 2018 Nov;44(11):1859-1869. doi: 10.1007/s00134-018-5378-3. Epub 2018 Oct 5. — View Citation

Taneja I, Reddy B, Damhorst G, Dave Zhao S, Hassan U, Price Z, Jensen T, Ghonge T, Patel M, Wachspress S, Winter J, Rappleye M, Smith G, Healey R, Ajmal M, Khan M, Patel J, Rawal H, Sarwar R, Soni S, Anwaruddin S, Davis B, Kumar J, White K, Bashir R, Zhu R. Combining Biomarkers with EMR Data to Identify Patients in Different Phases of Sepsis. Sci Rep. 2017 Sep 7;7(1):10800. doi: 10.1038/s41598-017-09766-1. Erratum In: Sci Rep. 2019 Nov 19;9(1):17419. — View Citation

Weiss SL, Fitzgerald JC, Balamuth F, Alpern ER, Lavelle J, Chilutti M, Grundmeier R, Nadkarni VM, Thomas NJ. Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis. Crit Care Med. 2014 Nov;42(11):2409-17. doi: 10.1097/CCM.0000000000000509. — View Citation

Weiss SL, Parker B, Bullock ME, Swartz S, Price C, Wainwright MS, Goodman DM. Defining pediatric sepsis by different criteria: discrepancies in populations and implications for clinical practice. Pediatr Crit Care Med. 2012 Jul;13(4):e219-26. doi: 10.1097/PCC.0b013e31823c98da. — View Citation

Wiersema R, Jukarainen S, Vaara ST, Poukkanen M, Lakkisto P, Wong H, Linder A, van der Horst ICC, Pettila V. Two subphenotypes of septic acute kidney injury are associated with different 90-day mortality and renal recovery. Crit Care. 2020 Apr 15;24(1):150. doi: 10.1186/s13054-020-02866-x. — View Citation

Williams JB, Ghosh D, Wetzel RC. Applying Machine Learning to Pediatric Critical Care Data. Pediatr Crit Care Med. 2018 Jul;19(7):599-608. doi: 10.1097/PCC.0000000000001567. — View Citation

Wong A, Otles E, Donnelly JP, Krumm A, McCullough J, DeTroyer-Cooley O, Pestrue J, Phillips M, Konye J, Penoza C, Ghous M, Singh K. External Validation of a Widely Implemented Proprietary Sepsis Prediction Model in Hospitalized Patients. JAMA Intern Med. 2021 Aug 1;181(8):1065-1070. doi: 10.1001/jamainternmed.2021.2626. Erratum In: JAMA Intern Med. 2021 Aug 1;181(8):1144. — View Citation

Wong HR, Caldwell JT, Cvijanovich NZ, Weiss SL, Fitzgerald JC, Bigham MT, Jain PN, Schwarz A, Lutfi R, Nowak J, Allen GL, Thomas NJ, Grunwell JR, Baines T, Quasney M, Haileselassie B, Lindsell CJ. Prospective clinical testing and experimental validation of the Pediatric Sepsis Biomarker Risk Model. Sci Transl Med. 2019 Nov 13;11(518):eaax9000. doi: 10.1126/scitranslmed.aax9000. — View Citation

Wong HR, Salisbury S, Xiao Q, Cvijanovich NZ, Hall M, Allen GL, Thomas NJ, Freishtat RJ, Anas N, Meyer K, Checchia PA, Lin R, Shanley TP, Bigham MT, Sen A, Nowak J, Quasney M, Henricksen JW, Chopra A, Banschbach S, Beckman E, Harmon K, Lahni P, Lindsell CJ. The pediatric sepsis biomarker risk model. Crit Care. 2012 Oct 1;16(5):R174. doi: 10.1186/cc11652. — View Citation

Yamagata Y, Kozaki K, Imai T, Ohe K, Mizoguchi R. An ontological modeling approach for abnormal states and its application in the medical domain. J Biomed Semantics. 2014 May 21;5:23. doi: 10.1186/2041-1480-5-23. eCollection 2014. — View Citation

* Note: There are 42 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Effective Expert System-based Pediatric Sepsis Screening Tool (PSCT)	Over a usability test period, by emulation of the logic of experts in a screening tool that cam be continuously improved with experience, achieve a high level of ED workflow usability towards improved early recognition of IPSO sepsis, as perceived by practicing ED clinicians engaged in usability testing.	Final 3 months of study period.
Primary	High performance Expert System-based Pediatric Sepsis Screening Tool (PSCT)	To derive a high performing (e.g., sensitivity/specificity > 90%, PPV > 40%) PSCT to identify patients in the ED meeting IPSO sepsis criteria using early encounter data (e.g. upon receipt of biomarker data within 1st 1-3 hours of presentation).	Using "early data" following presentation to ED, e.g., upon receipt of biomarker data within 1st 3 hours of presentation)
Secondary	Effective sepsis phenotyping for personalized treatment	To show that combined PERSEVERE biomarker and EHR data as clustering features (e.g. using latent class analysis) enhances the detection of clinically useful prognostic phenotypes.	Features based on 1st 6 hours following presentation in patients diagnosed with sepsis and treatment protocol initiated.

External Links

•   "Expert Systems in the World of Medicine - Think Big".
•   "Introduction to Classification & Regression Trees (CART) - Data Science Central."
•   "OMOP Common Data Model - OHDSI."
•   "Plan-Do-Study-Act (PDSA) Worksheet | IHI - Institute for Healthcare Improvement."