Change Package

Guidance for special populations

When implementing the pediatric sepsis bundle, unique populations require specialized strategies. This guidance is intended to assist in program development and does not replace the real-time guidance of population experts. Please continue to consult your local pediatric specialists for these populations during care of high-risk patients.

Hematology and oncology

Special considerations	Strategies
Patients in the hematology/oncology and bone marrow transplant (BMT) populations may be at higher risk of sepsis development due to: Immunocompromise at baseline or due to medications. Central line presence. Decreased splenic function (either due to splenectomy, radiation, or dysfunction).	Incorporate strategies to identify these patients as high-risk early. For example, flag it in the EHR and include it in sepsis screen/huddle process. Discharge teaching for families should include signs and symptoms of sepsis and instructions for when to bring child back to the hospital. Antibiotics should be tailored to the patient population’s unique risk for bacteremia events due to underlying immunocompromise, prior infection, and local antibiogram.
Optimal timing and type of first antibiotic for febrile neutropenic patients is still being evaluated (De Castro et al, 2024; Hausler et al, 2024).	Develop and maintain a relationship with pediatric hematology/oncology and infectious disease experts to ensure adherence to latest guidelines for this population.
Vital sign abnormalities in this population may be due to underlying pathophysiology such as: Tachycardia due to anemia Fever and hypotension due to cytokine release syndrome	Begin with a broad differential; continue to consider sepsis in a differential diagnosis and focus on developing screening tools to allow treatment of multiple potential etiologies. The screening of hematology/oncology patients may involve different vital sign or lab triggers than other care settings.

Critical care

Special considerations	Strategies
Pediatric critical care patients are more commonly fluid overloaded prior to onset of initial or repeat sepsis.	In some cases, low-volume boluses and/or vasoactive medications only may be indicated. Consider chart review to determine reasons for deviations from bundle.
Pediatric critical care patients often have abnormal vital signs even when not septic.	Begin with a broad differential; continue to consider sepsis in a differential diagnosis and focus on developing screening tools to allow treatment of multiple potential etiologies. Screening critical care patients may involve different vital sign or lab triggers than other care settings. Recognition is more difficult in this population but is key in contributing to lowering mortality.
Many pediatric critical care environments respond to their own emergencies rather than hospital-wide emergency response teams (e.g. medical emergency team, rapid response team, etc).	Sepsis huddles in the ICU may involve a smaller response team with some combination of these roles: charge nurse, bedside nurse, resident/fellow/attending.
Congenital cardiac disease patients have: Unique physiology which can make sepsis recognition challenging and change treatment guidance Increased risk factors for sepsis (e.g. indwelling lines and hardware)	Consider second-tier screening tools that incorporate patient-specific physiology and risk factors. Include pediatric cardiac experts in the development of sepsis recognition tools and treatment pathways.
Many pediatric critical care patients are technology-dependent at baseline.	See additional special populations for strategies for technology-dependent patients.

Caring for children in systems serving adult and pediatric populations

The following strategies are intended for teams caring for children outside of free-standing children’s hospitals and may include general, community, and rural hospitals and children’s hospitals within health systems.

Special considerations	Strategies
Adult-focused protocols will require adaptations for children.	Adult recognition and treatment protocols for older teens may be acceptable; however, children will need tailored protocols: Adult sepsis screens do not perform as well in children. Consider running EHR-based screening tools silently and optimizing before “go-live” or utilizing a pediatric-specific screen. Pediatric-specific screening protocols will require age-based vital sign parameters and different lab reference ranges. Establish and maintain a process for training front-line staff on pediatric-specific protocols. Specialized training should include: Pediatric medication dose calculations Location and use of pediatric resources and references
Appropriately sized pediatric equipment for all weights is essential to providing high-quality sepsis care.	Ensure appropriately sized pediatric equipment is available: IV start kits Blood pressure cuffs Airway supplies IO supplies Establish and maintain a process for training front-line staff on use of pediatric equipment. Have the highest-skilled staff insert IVs (e.g. charge nurse, NICU team, CRNA, anesthesiologist). If unable to obtain pediatric equipment, ensure protocols are modified for implementation with available equipment.
Leverage partnerships with adult sepsis teams.	Align common sepsis metrics as able. This may include time-to-antibiotics, time-to-fluids, lactate, and more. Collaborate on additional common elements of sepsis data tracking, including commitments to data accuracy, scrutiny of workflows, and reporting. Consider building on existing adult-focused structures by adding pediatric-specific expertise (e.g., vitals norms, lab norms, bundle specifics, pediatric equipment considerations).
Sepsis reporting systems are different for pediatric care than for adult care. While SEP-1 reporting requirements exist for adults, there is no current national mandated reporting for pediatric sepsis.	Align pediatric sepsis improvement work with established adult SEP-1 reporting systems. Assess and adhere to any applicable state-mandated reporting requirements for pediatric sepsis. Consider participating in pediatric-specific benchmarking through national efforts such as Children’s Hospital Association’s Sepsis Data Tracking. Track data locally to evaluate the impact of process metric improvements on mortality and quality outcomes. Harness existing cultures of high-quality care.

Transport

Special considerations	Strategies
Pediatric sepsis recognition is different than adult sepsis recognition.	Adopt a pediatric-specific sepsis scoring tool to use during transport. Align the tool with existing screens to facilitate clear communication of patient status. This can be on paper first until it can be integrated into the transport team’s charting system.
Pediatric patient IV access may be more challenging to obtain.	Ensure stable IV access prior to transport: Have the highest-skilled staff insert IVs (i.e. charge nurse, CRNA, anesthesiologist). Consider using tools to assist with IV access such as a vein viewer or ultrasound. Identify a clear threshold for IO placement after a certain number of unsuccessful IV attempts or a certain amount of time.
If onset of sepsis occurs prior to hospital arrival, recognition and care initiation in transport will improve the timeliness of interventions.	Implement a transport sepsis protocol that aligns with the hospital sepsis protocol. However, it must account for supply and personnel differences and importance of collaboration with medical control. Transport sepsis protocols may include the following: Notify medical control of patient’s positive sepsis score Place on cardiac monitor Place on oxygen Obtain blood gas, lactate, blood glucose, and blood cultures Establish IV access Administer fluid bolus Administer antibiotics

Additional special populations

Special considerations	Strategies
Neonates (newborn infants under 28 days old)	Any fever >100.4 degrees Fahrenheit in this population requires a full or partial sepsis workup (Pantell et al, 2021). The IPSO bundle was not designed for neonates.
Nonverbal children	Be especially attentive to those with abnormal vital signs and use a lower threshold for lab workups. Partner with parents and guardians to understand child’s baseline mental status and patient-specific cues.
Unvaccinated or partially vaccinated children	Include high-risk conditions in the calculation for sepsis trigger tools. Consider broader empiric antibiotic coverage.
Technology-dependent children	Indwelling devices place patients at higher risk of infection. Include high-risk conditions in the calculation for sepsis trigger tools. Children with medical complexity can have abnormal baseline vital signs which confounds positive sepsis screens. Use percent changes vs. absolute vital sign values for inpatients. Establish clear, individualized vital sign parameters when indicated. When choosing empiric antibiotic coverage: Evaluate for history of prior infections, including MDROs, and adjust empiric coverage accordingly. Consider common device-related infections based on site of indwelling device.
Pediatric patients from long-term care facilities	See “technology-dependent children” above. Communication with both the family and the facility are vital to ensuring continuity of care: Admission – Review the sequence of events, treatments provided, and patient-specific information with facility caregivers and patients/families. During hospitalization – Provide regular status updates to family and facility. Discharge – Ensure complete documentation of care provided and anticipatory guidance.

For citations, see our references page. This change package was created in March 2025 by Children’s Hospital Association quality improvement consultants and Improving Pediatric Sepsis Outcomes thought leaders and reflects best evidence to date at the time of publication. Pediatric sepsis evidence is always evolving, and readers should make every effort to ensure incorporation of the latest best evidence during implementation of sepsis improvement projects.