Improving Pediatric Sepsis Outcomes

Improving Pediatric Sepsis Outcomes

Change Package

Optimal bundle of care

Leveraging existing evidence, guidelines, and expert opinion, the IPSO collaborative developed five key processes associated with improved outcomes for children with sepsis (Paul et al, 2023).

The first three processes—sepsis screen, huddle, and order set—relate to the timely and appropriate recognition of pediatric sepsis. The final two processes—fluid bolus and antibiotic administration—relate to the timely and appropriate treatment of sepsis.

Compliance with each key process is recommended and in line with the Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children (Weiss et al, 2020b).

All-or-none bundle compliance

Evidence from the IPSO collaborative demonstrated that performing these interventions together, as a bundle of care, resulted in lower sepsis-attributable mortality (Figure 1). IPSO evaluated this bundle of care with thresholds for time to fluid bolus and antibiotic administration, finding that adherence to moderate threshold goals (Table 1) resulted in the best outcomes for patients when performed as part of the bundle (Paul et al, 2023). 

Figure 1
Association between sepsis-attributable mortality and bundle compliance

Exceeding IPSO’s maximum time thresholds for therapeutic interventions is associated with worse outcomes. If a hospital exceeds a threshold or doesn’t comply with the whole bundle, IPSO recommends a review within safety event reporting structures.

Key Process Threshold
Recognition
Positive screen, positive huddle, or order set utilization
Fluid bolus
Within 60 minutes of sepsis onset*
Antibiotic administration
Within 180 minutes of sepsis onset*

Individual key process targets

The recommended thresholds reflect the minimum requirements for bundle compliance. However, hospitals should establish more stringent targets for each process to optimize recognition and ensure treatment times are in accordance with national guidelines (Weiss et al, 2020b). For more guidance on establishing stringent individual key process targets, see Individual Key Process Targets and Individual Targets vs. Bundle Compliance Thresholds.


Key process recommendations

The following sections describe IPSO recommendations for each key process of the bundle, including implementation guidance, common barriers and mitigation strategies, and resources.

Recognition

Using one or more of the sepsis recognition processes is independently associated with lower sepsis-attributable mortality, fewer hospital days, and fewer intensive care unit (ICU) days (Paul et al, 2023). In addition, standardizing recognition processes reduces disparities in sepsis recognition (Rutman et al, 2024; Diversity Kids Data, 2024).

Sepsis recognition processes include:

  • Screen: Early identification using systematic tools
  • Huddle: Just-in-time, team-based discussion on patient status
  • Order Set: Standardized treatment orders to facilitate timely interventions

For examples of comprehensive recognition processes, see Recognition.

Sepsis screen

International guidelines recommend systematic screening to detect sepsis early and improve the timeliness of interventions. Multiple strategies using the electronic health record (EHR) or a paper screen have been published in the literature.

IPSO recommendation

Implement a screening tool adapted for a specific care setting.

Implementation guidance
  • Start with a paper screen if clinical informatics resources are limited.
  • Two-tiered screens may improve specificity. For example, tier one is based on vital signs while tier two includes additional indicators such as the presence of high-risk conditions, altered mental status, or poor perfusion.
  • Thresholds for a “positive screen” may vary and should be determined locally.
  • Vital sign measures can include temperature, heart rate, respiratory rate, and blood pressure parameters as delineated by Pediatric Advanced Life Support (PALS) or other standard references. To improve specificity, consider temperature-adjusted heart rate.
  • Vital-sign-based screens are often oversensitive, so specificity and sensitivity must be analyzed.
  • Screens used later in the clinical course can incorporate laboratory values indicative of organ dysfunction.
  • Screens used to detect sepsis can also detect other critical conditions. Consider integrating sepsis screening with other organizational escalation-of-care protocols.
  • Screen performance can vary by care setting due to complexity of patient population; consider customization before spreading to new care areas.
  • Follow positive screens with a bedside clinician huddle.
Strategies for common barriers
Alert fatigue
  • Trial screens in the background (without clinician alerts) to optimize sensitivity and specificity before “go-live.”
  • Once live, continuously evaluate the balance of positive predictive value (PPV) and sensitivity of screens.
  • Adapt lockout times based on care settings. For example, longer lockout times may be needed in intensive care areas and for chronically ill children.
  • Monitor alert fatigue as a balancing measure and consider adapting screening criteria, frequency, or lock out intervals to optimize specificity.
Anchoring bias
  • Ensure standardized approach to screening.
Staff buy-in

Currently, no screens detect sepsis with 100% sensitivity and specificity. In fact, in a survey of IPSO hospitals who measured screen performance, sensitivities ranged from 3-92% and specificities ranged from 44-100%. No individual screen had over 90% sensitivity and specificity. Because screens are not always accurate, staff may not buy into the screening process.

Strategies to overcome this include:

  • View screens as a supplement to clinical judgement, not a replacement; set expectations across the organization accordingly.
  • Empower bedside nurses to initiate huddles based on clinical judgement.
Information technology (IT) resources
  • Include IT early in the process as a key stakeholder.
  • Consider starting with a paper screening tool and performing small tests of change to optimize the screen before embedding it in the EHR.
  • Establish procedures for evaluating the impact of IT updates on sepsis EHR workflows.
Library of tools
Resources

Sepsis huddle

Huddles are just-in-time, team-based discussions about a patient’s clinical condition and next steps. Huddles can improve sepsis recognition and raise situational awareness, ensuring the team has a shared mental model and a coordinated plan of care. Huddles can be useful when potential sepsis is recognized and when there are concerns for clinical deterioration or unexpected responses to treatment. Huddles can be called at any time by any care team member.

IPSO recommendation

When potential sepsis is identified, or if there is concern about continued deterioration from sepsis at any point, conduct a huddle to review the clinical findings, determine if sepsis is evolving, and plan next steps in care.

Some triggers for huddles include:

  • Positive sepsis screens
  • High early warning score
  • Clinician concern
  • Deterioration from sepsis at any point

A positive sepsis huddle should prompt a sepsis order set, pathway, or a clear action plan for further diagnostic testing and sepsis treatment.

Implementation guidance
  • Complete the huddle within 15 minutes of a trigger.
  • Keep the huddle brief and focused.
  • Include a nurse, provider, and additional staff as needed. Establish processes for including an attending physician or other experienced clinician.
  • Conduct a structured clinical assessment during the huddle if not already completed as part of a sepsis screen. Include an assessment of mental status, perfusion, high-risk conditions, and parental impression of severity of illness.
  • Use standard tools to communicate huddle findings and plan.
  • If the huddle indicates concern for sepsis, provisionally categorize the findings as possible sepsis and initiate a sepsis order set or other standardized ordering process.
  • The huddle drives interventions for sepsis and determines plans for monitoring patients at high risk for sepsis.
Strategies for common barriers
Staff capacity/competing priorities
  • Build on other local successful processes (e.g., watcher programs, rapid response teams, or other real-time huddles).
  • Thoughtfully include only necessary personnel.
  • Utilize virtual options.
  • Consider simulation.
Staff buy-in
  • Communicate wins, set expectations regarding huddle duration (they do not take long), and optimize huddle frequency (minimize interruptions of other vital work).
  • Provide positive feedback to staff members who call necessary huddles.
  • Incorporate huddle and sepsis processes into hospital-wide educational modules to ensure staff can recognize signs and symptoms of sepsis and understand the huddle purpose and process.
Psychological safety
  • Use standardized scripts or checklists to ensure all concerns are heard.
  • Empower staff of all disciplines to use their clinical judgement to identify huddle opportunities.
Unclear huddle outcomes
  • Pair huddles with processes to initiate order sets and facilitate timely interventions (e.g., have sepsis cart stocked with necessary supplies brought to huddle).
  • Use scripts, checklists, and/or clinical pathways to ensure important clinical aspects (e.g., mentation, perfusion) are reviewed and next-steps plan and escalation parameters are set (e.g., standardized communication or documentation tool that includes key steps).
Suboptimal huddle documentation
  • Use the EHR to document the huddle and include in data reports.
  • Ensure huddle documentation aligns with nursing workflow in each care area – this may require different processes in different care settings.
Library of tools
Resources

Sepsis order set

An order set is a pre-made, standardized list of provider orders that facilitate prompt and efficient ordering and administration of all necessary care for a specific condition or disease state.

Note: The IPSO collaborative considers order sets the final component of sepsis recognition because its use signifies an intention-to-treat sepsis that is communicated to the entire care team. While the order set is used after sepsis is recognized through a screen, huddle, or clinician judgement, it ultimately serves to support the timeliness and standardization of interventions. Though IPSO classifies order sets as a measure of recognition, order sets are ultimately a link between recognition and timely treatment.

IPSO recommendation
Use an evidence-based guideline to standardize evaluation and treatment orders for patients with suspected sepsis. Ensure the order set is built to support rapid workup and treatment (e.g., “STAT” for labs and antibiotics). Include priority orders:
  • Cultures (blood, urine, and additional cultures)
  • First fluid bolus
  • STAT antibiotic (with weight-based dosing recommendation)
Implementation guidance
  • Create a multidisciplinary team of key stakeholders (including EHR experts) from the beginning to develop a sepsis order set and periodically update as needed.
  • Use order sets as a tool to accompany a clinical pathway.
  • Design order sets to support bundle compliance and timely care delivery. Ensure alignment between the sepsis pathway and order set.
Make key decisions
  • Single order set vs. multiple options based on risk assessment
  • Inclusion vs. exclusion of specific orders for patients with high-risk conditions
  • Hospital-wide vs. care-setting specific order sets
  • Priority orders for “STAT” delivery (e.g., fluids, antibiotics)
Strategies for common barriers
Staff buy-in
  • Enlist key stakeholders in the development and review of an order set (e.g. physicians, nurses, pharmacists, laboratory specialists, respiratory therapists).
  • Before “go-live,” perform simulations with clinicians to assess opportunities for improvement.
  • Include physician trainees in order set development, testing, and education, as they use the order set most frequently.
Low utilization
  • Streamline EHR workflow to facilitate ease of use (e.g., link directly from a sepsis screen or huddle documentation).
  • Provide feedback on successful utilization and non-compliant episodes to demonstrate how order sets improve timely interventions.
Library of tools

Treatment

In conjunction with sepsis recognition, timely and appropriate treatment of sepsis improves outcomes (Paul et al, 2023).

Sepsis treatment processes include:

  • Fluid bolus administration
  • Antibiotic administration

For examples of comprehensive sepsis pathways, see Pathways.

Fluid bolus timeliness

Patients with sepsis, including septic shock, may have ineffective circulating intravascular volume and decreased organ perfusion. The cause is often multifactorial: Patients with sepsis may experience hypovolemia, vasodilation (distributive shock), and impaired cardiac function. Restoring intravascular volume is a core element of international sepsis guidelines (Weiss et al, 2020b). Though evidence for the exact amount of fluid to administer remains dynamic, the goal of intravenous (IV) fluid resuscitation is to restore normal perfusion and blood pressure.

IPSO recommendation
Within the first 60 minutes of recognition, administer up to 40-60 ml/kg in bolus fluid (10-20 ml/kg per bolus; maximum of 1 liter per bolus) by push-pull, pressure bag, or rapid infuser method.
  • For patients with significant cardiac or renal dysfunction, consider smaller bolus volumes (e.g., 5-10 milliliters per kilogram (mL/kg)).
After each bolus, reassess the patient’s clinical status and discuss with the team. The assessment should include:
  • Evaluate for clinical signs of fluid overload (rales, gallop rhythm, increased work of breathing, or increased oxygen need).
  • Evaluate for persistence of shock state and consider need for additional fluid bolus.
  • Consider point of care ultrasound to assess intravascular volume status and cardiac function for centers that utilize this modality (Singh et al, 2020).
Implementation guidance
  • Ensure enough fluids are stocked in each unit.
  • Develop sepsis pathways and order sets that:
    • Include establishing early intravenous access (IV) and intraosseous (IO) access if unable to obtain.
    • Emphasize rapid administration methods (e.g., rapid infuser, push-pull, pressure bag).
    • Guide appropriate fluid choices (balanced, lactated ringers vs. 0.9% saline).
    • Prompt regular reassessments to monitor for fluid overload and/or need for additional fluid boluses.
  • Develop a method to accurately document IV fluid start times (e.g., EHR, laminated tool, sepsis checklist).
Strategies for common barriers
Delay in IV access
  • Leverage individuals with the highest likelihood of peripheral IV success (e.g., trauma charge RN, IV team, transport team). 
  • Establish a standard escalation process for difficult IV access. 
  • Use existing central venous lines when present. 
  • Include IO access in the sepsis management pathway and identify a clear threshold for IO placement (e.g., number of unsuccessful peripheral IV attempts, maximum time elapsed). 
Staff awareness
  • Incorporate training into orientation and ongoing education for all stakeholders (e.g., nurses, physician trainees, additional disciplines).
  • Use multimedia educational campaigns to maintain awareness.
Bedside staff competing priorities
  • Develop a method to alert clinicians to target administration time (e.g., EHR timers, in-room timer “countdown,” laminated tool with target times displayed).
Staff buy-in
  • Provide education (e.g., didactic, simulation lab, interactive media) to overcome hesitancy to deliver IV fluid before a sepsis diagnosis can be confirmed.
  • Provide evidence-based guidance that supports resuscitation strategies.
  • Ensure pathways include specific conditions that prevent large-volume resuscitation
    (e.g., cardiac failure) and provide specific guidance for alternative management.
Library of tools
Resources

Antibiotic timeliness

Antibiotics are a key component of timely pediatric sepsis management and imperative to treating bacterial pathogens associated with sepsis. It is important to give parenteral antibiotics quickly, as they directly target bacteria causing infection. Studies have found that using a set of interventions that includes administration of parenteral antibiotics leads to improved outcomes (Lane et al, 2023).

IPSO recommendation

Initiate timely empiric antibiotics.

  • As soon as possible and within 1 hour of recognition of septic shock
  • Within 3 hours of recognition of sepsis without shock*

Provide appropriate empiric antibiotic therapy.

  • Empiric treatment should be broad spectrum with one or more antibiotics to cover all likely pathogens and should be guided by the suspected site of infection.

Provide source control if appropriate.

  • Consider surgical consult for source control if indicated (e.g., concern for foreign body, infected device, appendicitis, or infected joint/space).
  • Modify or stop immunosuppressive therapy if appropriate.
  • Narrow empiric antibiotic therapy as appropriate once the pathogen(s) and sensitivities are available.

*In some conditions, a more stringent time interval may apply. If a more stringent time interval is widely accepted, it should be followed.

Implementation guidance
  • Include pharmacy staff in developing antibiotic ordering, delivery, and administration procedures.
  • Develop sepsis pathways and order sets that:
    • Include establishing early IV and IO access if unable to obtain.
    • Emphasize rapid administration methods when appropriate (e.g., intramuscular antibiotic administration, appropriate antibiotics for IV push).
    • Provide prompt reassessment and ability to narrow therapy.
  • Develop a method to accurately document IV antibiotic start times (e.g., laminated tool, sepsis checklist).
  • Provide a guideline for empiric antibiotic choices that considers sites of infection, high-risk/immunocompromised patients, and patients with history of multidrug-resistant organisms (MDROs).
  • Consider local resistance rates and antibiotic availability.
Strategies for common barriers
Delay in IV access
  • Leverage individuals with the highest likelihood of IV success (e.g., trauma charge RN, IV team, transport team). 
  • Establish a standard escalation process for difficult IV access. 
  • Use existing central venous lines when present. 
  • Include intramuscular (IM) antibiotic administration and IO access in the sepsis management pathway, and identify a clear threshold for each (e.g., number of unsuccessful peripheral IV attempts, maximum time elapsed). 
Staff awareness
  • Incorporate training into orientation and ongoing education for all stakeholders, including nurses, physician trainees, and other relevant staff members.
  • Use multimedia educational campaigns to maintain awareness.
Bedside staff competing priorties
  • Develop a method to alert clinicians to target administration time (e.g., EHR timers, in-room timer “countdown,” laminated tool with target times displayed).
Staff buy-in
  • Provide education (e.g., didactic, simulation lab, interactive media) to overcome hesitancy to deliver IV antibiotics before a sepsis diagnosis can be confirmed.
  • Align sepsis antibiotic work with related quality improvement initiatives (e.g., antimicrobial stewardship, fever/neutropenia pathways).
Delays in antibiotic ordering/delivery
  • Encourage the use of the sepsis order set.
  • Provide empiric antibiotic therapy guidance and weight-based dosing recommendations.
  • Use Gemba walks (observe where the real work happens) and staff feedback to identify opportunities to improve timeliness (e.g., availability of medication within unit vs. pharmacy delivery, mixing medication challenges, tube system issues).
  • Consider local process differences (e.g., day vs. night shift staffing, unit-based proximity to pharmacy). Adjust process accordingly.
Library of tools
Resources
Download the Change Package

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.