<p>Sepsis, defined as an infection with dysregulated host response leading to life-threatening organ dysfunction, continues to carry a high potential for morbidity and mortality in children. The recognition of sepsis in children in the emergency department (ED) can be challenging, related to the high prevalence of common febrile infections, poor specificity of discriminating features, and the capacity of children to compensate until advanced stages of shock. Sepsis outcomes are strongly dependent on the timeliness of recognition and treatment, which has led to the successful implementation of quality improvement programs, increasing the reliability of sepsis treatment in many US institutions. We review clinical, laboratory, and technical modalities that can be incorporated into ED practice to facilitate the recognition, treatment, and reassessment of children with suspected sepsis. The 2020 updated pediatric sepsis guidelines are reviewed and framed in the context of ED interventions, including guidelines for antibiotic administration, fluid resuscitation, and the use of vasoactive agents. Despite a large body of literature on pediatric sepsis epidemiology in recent years, the evidence base for treatment and management components remains limited, implying an urgent need for large trials in this field. In conclusion, although the burden and impact of pediatric sepsis remains substantial, progress in our understanding of the disease and its management have led to revised guidelines and the available data emphasizes the importance of local quality improvement programs.</p>

<p><strong>OBJECTIVE: </strong>To characterize the cohort of missed sepsis patients since implementation of an electronic sepsis alert in a pediatric emergency department (ED).</p>

<p><strong>METHODS: </strong>Retrospective cohort study in a tertiary care children's hospital ED from July 1, 2014, to June 30, 2017. Missed patients met international consensus criteria for severe sepsis requiring intensive care unit admission within 24 hours of ED stay but were not treated with the sepsis pathway/order set in the ED. We evaluated characteristics of missed patients compared with sepsis pathway patients including alert positivity, prior intensive care unit admission, and laboratory testing via medical record review. Outcomes included timeliness of antibiotic therapy and need for vasoactive medications.</p>

<p><strong>RESULTS: </strong>There were 919 sepsis pathway patients and 53 (5%) missed patients during the study period. Of the missed patients, 41 (77%) had vital signs that flagged the sepsis alert. Of these 41 patients, 13 (32%) had a documented sepsis huddle where the team determined that the sepsis pathway was not indicated and 28 (68%) had no sepsis alert-related documentation. Missed patients were less likely to receive timely antibiotics (relative risk, 0.4; 95% confidence interval, 0.3-0.7) and more likely to require vasoactive medications (relative risk, 4.3; 95% confidence interval, 2.9-6.5) compared with sepsis patients.</p>

<p><strong>CONCLUSIONS: </strong>In an ED with an electronic sepsis alert, missed patients often had positive sepsis alerts but were not treated for sepsis. Missed patients were more likely than sepsis pathway patients to require escalation of care after admission and less likely to receive timely antibiotics.</p>