National Estimates of Pediatric Sepsis in US Hospitals Using Clinical Data

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Importance: Pediatric sepsis causes substantial morbidity and mortality, but population surveillance relies on administrative codes with limited and variable accuracy. Objective: To estimate US national incidence, mortality, and trends of sepsis in nonneonatal children using a Pediatric Sepsis Event (PSE) definition adapted from the 2024 Phoenix criteria for scalable electronic health record (EHR)-based surveillance using routinely captured clinical data. Design, Setting, and Participants: Retrospective cohort study of 3.9 million hospitalizations (age, >30 days to 17 years) in 2 EHR datasets: Epic Cosmos (245 health care systems, 2016-2023) and HCA Healthcare (146 hospitals, 2018-2023). Secondary datasets were analyzed to assess feasibility of implementation and face validity across heterogeneous settings. The PSE was validated through medical record reviews of 581 high-risk encounters at 3 geographically diverse hospitals. Exposures: A PSE required presumed infection with concurrent organ dysfunction using Phoenix-derived thresholds adapted for routine EHR data. Septic shock was defined as a PSE with cardiovascular dysfunction. Main Outcomes and Measures: Sepsis incidence, characteristics, and in-hospital mortality were calculated. Sensitivity and specificity of PSE for physician-adjudicated Phoenix sepsis were compared with administrative codes for severe sepsis/septic shock. National sepsis case counts and deaths in 2022 and temporal trends from 2016 to 2022 were estimated using regression models. Results: Among 3 925 809 pediatric hospitalizations from 2016 to 2023, 51 542 sepsis cases (mean age, 6.6 [SD, 6.0] years; 22 840 [44.3%] female) were identified (1.3% incidence); 37 405 (72.6%) were community onset and 31 744 (61.6%) had septic shock. In-hospital mortality was 10.1% and sepsis was present in 17.8% of hospitalizations that culminated in death. Incidence, characteristics, and mortality were broadly consistent across secondary datasets. On medical record review, the PSE definition had 69.9% sensitivity (95% CI, 58.1%-79.8%) and 93.1% specificity (95% CI, 89.6%-95.7%), with higher sensitivity than and comparable specificity with administrative codes. National estimates for 2022 were 18 231 sepsis cases (95% CI, 16 129-20 334) and 1877 deaths(95% CI, 1629-2126). Neither sepsis cases nor deaths changed significantly from 2016 to 2022 (annual change, 0.2% [95% CI, -2.2% to 2.7%] and 0.3% [95% CI, -3.1% to 3.8%], respectively). Conclusions and Relevance: An EHR-based definition for pediatric sepsis demonstrated strong validity compared with physician-adjudicated Phoenix sepsis and identified sepsis in 1.3% of pediatric hospitalizations with 10% mortality, corresponding to more than 18 000 cases and more than 1800 deaths annually in the US.

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