International Consensus Criteria for Pediatric Sepsis and Septic Shock.

Importance: Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children. Objective: To update and evaluate criteria for sepsis and septic shock in children. Evidence Review: The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria. Findings: Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4-respiratory, cardiovascular, coagulation, and/or neurological-organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively. Conclusions and Relevance: The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.

Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock.

Importance: The Society of Critical Care Medicine Pediatric Sepsis Definition Task Force sought to develop and validate new clinical criteria for pediatric sepsis and septic shock using measures of organ dysfunction through a data-driven approach. Objective: To derive and validate novel criteria for pediatric sepsis and septic shock across differently resourced settings. Design, Setting, and Participants: Multicenter, international, retrospective cohort study in 10 health systems in the US, Colombia, Bangladesh, China, and Kenya, 3 of which were used as external validation sites. Data were collected from emergency and inpatient encounters for children (aged <18 years) from 2010 to 2019: 3 049 699 in the development (including derivation and internal validation) set and 581 317 in the external validation set. Exposure: Stacked regression models to predict mortality in children with suspected infection were derived and validated using the best-performing organ dysfunction subscores from 8 existing scores. The final model was then translated into an integer-based score used to establish binary criteria for sepsis and septic shock. Main Outcomes and Measures: The primary outcome for all analyses was in-hospital mortality. Model- and integer-based score performance measures included the area under the precision recall curve (AUPRC; primary) and area under the receiver operating characteristic curve (AUROC; secondary). For binary criteria, primary performance measures were positive predictive value and sensitivity. Results: Among the 172 984 children with suspected infection in the first 24 hours (development set; 1.2% mortality), a 4-organ-system model performed best. The integer version of that model, the Phoenix Sepsis Score, had AUPRCs of 0.23 to 0.38 (95% CI range, 0.20-0.39) and AUROCs of 0.71 to 0.92 (95% CI range, 0.70-0.92) to predict mortality in the validation sets. Using a Phoenix Sepsis Score of 2 points or higher in children with suspected infection as criteria for sepsis and sepsis plus 1 or more cardiovascular point as criteria for septic shock resulted in a higher positive predictive value and higher or similar sensitivity compared with the 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria across differently resourced settings. Conclusions and Relevance: The novel Phoenix sepsis criteria, which were derived and validated using data from higher- and lower-resource settings, had improved performance for the diagnosis of pediatric sepsis and septic shock compared with the existing IPSCC criteria.

Hospital at Home: A New Model of Home Care in Brazil / Hospitalización a domicilio: un nuevo modelo de atención domiciliaria en Brasil

Introducción: Home Care (HC) es directamente responsable por la reducción de la demanda de camas hospitalarias en Brasil. El modelo brasileño de hospitalización domiciliaria en el sector privado se basó en la atención continua de enfermería durante los últimos 30 años sin revisión adicional. Objetivos: Descubrir si el modelo brasileño de hospitalización domiciliaria se alinea con los diferentes modelos HC vigen-tes en todo el mundo, analizar sus limitaciones y desafíos y proponer un nuevo modelo rentable de atención domiciliaria en Brasil llamado Hospital at Home (HaH). Método: Revisión de artículos publicados en bases de datos, actas de congresos, guías de práctica clínica y regulaciones guberna-mentales entre 2006-2022. Se analizaron 920 pacientes atendidos en la modalidad de Hospitalización Domiciliaria por una empresa privada de HC en Brasil en noviembre de 2022. Resultados: Los modelos de HC europeos y norteamericanos no se basan en cuidados de enfermería continuos. Si analizó la elegibilidad de 920 pacientes atendidos en la modalidad de Hospitalización Domiciliaria por una empresa privada de HC en Brasil en noviembre de 2022 para inclusión en el nuevo modelo HaH, propuesto con 10 pilares basados en evidencia donde un equipo multidisciplinario es ayudado por enfoque de participación del socio de atención y una estrategia de gestión clínica basada en análisis de datos apoyados en recursos digitales de salud. Conclusiones: Creemos que el modelo HaH remodelará la hospitalización domiciliaria en Brasil, establecerá las bases para la atención domiciliaria basada en el valor y contribuirá a la sostenibilidad de la HC brasileña. (AU)

Introduction: Home Care (HC) is directly responsible for reducing the demand for hospital beds in Brazil. Brazilian Home Hospitalization model in the private sector was built on continuous nursing care for the last 30-years without further review. Objectives: Find if Brazilian Home Hospitalization model aligns with the different HC models in effect around the world, evaluate its limitations and challenges and propose a new cost-effective model of domiciliary care in Brazil called Hospital at Home (HaH). Method: Review of articles published in data bases, conference proceedings, clinical practice guidelines, and government regulations between 2006-2022. 920 patients receiving care in the Home Hospitalization modality by a private HC company in Brazil were analyzed in November 2022. Results: European and North American HC models are not built on continuous nursing care. 920 patients receiving care in the Home Hospitalization modality by a private HC company in Brazil had their eligibility assessed in November 2022 to be included in the new HaH model, proposed with 10 evidence-based pillars where a multidisciplinary team is aided by a care partner engagement approach and a clinical management strategy based on data analysis supported by digital health resources. Conclusions: We believe the HaH model will reshape home hospitalization in Brazil, set up the groundwork for value-based Home Care and contribute to the sustainability of Brazilian HC. (AU)

Operationalizing Appropriate Sepsis Definitions in Children Worldwide: Considerations for the Pediatric Sepsis Definition Taskforce.

Sepsis is a leading cause of global mortality in children, yet definitions for pediatric sepsis are outdated and lack global applicability and validity. In adults, the Sepsis-3 Definition Taskforce queried databases from high-income countries to develop and validate the criteria. The merit of this definition has been widely acknowledged; however, important considerations about less-resourced and more diverse settings pose challenges to its use globally. To improve applicability and relevance globally, the Pediatric Sepsis Definition Taskforce sought to develop a conceptual framework and rationale of the critical aspects and context-specific factors that must be considered for the optimal operationalization of future pediatric sepsis definitions. It is important to address challenges in developing a set of pediatric sepsis criteria which capture manifestations of illnesses with vastly different etiologies and underlying mechanisms. Ideal criteria need to be unambiguous, and capable of adapting to the different contexts in which children with suspected infections are present around the globe. Additionally, criteria need to facilitate early recognition and timely escalation of treatment to prevent progression and limit life-threatening organ dysfunction. To address these challenges, locally adaptable solutions are required, which permit individualized care based on available resources and the pretest probability of sepsis. This should facilitate affordable diagnostics which support risk stratification and prediction of likely treatment responses, and solutions for locally relevant outcome measures. For this purpose, global collaborative databases need to be established, using minimum variable datasets from routinely collected data. In summary, a "Think globally, act locally" approach is required.