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Licensed Unlicensed Requires Authentication Published by De Gruyter March 19, 2020

An estimate of missed pediatric sepsis in the emergency department

Christina L. Cifra, Erik Westlund, Patrick Ten Eyck, Marcia M. Ward, Nicholas M. Mohr and David A. Katz
From the journal Diagnosis



Timely diagnosis of pediatric sepsis remains elusive. We estimated the risk of potentially missed pediatric sepsis in US emergency departments (EDs) and determined factors associated with its occurrence.


In a retrospective study of linked inpatient and ED records from four states using administrative data (excluding 40% with missing identifiers), we identified children admitted with severe sepsis and/or septic shock who had at least one ED treat-and-release visit in the 7 days prior to sepsis admission. An expert panel rated the likelihood of each ED visit being related to subsequent sepsis admission. We used multivariable regression to identify associations with potentially missed sepsis.


Of 1945 patients admitted with severe sepsis/septic shock, 158 [8.1%; 95% confidence interval (CI), 6.9%–9.4%] had potentially missed sepsis during an antecedent treat-and-release ED visit. The odds of potentially missed sepsis were lower for each additional comorbid chronic condition [odds ratio (OR), 0.86; 95% CI, 0.80–0.92] and higher in California (OR, 2.26; 95% CI, 1.34–3.82), Florida (OR, 3.33; 95% CI, 1.95–5.70), and Massachusetts (OR, 2.87; 95% CI, 1.35–6.09), compared to New York.


Administrative data can be used to screen large populations for potentially missed sepsis and identify cases that warrant detailed record review.

Corresponding author: Christina L. Cifra, MD, MS, Clinical Associate Professor, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 8600-M JCP, Iowa City, IA 52242, USA, Phone:  +(319)-384-8659


The authors thank the University of Iowa Institute for Clinical and Translational Science Bioinformatics Core (Heather Davis, James Schappet, and Nicholas Smith) for their assistance in downloading, preparing, and organizing data for this study. The authors also thank the members of their expert panel, Dr. Susan Feigelman, Dr. Charles Jennissen, and Dr. Veerajalandhar Allareddy, for lending their time and expertise. Finally, they thank Dr. David Newman-Toker for his valuable input into the overall design of this study.

  1. Author contributions: CLC conceptualized and designed the study; acquired the databases used, collected, organized, analyzed, and interpreted the data; drafted the initial manuscript; and reviewed and revised the manuscript. EW and PTE contributed to the conception and design of the study; organized, analyzed, and interpreted the data; and reviewed the manuscript. MMW, NMM, and DAK contributed to the conception and design of the study, supervised data collection and organization, interpreted the data, and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

  2. Research funding: All phases of this study were supported by the Children’s Miracle Network-University of Iowa Department of Pediatrics Research Grant. Support for informatics and statistical analysis was provided through a National Institutes of Health (NIH) Clinical and Translational Science Award Funder Id:, #UL1TR002537. Additionally, CLC is supported by an NIH Institutional K12 Funder Id:, grant #HD027748, and NMM is supported by an Agency for Healthcare Research and Quality K08 grant #HS025753, Funder Id: The content of this work is solely the responsibility of the authors and does not necessarily represent the official views of these funding agencies.

  3. Employment or leadership: None declared.

  4. Honorarium: None declared.

  5. Competing interests: None declared.

  6. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

  7. Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.


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Supplementary Material

The online version of this article offers supplementary material (

Received: 2020-02-07
Accepted: 2020-02-19
Published Online: 2020-03-19
Published in Print: 2021-05-26

©2020 Walter de Gruyter GmbH, Berlin/Boston

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