Table 1.

Identified gaps and targets for potential countermeasures, grouped by themes.

Themes	Identified gaps
Educational deficits	Process in pediatric intensive care unit Medical Doctor/Nurse practitioners do not consistently attend bedside huddle Note not written after huddle completion No accountability/feedback on completion of the sepsis huddle protocol, including documentationKnowledge deficit Unaware of pediatric Surviving Sepsis Campaign 2020 No Clinical Practice Guideline or sepsis bundle Recognition of deteriorating patients by frontline providers Re-evaluation after sepsis diagnosis Unaware of Sepsis Order Set Not confident in diagnosis or sepsis or septic shock No pocket cards for reference
Technologic deficits	EMR-Health Information Technology Services related Patients not being identified appropriately by screen Primary screens trigger after sepsis and/or septic shock identified Already treating sepsis prior to screen trigger No mortality prediction (pSOFA) Functional time zero not part of the protocol, nor tracked Not all primary screens lead to secondary huddlea Alert responses do not correlate with options on screen used by bedside nursing (eg, no option for already treating sepsis or end of life care)aEMR user related RN activity link/override, opting out of completion of screening Respiratory therapy treatments triggering primary screen Number of primary screen fires too frequentlya Repeated pages to charge nursesDocumentation Severe Sepsis/Septic Shock not documented (ICD-10 codes) Bedside huddles are not identifying severe sepsis or septic shock Unable to determine actions at huddleData gathering No benchmark data Not tracking trigger number at which primary screen firesa Data across multiple spreadsheetsa
Patient safety considerations	Delay in care Length of time medications take to arrive at bedside Delayed interventions (eg, fluid bolus) Awaiting additional consulting service recommendations prior to treatment Frontline providers too busy to complete screens

^adenotes remaining gaps. pSOFA = pediatric sequential organ failure assessment. Functional time zero is defined by CHA IPSO as intent to treat sepsis.