698 - Assessing the Impact of Bundle Compliance on Outcomes in Pediatric Phoenix Sepsis

Publication Number: 3675.698

Chelsey Mitchell, Columbia University Vagelos College of Physicians and Surgeons, Scarsdale, NY, United States; Benjamin L. Ranard, Columbia University, New York, NY, United States; Gregory Hruby, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, United States; Katherine Ryan, Boston Children's Hospital, Boston, MA, United States; Jason Adelman, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Halden F. Scott, University of Colorado School of Medicine, Denver, CO, United States

Background: Sepsis causes significant pediatric morbidity and mortality. Early resuscitation and treatment bundles are recommended, but the impact of a modified 3-hour pediatric sepsis bundle in Phoenix-defined sepsis has not yet been well described. We evaluated the association between bundle concordance and clinical outcomes in children with Phoenix-defined sepsis.

Objective: To determine whether concordance with a modified 3-hour sepsis bundle is associated with improved hospital-free days and in-hospital mortality among pediatric patients with Phoenix-defined sepsis.

Design/Methods: We retrospectively studied 485 pediatric patients ( < 18 years and > 30 days) who presented to the emergency department with Phoenix-defined sepsis or septic shock between February 2020 and May 2025. Bundle concordance was defined as antibiotics within 3 hours and fluid administration within 1 hour of sepsis recognition. Primary outcomes were hospital-free days at 30 and 90 days (HFD-30, HFD-90) and in-hospital mortality. Patients who died were assigned 0 HFD. Multivariable regression models adjusted for age, comorbid conditions, illness severity (Phoenix sepsis score), and site characteristics.

Results: Bundle concordance occurred in 47.4% of patients with variable concordance between sites. Mean HFD-30 did not differ significantly between concordant and non-concordant groups, and bundle concordance was not associated with HFD-30 or HFD-90 in adjusted models (β ~0.7-0.9, p>0.28). In-hospital mortality was 5.2% overall and did not differ significantly by concordance (adjusted OR ~0.60, p>0.22). Higher Phoenix sepsis severity scores were strongly associated with fewer hospital-free days (β ≈ −1.7, p< 0.001) and increased mortality (aOR ≈ 1.44, p< 0.001).

Conclusion(s): Bundle concordance was not independently associated with improved hospital-free days or in-hospital mortality. Illness severity at presentation was the strongest predictor of outcomes. Larger, multi-site studies are needed to evaluate whether current bundled care elements are best goals for improving sepsis outcomes in the Phoenix sepsis population.

Distribution of 30-Day Hospital-Free Days by Concordance Status
*CCC= Complex Chronic Conditions
Box-and-whisker plots comparing the distribution of HFD-30 between bundle-concordant and non-concordant patients demonstrate similar medians and interquartile ranges across groups. Both groups display floor effects at zero due to mortality/hospice cases.

Hospital-Free Days (30-Day) by Bundle Concordance
*CCC= Complex Chronic Conditions
Hospital-free days (HFD-30) were analyzed with patients who died (and separately, those discharged to hospice) assigned a value of zero days. Median HFD-30 did not differ significantly between bundle-concordant and non-concordant groups in either definition.

Association of Bundle Concordance With Mortality Outcomes
*CCC= Complex Chronic Conditions
Adjusted logistic regression models examining the relationship between the modified three-hour sepsis bundle concordance and outcomes. Models controlled for age, number of chronic complex conditions (CCC), and Phoenix Sepsis Score. Bundle concordance was not significantly associated with either in-hospital mortality or the combined outcome of mortality or hospice discharge, while higher Phoenix Sepsis Scores were consistently associated with increased odds of adverse outcomes.