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Paediatrics
Original research
Clinical decision support tools for paediatric sepsis in resource-poor settings: an international qualitative study
  1. Andrea Jimenez-Zambrano1,2,
  2. Carly Ritger2,
  3. Margaret Rebull3,
  4. Matthew O Wiens4,5,6,
  5. Olive Kabajaasi6,
  6. Juan Camilo Jaramillo-Bustamante7,
  7. Andrew C Argent8,9,
  8. Niranjan Kissoon10,11,
  9. Luregn J Schlapbach12,13,
  10. Lauren R Sorce14,15,
  11. R Scott Watson16,17,
  12. Brooke Dorsey Holliman2,18,
  13. Lazaro N Sanchez-Pinto14,15,
  14. Tellen D Bennett19
  1. 1Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
  2. 2Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado, USA
  3. 3Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, Colorado, USA
  4. 4Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
  5. 5Center for International Child Health, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
  6. 6Walimu, Kampala, Uganda
  7. 7Department of Pediatric Critical Care, Hospital General de Medellín Luz Castro de Gutiérrez E.S.E, Medellin, Colombia
  8. 8Paediatrics and Child Health, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
  9. 9Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Rondebosch, South Africa
  10. 10British Columbia Children's Hospital, Vancouver, British Columbia, Canada
  11. 11Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
  12. 12Department of Intensive Care and Neonatalogy, University Children's Hospital Zürich, Zurich, Switzerland
  13. 13Child Health Research Centre, The University of Queensland, Saint Lucia, Queensland, Australia
  14. 14Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
  15. 15Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  16. 16Seattle Children's Hospital, Seattle, Washington, USA
  17. 17Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
  18. 18Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
  19. 19Departments of Biomedical Informatics and Pediatrics (Critical Care Medicine), University of Colorado School of Medicine, Aurora, Colorado, USA
  1. Correspondence to Dr Tellen D Bennett; tell.bennett{at}cuanschutz.edu

Abstract

Objective New paediatric sepsis criteria are being developed by an international task force. However, it remains unknown what type of clinical decision support (CDS) tools will be most useful for dissemination of those criteria in resource-poor settings. We sought to design effective CDS tools by identifying the paediatric sepsis-related decisional needs of multidisciplinary clinicians and health system administrators in resource-poor settings.

Design Semistructured qualitative focus groups and interviews with 35 clinicians (8 nurses, 27 physicians) and 5 administrators at health systems that regularly provide care for children with sepsis, April–May 2022.

Setting Health systems in Africa, Asia and Latin America, where sepsis has a large impact on child health and healthcare resources may be limited.

Participants Participants had a mean age of 45 years, a mean of 15 years of experience, and were 45% female.

Results Emergent themes were related to the decisional needs of clinicians caring for children with sepsis and to the needs of health system administrators as they make decisions about which CDS tools to implement. Themes included variation across regions and institutions in infectious aetiologies of sepsis and available clinical resources, the need for CDS tools to be flexible and customisable in order for implementation to be successful, and proposed features and format of an ideal paediatric sepsis CDS tool.

Conclusion Findings from this study will directly contribute to the design and implementation of CDS tools to increase the uptake and impact of the new paediatric sepsis criteria in resource-poor settings.

  • paediatrics
  • infectious diseases
  • health informatics

Data availability statement

No data are available. Data are included in the article tables.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2023-074458

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • Our multidisciplinary study team and the gold-standard iterative qualitative analytic process, which decreased the likelihood of injecting bias into the analysis because of the role separation between the qualitative and clinical study team members.

    • Multidisciplinary clinicians (both physicians and nurses) and health system administrators were largely aligned in their perspectives, which increases the likelihood of implementation and adoption of clinical decision support (CDS) tools and the forthcoming new paediatric sepsis criteria.

    • Although we conducted the study across the three major world regions where the impact of paediatric sepsis is most powerful, we did not capture perspectives from participants in every potentially important country or subregion.

    • Because the future sepsis CDS tools will be clinician-facing, we did not collect patient or caregiver perspectives, which will be important to obtain in future work.

    • Participant perspectives about paediatric sepsis decision-making may have been influenced by past experiences, raising the potential for social desirability bias because of the group format.

    Introduction

    Paediatric sepsis is a major global public health problem. In 2017, an estimated 25 million cases of paediatric sepsis worldwide were associated with 3.3 million deaths.1 Children in resource-poor settings suffer disproportionately from sepsis, but few tools exist to guide clinical decision-making in those environments. There is an urgent need for generalisable and accurate clinical decision support (CDS) tools to improve sepsis recognition, treatment and risk stratification. This need was emphasised in the United Nations World Health Assembly 2017 resolution which recognised sepsis as a global health priority and proposed specific actions, including the development and implementation of CDS tools, to improve sepsis outcomes around the world.2

    Well-designed decision support tools can improve the quality of medical decision-making and can facilitate the uptake of new knowledge, guidelines and policies.3–5 However, to facilitate uptake of the new paediatric sepsis criteria, before a decision support tool can be developed, it is necessary to understand what information is most useful to decision-makers. Identifying these elements through a decisional needs assessment is typically performed using qualitative research techniques.6

    We are developing new paediatric sepsis criteria with a group of over 40 international experts as part of the Paediatric Sepsis Definition Task Force,7–11 an effort sponsored by the Society of Critical Care Medicine and supported by the WHO, the World Federation of Pediatric Intensive and Critical Care Societies and the European Society of Pediatric and Neonatal Intensive Care, among others. Dissemination of the new sepsis criteria as ready-to-use CDS tools will increase the likelihood of impact on clinical outcomes, including in resource-poor settings. However, it is not known what type of sepsis CDS tools clinicians and administrators in resource-poor settings will find most useful (eg, on paper, mobile devices, web-based, or in electronic health records (EHRs)), particularly in low-income and middle-income countries (LMICs). Historically, most sepsis criteria and guidelines have been developed with limited engagement from clinicians and health systems in LMICs.

    We, therefore, performed a qualitative decisional needs assessment study to fill this gap. The goals of the study were to understand (1) current decision-making processes, (2) current use of CDS tools or other decisional aids (eg, clinical guidelines) and (3) the essential features and format of a CDS tool for paediatric sepsis across three diverse regions (Asia, Africa and Latin America) which have the highest incidence of sepsis cases and deaths globally. We will use this information to design and build decisional needs-informed CDS tools to facilitate use of the new paediatric sepsis criteria in resource-poor settings.

    Methods

    Study design

    We based the study on the Ottawa Decision Support Framework,12 which is based on the idea that designing decision support tools to meet identified decisional needs (eg, knowledge gaps, conflicts/uncertainty, values) will improve decision quality. Under this framework, a high-quality decision is both well-informed and reflective of the decider’s values. In order to understand clinician and administrator value-informed perspectives about CDS tools for paediatric sepsis, we used a qualitative approach. We used the same approach in conducting clinician13 and parent14 decisional needs assessments related to the care of children with another acute paediatric condition, traumatic brain injury. In order to build tools with the potential for widespread adoption, particularly in LMICs, we must understand potential barriers to and facilitators of implementation. To gain that understanding, we asked clinicians, including physicians and nurses, and hospital or health system administrators about their current paediatric sepsis management protocols and decision-making processes, their desired CDS tool capabilities, and barriers and facilitators for implementation of a CDS tool.

    Sampling and recruitment

    Research team members and members of the Paediatric Sepsis Definition Task Force identified potential clinician (nurse and physician) and health system administrator participants using purposive sampling from across three LMIC regions: Africa, Asia and Latin America. A list was generated from which study team members contacted participants and offered participation via email. Participants were purposefully recruited with a broad range of years of practice and a balance of men and women. Focus groups took place between April and May 2022. We included clinicians who are involved with decisions about how to treat paediatric sepsis but do not have primary decision-making responsibility (eg, nurses) to give us a greater breadth of understanding about the decision-making process. We also used purposeful recruitment to obtain perspectives from administrators involved in the implementation and dissemination of CDS tools and clinical information systems for their health systems. Verbal informed consent was obtained from all participants. Each participant was offered the equivalent of a US$25 gift card in their preferred currency.

    Data collection

    We conducted three semistructured 120 min focus groups with clinicians including 8–14 participants per group (Africa n=8, Asia n=13, Latin America n=14) and five semistructured interviews with health system administrators (approximately 45 min each). All focus groups and interviews were conducted using Zoom, a video conferencing platform freely available to the study team (University of Colorado, HIPAA-compliant license). Clinical (TDB, LNS-P and MOW) and qualitative (BDH, AJ-Z and CR) experts collaboratively designed the focus group and interview guides based on the RE-AIM framework (see online supplemental material).15 The semistructured guides focused on exploring (1) current decision-making processes, (2) data required for decision-making, (3) desired data presentation and CDS tool capabilities and (4) barriers and facilitators for implementation of CDS tools.

    Qualitative analysis

    Audiorecordings were professionally transcribed verbatim in the language of the interview (English or Spanish) and Spanish-language interview transcripts were professionally translated into English. All translated transcripts were validated by the interviewer, who listened to the audio file and verified both the transcription and translation for accuracy. All interview transcripts were uploaded to ATLAS.ti (ATLAS.ti Scientific Software Development, Berlin, Germany) for data management, coding and analysis. Thematic analysis was the overall approach. For additional details about the qualitative analysis, please see online supplemental methods.

    Role of the funding source

    The study sponsor had no role in study design, data collection, analysis, or interpretation, report writing, or decision to submit the paper for publication.

    Patient and public involvement

    We did not involve patients or the public in the design, conduct, reporting or dissemination plans of our research because the participants in this study were clinicians and because the CDS tools to be built in the future will be clinician-facing.

    Results

    Participants

    The three regional focus groups included 35 clinicians (eight nurses and 27 physicians). The settings in which participants worked varied. In the Africa focus group, these settings included teaching hospitals, public tertiary care hospitals, regional referral hospitals and district hospitals. Participants of the Asia focus group worked at institutions such as an international health research organisation; a large, private, for-profit hospital chain; a public hospital and medical school; an independent, non-profit paediatric hospital; a public tertiary care hospital and a public medical university. Those who participated in the Latin America focus group worked at settings that included public or private hospitals, teaching hospitals, university-affiliated hospitals, referral hospitals, multipurpose hospitals and social security hospitals. Participants reported working in paediatric intensive care units (ICUs), adult ICUs and emergency rooms, among other departments. Some institutions had ICUs and some did not. Five health system administrators (four practising physicians and one who no longer practices clinically) participated in individual interviews. Interview participants also worked in a variety of academic and clinical settings, including a large non-governmental organisation, a private university hospital, a public university for health sciences and a paediatric hospital.

    Table 1 shows demographic and other characteristics of the participants. The 40 participants had a mean age of 44.5 years (range 28–70 years), mean experience of 14.6 years (range 1–30 years), and 45% were female.

    View this table:
    Table 1

    Characteristics of participants in the focus groups and interviews

    Themes

    Overall, three central themes emerged from our qualitative analysis. Those three themes were: (1) variation across regions and institutions in clinical decision-making processes, (2) necessity of flexibility for successful CDS tool implementation and (3) proposed features and format of an ideal paediatric sepsis CDS tool. Clinician and administrator perspectives were largely aligned and provided insight into current decision-making processes, tools and guidelines related to paediatric sepsis in resource-poor settings, and essential features and format of future CDS tools.

    Theme 1: variation across regions and institutions in clinical decision-making processes

    Four subthemes emerged related to variation in clinical decision-making processes for paediatric sepsis: (a) institutions’ reliance on guidelines or criteria, (b) challenges in paediatric sepsis diagnosis and treatment related to infectious aetiologies that are prevalent in these regions (and many low-resource environments), (c) prevalence of offline, often paper-based, formats for guidelines, criteria and tools and (d) limitations in paediatric sepsis recognition and treatment related to knowledge gaps, challenges educating rotation trainees, and a lack of laboratory and other resources (table 2). First, across all three regions many clinicians and administrators reported not using established CDS tools, but rather basing their approach on guidelines and subjective clinical knowledge and decision-making. A variety of guidelines are used, even within the same region. Some existing criteria, protocols and guidelines that are used include the 2005 International Pediatric Sepsis Consensus Conference criteria,16 the adult Sepsis-3 criteria,17 the ‘Sepsis 6’ bundle,18 the Surviving Sepsis Campaign guidelines,19 the American College of Critical Care Medicine guidelines20 and the Smart triage platform.21 Both clinicians and administrators reported that these guidelines defined a ‘standard approach’ to sepsis care, but they also noted being unclear which standard approach should be used. In addition, many clinicians and administrators reported the difficulty of making a paediatric sepsis diagnosis while simultaneously diagnosing and treating other conditions (eg, malnutrition, dengue, malaria, etc). Most of these guidelines were implemented using paper versions, as many of the clinicians and administrators in all three regions reported not having access to EHRs or other clinical information systems in their healthcare environment. A few participants reported mobile/digital capabilities at their current institutions. In addition, some participants mentioned the limitation of paediatric sepsis recognition due to the lack of laboratory capabilities, general lack of sepsis knowledge in their environment, difficulty with educating rotating trainees and resource limitations.

    View this table:
    Table 2

    Illustrative quotes related to variation across region and institution in clinical decision-making processes

    Theme 2: necessity of flexibility in format, customisation and support for successful CDS tool implementation

    Participants emphasised that in order for implementation to be successful, any future CDS tool needed to be flexible and customisable to local realities. In addition, four subthemes emerged related to suggestions for successful paediatric CDS sepsis tool implementation: (a) adaptation to user level of training, (b) context-specific constraints, (c) language translation and cultural tailoring and (d) leadership buy-in and support (table 3). Clinicians and administrators communicated that it is imperative for a paediatric sepsis CDS tool to be adapted to different users with varying levels of clinical training (ie, nurses, medical trainees, community health workers). Most participants emphasised that context-specific barriers should be considered when developing a paediatric sepsis CDS tool, specifically considering the lack of confirmatory laboratory tests, access to EHRs, as well as the lack of general awareness of paediatric sepsis. Participants emphasised the diversity within their own environments and recognised the importance of accurate and specific language translation and cultural tailoring for each country and each region where it will be implemented. Clinicians and administrators recognised the importance of having supportive leadership within hospital systems and local health authorities. This type of leadership buy-in and support would enable the necessary stakeholder engagement and CDS tool piloting and local validation. Although most participants discussed the necessary components for successful CDS tool implementation, some clinicians expressed concern about whether CDS tools would improve clinical outcomes in their institutions.

    View this table:
    Table 3

    Illustrative quotes related to necessity of flexibility for successful CDS tool implementation

    Theme 3: proposed features and format of an ideal paediatric sepsis CDS tool

    Three subthemes emerged related to the ideal features and content of a CDS tool for the new paediatric sepsis criteria: (a) ease of use and affordability of the tool, (b) risk stratification functionality and focus on sensitivity vs specificity and (c) focus on clinical assessment rather than laboratory data (table 4). First, participants, both clinicians and administrators, agreed that a potential paediatric sepsis CDS tool should be simple and easy to use so that a diverse group of providers can use it, including general practitioners, specialists, trainees, nurses and community health workers. They also emphasised that the tool would need to be affordable and inexpensive to maintain. An ideal tool should be able to differentiate between lower risk and higher risk forms of sepsis, as well as include clear criteria for sepsis. Participants shared the reality of diversity within regions, countries and hospital systems, compounded by local resource constraints which would impact how a paediatric sepsis CDS tool would be used in different locations. Therefore, they suggested that an ideal CDS tool (and the criteria on which it is based) should be primarily based on clinical assessment, with laboratory diagnostic data as an optional component, but not an essential part of the tool. It was re-emphasised in theme 3 that the desired format of a paediatric sepsis CDS tool may vary based on local context. Participants highlighted the need for this CDS tool to be available in different formats (paper, mobile phone or EHR) appropriate for both low and high resource settings within LMICs. Having this flexibility would allow the tool to fit within each local context and work within its restraints. Clinicians in the Asia and the Latin America focus groups recognised that overdiagnosis of paediatric sepsis is an issue. Among participants there were mixed opinions on whether sensitivity or specificity should be prioritised when designing a paediatric sepsis CDS tool (even within the same region), however, overall there was a greater preference for a more specific and accurate tool.

    View this table:
    Table 4

    Illustrative quotes related to proposed features and format of an ideal paediatric sepsis CDS tool

    Discussion

    We conducted a qualitative study of multidisciplinary clinicians who care for children with sepsis and health system administrators from LMICs in three regions of the world to understand what type of CDS tools will be most useful for dissemination of forthcoming new paediatric sepsis criteria in resource-poor settings. Incorporating multidisciplinary clinician input during the needs assessment will increase the likelihood that a future CDS tool will meet the needs of clinicians and have uptake and impact. We identified three main themes, namely: (1) variation across regions and institutions in clinical decision-making processes; (2) a need for flexibility for successful CDS tool implementation and (3) proposed features and format for an ideal paediatric sepsis CDS tool. These themes were directly related to the decisional needs of clinicians as they care for children with sepsis and of health system administrators as they make decisions about which CDS tools to implement in LMICs.

    One overarching theme that was present throughout the focus group and interview discussions was a need for CDS tools to be customisable to the respective local context. This customisability was mentioned at several levels: context-specific versions of the new paediatric sepsis criteria, local adaptation to language, culture, and training, and dissemination format (digital vs paper, etc). Because of resource constraints related to availability of internet access, water and other hygiene supplies, clinical information systems and laboratory testing, as well as variation in personnel awareness of paediatric sepsis, CDS tools and the criteria they are designed to disseminate may need to be built (and validated) in several different formats adapted to local realities. Those formats could be paper based, mobile device based or embedded into an EHR or clinical information system, depending on local resources. Each has different implications for feasibility, affordability and accessibility in different contexts for different users that will need to be tested with prototype versions of the CDS tools. Similarly, whether the tools include laboratory values will depend on local availability and the validated criteria being used. The CDS tools will need to be adapted to both local language and local cultural context. Participants highlighted the unique challenges in their regions compared with the regions where many paediatric sepsis guidelines and protocols originate. Different infectious aetiologies of paediatric sepsis in different regions require that paediatric sepsis criteria and CDS tools be developed and calibrated using data from those regions to accurately capture baseline risk and better incorporate specific risk factors observed and measured in those contexts. Some participants suggested that CDS tools should be customisable over time as available local resources varied with, for example, dry versus wet seasons and associated burden of disease. In peripheral and field care locations, rotating clinicians may provide most of the care. Because of varying educational backgrounds and experience, their needs for paediatric sepsis CDS tools may be different than experienced clinicians at paediatric centres in urban settings. A balancing measure may be that message inconsistency in CDS tools could be perceived by clinicians in remote locations as demeaning. If, for example, they developed a care plan based on the new CDS tools and that plan was changed immediately after transfer, overall CDS tool perception may worsen.

    A need for multiple versions of paediatric criteria (eg, including laboratory assessments or not) and customisability of CDS tools will pose unique challenges to criteria and tool developers. Criteria are easier to evaluate, disseminate and reinforce when they are simple and consistent, instead of in multiple forms. Multiple forms of CDS tools (eg, paper based, mobile device based and EHR based) will be more costly to implement, maintain and update. However, overcoming these challenges may improve dissemination and implementation of paediatric sepsis criteria and ultimately have a greater impact on paediatric sepsis outcomes. Similarly, other investigators have suggested that the current guidelines for the treatment of paediatric sepsis may not be equally useful in the different regions where sepsis is frequent and that their recommendations should be adjusted to these realities.22

    Several subthemes that emerged in our study can also directly inform future CDS tool design and implementation. Participants emphasised the value of careful clinical assessments that include not only vital signs, but also metrics like perfusion/capillary refill and mental status. These metrics may be less standardised than quantitative vital signs. Supporting personnel and systems to reliably capture and record these metrics will be of high value. One potential secondary benefit of paediatric sepsis CDS tools in resource-poor settings is that they can also serve as data collection tools.23 This will increase the availability of digitised data from LMICs and allow future calibration and improvement of sepsis and organ dysfunction criteria based on more extensive data over time.24 In areas with and without laboratory capabilities, increased capture, standardisation, and digitisation and standardisation of clinical assessments will add tremendous value.

    Participants indicated a desire for CDS tools to contribute to both paediatric sepsis identification and risk stratification. This result is consistent with the findings of a recent international survey that asked clinicians to state needs in relation to new paediatric sepsis criteria.7 One related subtheme that emerged is the balance of sensitivity vs specificity of a CDS tool’s diagnostic threshold. Participants from two regions (Asia, Latin America) described that overdiagnosis was an unintended consequence of some paediatric sepsis initiatives. Even in resource-rich settings, there is a tension between sepsis quality improvement initiatives encouraging early antibiotic therapy (more early/emergency department focused) and antibiotic stewardship initiatives to reduce antimicrobial resistance (more inpatient/intensive care focused). This tension is the reason that some infectious disease organisations did not endorse the adult 2017 Surviving Sepsis Campaign.25 Furthermore, in some settings, sufficient resources may not be available to treat or transport every patient identified by a highly sensitive tool. Customisability to local context (eg, of the diagnostic threshold) has the potential to alleviate some of these tensions, but will need to be carefully evaluated by both criteria developers and local implementation teams. In the future, multiple CDS tools (or a single CDS system with multiple modules) will be needed, as the necessary support for early recognition and treatment decisions will likely be different than support for later escalation/de-escalation decisions based on risk stratification.

    One key strength of the findings of this study is that multidisciplinary clinicians (both physicians and nurses) and health system administrators were largely aligned in their perspectives. Alignment between these key groups of stakeholders will increase the likelihood of implementation and adoption of CDS tools and the new paediatric sepsis criteria. For example, if clinicians valued CDS tools of a type or format that was not readily implementable by health systems, the tools would be less likely to have uptake. Conversely, if administrators preferred CDS tools of a type or format not perceived as useful by clinicians, then the tools might not be used after implementation. Another strength of the study is the multidisciplinary study team and the gold-standard iterative process. Injection of pre-existing bias was less likely because of the role separation between the qualitative and clinical study team members.

    This study has several potential limitations. First, while we conducted the study across the three major world regions where the impact of paediatric sepsis is most powerful, we did not capture perspectives from participants in every potentially important country or subregion. The themes and perspectives identified may not generalise to all clinicians and health system administrators. Second, we chose to focus on clinician perspectives in this study because the future CDS tools will be clinician-facing. Because of that choice, we did not collect patient or caregiver perspectives, which will be important to obtain in future work. Third, all of the health system administrators we interviewed either previously or currently practice clinically as physicians. The perspectives of non-clinician administrators may differ. Fourth, participant perspectives about paediatric sepsis decision-making may have been influenced by past experiences. There is the potential for social desirability bias because of the group format. Focus group facilitators were aware of that potential and attempted to minimise it by reviewing discussion guidelines and ground rules with the participants prior to the focus group. These guidelines and ground rules instruct participants to equally contribute to the discussion, describe viewpoints in first or third person, respect all viewpoints and keep information provided during the focus group confidential. In addition, participants were told by the focus group facilitators that the purpose of the focus group is to obtain their perspectives, therefore it’s most important they provide honest information and there is no right or wrong way to respond.

    Conclusion

    Dissemination of the forthcoming new paediatric sepsis criteria as customisable and ready-to-use CDS tools will increase their uptake and impact in resource-poor settings. The findings from this study will directly contribute to the design and implementation of decisional-needs informed multidisciplinary CDS tools to disseminate and support use of the new paediatric sepsis criteria in LMICs and resource-poor settings.

    Data availability statement

    No data are available. Data are included in the article tables.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by Colorado Multiple Institutional Review Board (COMIRB) #21-4855. Participants gave informed consent to participate in the study before taking part.

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    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • BDH, LNS-P and TDB are joint senior authors.

    • Twitter @TellBennett

    • Contributors AJ-Z, CR, OK and BDH designed and conducted the qualitative analysis. TDB, LNS-P and MOW served as paediatric sepsis experts. TDB and LNS-P obtained funding and, with MR, supervised the project. AJ-Z and CR wrote the first draft of the manuscript. All authors contributed to its revision and approved the final manuscript.

    • Funding US NIH/NICHD Grant R01HD105939.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.