1381: Impact of Sepsis Huddle Documentation Compliance on Pediatric Sepsis Management: A Qi Project

Introduction: Early recognition and timely treatment of sepsis in pediatric patients are critical to improving outcomes. Many institutions implement proprietary sepsis alerts and structured team huddles to support prompt clinical decision-making. Despite the known importance of timely intervention, the impact of huddle documentation compliance on the delivery of sepsis-directed care has not been well studied. This project aims to evaluate whether higher compliance with documentation of sepsis huddle protocols is associated with increased rates of interventions, such as fluid resuscitation and antibiotic administration. Methods: We conducted a retrospective analysis of pediatric patients admitted to the inpatient floor and the PICU at Staten Island University Hospital who had a sepsis alert triggered in the electronic medical record (EMR) between January and June 2025, with data collection ongoing through December 2025. Sepsis huddle compliance was defined as documentation of a team huddle in the EMR. A high-compliance month was defined as one in which ≥20% of sepsis alerts included a documented huddle. The primary outcome was the rate of sepsis-related interventions, including fluid bolus administration and antibiotic initiation. Fisher’s exact test was used to compare intervention rates between high- and low-compliance months. Results: A total of 542 encounters were included, and a total of 75 compliant encounters were analyzed (47 encounters in low compliance months, 28 in high compliance months). 33% of months met criteria for high compliance. Intervention rates were not statistically different between high-compliance months compared to low-compliance months p = 0.16 (boluses) and 1.0 (antibiotics). Conclusions: There was no statistically significant difference in intervention rates between high- and low-compliance months. Ongoing data collection aims to strengthen the analysis. Notably, fewer interventions occurred in high-compliance months, suggesting that low compliance may be associated with unnecessary interventions driven by overreaction to false-positive alerts rather than deliberate clinical judgment. Further analysis is needed to clarify this trend and assess the role of huddles in reducing overtreatment.