Research Article: Determining predictors of sepsis at triage among children under 5 years of age in resource-limited settings: A modified Delphi process

Date Published: January 28, 2019

Publisher: Public Library of Science

Author(s): Jollee S. T. Fung, Samuel Akech, Niranjan Kissoon, Matthew O. Wiens, Mike English, J. Mark Ansermino, Marleen Smits.


Sepsis is a life-threatening dysfunction of the immune system leading to multiorgan failure that is precipitated by infectious diseases and is a leading cause of death in children under 5 years of age. It is necessary to be able to identify a sick child at risk of developing sepsis at the earliest point of presentation to a healthcare facility so that appropriate care can be provided as soon as possible. Our study objective was to generate a list of consensus-driven predictor variables for the derivation of a prediction model that will be incorporated into a mobile device and operated by low-skilled healthcare workers at triage. By conducting a systematic literature review and examination of global guideline documents, a list of 72 initial candidate predictor variables was generated. A two-round modified Delphi process involving 26 experts from both resource-rich and resource-limited settings, who were also encouraged to suggest new variables, yielded a final list of 45 predictor variables after evaluating each variable based on three domains: predictive potential, measurement reliability, and level of training and resources required. The final list of predictor variables will be used to collect data and contribute to the derivation of a prediction model.

Partial Text

Infectious diseases, primarily pneumonia, malaria, and diarrheal illnesses, constitute the major causes of post-neonatal deaths in children younger than 5 years of age [1]. According to the Global Burden of Disease Study in 2016, among the 4.9 million deaths in children under 5 years of age, infectious diseases accounted at least 50% of these deaths. [2] The final common pathway to death from most infectious etiologies is sepsis which is defined as a dysregulated immune response leading to multiorgan dysfunction [3]. A recent meta-analysis of population-based neonatal and pediatric sepsis epidemiology extrapolated approximately 3.0 million cases of neonatal sepsis and 1.2 million cases of pediatric sepsis annually, highlighting the immense burden of sepsis as an ultimate outcome of infectious diseases. [4] As most of these deaths occur in resource-limited countries, low socio-economic status and geographic barriers to healthcare facilities represent the major factors associated with mortality due to sepsis. [5] At the 2017 World Health Assembly, sepsis was recognized as a global health priority for the World Health Organization (WHO) [6–8]. An important aspect of the resolution is the promotion of research aimed at improving timely prediction, diagnosis, and treatment of sepsis.

Ethics approval was obtained from the Child and Women’s Research Ethics Board at the University of British Columbia (H17-01893). Voluntary completion of the questionnaire implied consent. The participants’ responses were received and analyzed anonymously.

The systematic review identified 72 potential predictors that were reduced to 45 using a modified two-round Delphi process. (Table 3) These predictors will be used to collect data in a large cohort of patients which will then be used to create the initial prediction model.

The modified Delphi process enabled the distillation of an initial list of 72 predictor variables, identified through a systematic review, for identification of a sick child under 5, to a final list of 45 predictor variables. This was achieved using feedback from 26 expert contributors with different backgrounds from around the world. The final list of candidate predictor variables will be used to derive a prediction model that may be used to triage sick children at the time of presentation.




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