Rising Hope For All or Some? The Phoenix Sepsis Score and I ts Importance in the Early Recognition of Pediatric Sepsis In partial fulfillment of the requirements for the degree Master of Science in Physician Assistant Studies Amber Butler PA - S2 Heather Hudson, MS, PA - C January 202 6 Department of Physician Assistant Studies SUNY Upstate Medical University College of Health Professions Syracuse, New York 2 ABSTRACT Pediatric sepsis remains a leading cause of morbidity and mortality worldwide, yet current diagnostic tools such as SIRS and qSOFA often miss early signs in children. As these tools were developed for adults, they do not take pediatric physiology into acco unt. The Phoenix Sepsis Score is a pediatric - specific diagnostic tool which addresses the gap by incorporating clinical and laboratory parameters across multiple organ systems. Designed for use in both high - and low - resource clinical settings, it offers fl exibility in settings where diagnostics may be limited. By allowing for earlier identification of pediatric sepsis, delays in care are reduced, treatments are guided, and outcomes are improved. Its use in underserved areas also highlights its potential to reduce health disparities, although continued research and clinical integration are essential to maximize its impact. Educating providers on the Phoenix Sepsis Score and its use is critical, especially in settings where timely intervention is lifesaving. INTRODUCTION Sepsis is defined as life - threatening organ dysfunction caused by a dysregulated host response to infection. More than half of all sepsis cases worldwide occur in children, making pediatric sepsis one of the leading causes of morbidity and mortality in pediatric patients. The World Health Organization emphasizes that early diagnosis and timely, appropriate clinical management are critical to increasing survival and positive outcomes of patients with sepsis 1 In comparison to adult patients, sepsis in pediatric patients can be subtle and rapidly progressive, which makes early and accurate diagnosis a critical aspect, especially in resource - limited settings. Historically, the Systemic Inflammatory Response Syndrome (SIRS) criteria and the quick Sequential Organ Failure Assessment (qSOFA) have been used to aid in the diagnosis of sepsis. While these diagnostic tools have shown positive effect in adult populations, their sensitivity and specificity in pediatric patients is severely limited. The la ck of pediatric - specific diagnostic criteria can lead to delays in recognition and treatment, leading to poor outcomes and even death. These limitations highlight the need for a more tailored and accessible diagnostic tool for pediatric patients. In 2024, The Phoenix Sepsis Score was developed as a pediatric - specific diagnostic tool. It incorporates both clinical and laboratory values, with a wide range of testing options. This tool was created for use in both high - and low - resource settings. With this 3 new tool available, awareness and understanding are important in ensuring these benefits reach all pediatric patients, regardless of setting. DIAGNOSTIC TOOLS Systemic inflammatory response syndrome, also referred to as SIRS, is a condition that occurs due to a large immune response to stressors on the body. These stressors may include infection, trauma, surgery, or malignancy, often leading to widespread organ damage if not recognized and treated in a timely manner. The SIRS criteria was developed to help universally diagnose SIRS in patients. For diagnosis, at least 2 of the following must be met by patients: temperature greater than 38° C or less than 36° C , h ea rt rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute or PaCO2 less than 3 2mmHg, and white blood cell count greater than 12,000, less than 4,000, or greater than 10% immature forms. When a diagnosis of SIRS is made, sepsis may also be diagnosed if an infection is present 2 Although the SIRS criteria is highly sensitive, it has low specificity, especially in the first 24 hours of an intensive care unit ( ICU ) admission. In many cases, hospitalized patients meet SIRS cri teria even without being septic. A fever can be present without a bacterial cause, tachycardia can be common with fever, dehydration, anxiety, and even pain. Tachypnea is often seen in patients with respiratory complaints, a common reason for hospitalizati on. White blood cell counts can be falsely elevated from inflammation or medications, not only infection. These limitations and variability in diagnostics make SIRS less reliable as a stand - alone diagnostic tool, especially for pediatric patients. The q u ick Sequential Organ Failure Assessment (qSOFA) is another sepsis diagnostic tool that was created to determine sepsis - induced prognosis in adult patients 3 A positive qSOFA 4 score requires at least two of the following: respiratory rate greater than 22 bre aths per minute, altered mental status, and systolic blood pressure less than 100mmHg. A positive score suggests an increased risk of poor outcomes. While the specificity of the qSOFA is greater than the SIRS criteria in the adult population, the ability i n children is still severely limited 3 Pediatric patients often do not show signs of hypotension until late in the disease process, respiratory rates may be relative based on age, and being able to categorize mental status change in children is very subjec tive. In pediatric patients, qSOFA often delays recognition of sepsis and limits early treatment. LIMITATIONS OF CURRENT TOOLS With the main sepsis diagnostic tools being aimed for adults, the SIRS and qSOFA both show limited accuracy in pediatric pat ients. SIRS often captures too many false positives, while qSOFA risks the possibility of missing the chance to diagnose sepsis in the early stages. The gap in diagnostic tools for pediatric patients emphasizes the need for pediatric - specific scoring tools Having the ability to account for age - related conditions, physiology, and progression of pediatric sepsis will allow for earlier diagnosis and better outcomes of pediatric patients with sepsis. THE PHOENIX SEPSIS SCORE With the clear need for a new sepsis definition for pediatric patients, The Phoenix Sepsis Score was created, studied, and defined by the Third International Consensus Definitions for Sepsis and Septic Shock. The Society of Critical Care Medicine task force used a three - pronged approa ch to develop the new criteria: a global survey of 2,835 diverse clinicians, a systematic review and meta - analysis of data, and a data - driven derivation and validation study based on 5 more than three million health record encounters from four continents 4 T he Phoenix Sepsis Score assigns various points to different body systems, needing only a score of 2 to indicate potentially life - threatening sepsis. Respiratory function, cardiovascular status, coagulation studies and neurologic function are used as criter ia, as these systems were found to be highly predictive of mortality in pediatric populations. This diagnostic tool is also not limited to ICU settings, as many pediatric patients develop sepsis in an outpatient setting and present to emergency departments for care 5 Pediatric patients are known to decompensate rapidly, often with minimal or subtle warning signs. By addressing the unique characteristics pediatric patients present with, the Phoenix Sepsis Score becomes the first pediatric - specific diagnostic tool for sepsis which can drastically improve early recognition and outcomes for pediatric patients worldwide. An important benefit to this diagnostic tool is its availability to be applied even when complete laboratory testing is not available, which can be a common situation in low - resource or over - saturated hospital systems. With a wide range of clinical and laboratory criteria available for points in the Phoenix Sepsis Score, there are many pathways to generate a positive score. This flexibility ensure s that even without immediate access to advanced diagnostics, sepsis can still be diagnosed early with at least two clinical positives. Having a scale on the scoring makes precise diagnosis a feasible option, understanding pediatric patients often present with sepsis in unique and unconventional ways. The Phoenix Sepsis Score assigns zero to three points to the different body systems, totaling a cumulative score of zero to thirteen. With this score expanding the investigation across multiple organ systems , the Phoenix Sepsis Score improves diagnostic accuracy, early recognition of disease severity, and overall outcomes in pediatric sepsis (Table 1) 6 WHY EARLY DIAGNOSIS MATTERS In a 2025 study published through the American Academy of Pediatrics, it was found that the delayed sepsis recognition or the absence of sepsis recognition in the ICU correlated to a higher proportion of the patients with critical sepsis in the ICU (44%) compared to the general care unit (31.9%). In these settings, it was also fou nd when sepsis was identified only after first administration of intravenous ( IV ) antibiotics and/or IV fluid bolus, there was a significant increase in sepsis - attributable mortality rates (9.5% and 9.2%, respectively). However, when identifying sepsis usi ng a recognition tool, hospital - onset sepsis - attributable mortality notably decreased to 4.8% 5 These findings emphasize the crucial importance of early diagnosis in pediatric patients, both in the ICU and in general hospital settings. There is a likely re ason for an increase in sepsis being diagnosed first by IV antibiotics; the lack of an effective screening tool. With the introduction of The Phoenix Sepsis Score, providers can feel more confident in diagnosing sepsis for pediatric patients. As shown in t his study, using a recognition tool marginally decreases the mortality rate in these patients, and can continue to drop as a designated diagnostic tool continues to be used. In these situations, early recognition is critical in having the opportunity to in tervene early in the disease process. This is essential in preventing rapid clinical deterioration, reducing organ failure, and saving the lives of these patients. Understandably, pediatric sepsis has not been diagnosed in these timely manners due to the n on - specific tools, and the unique physiology pediatric patients often present with. With the implementation of t he Phoenix Sepsis Score, septic pediatric patients can be identified earlier, started on intervention, ultimately decreasing negative outcomes. CLINICAL IMPLICATIONS OF THE PHOENIX SEPSIS SCORE 7 The integration of the Phoenix Sepsis Score into clinical practice marks a significant advancement in pediatric sepsis recognition, particularly for frontline providers. As discussed earlier, pediatric patients often compensate until they suddenly crash; this score helps identify them before that happens. A study published by Han et al. (2025) in the Journal of Korean Medical Science found the Phoenix Sepsis Score exhibited sensitivity of 93.6% to 96.7%, specificity of 33.4% to 48.2%, and positive predictive value of 6.7% to 10.3% across mortality outcomes and assessment methods. 6 As the score increases, so does the associated risk of mortality, allowing providers to quickly stratify patients by disease severity. (Figure 1) This correlation enables providers to tailor interventions more precisely by initiating earlier fluid resuscitation, vasopressor support, and antibiotic therapy for those with high scores, while continuing close monitoring for patients with lower scores. By quantifying risk, the Phoenix Sepsis Score supports timely, evidence - based decisions that can significantly improve pediatric outcomes across diverse care setting s. Incorporating the Phoenix Sepsis Score into pediatric triage protocols can significantly enhance early diagnosis and guide clinical decision making. For patients presenting with moderate scores, providers may initiate early supportive care and closely monitor for progression, while those with high scores may require immediate transfer to higher levels of care. This improvement allows for faster identification of critically ill children who may otherwise be miscategorized using adult - based diagnostic to ol s , such as SIRS or qSOFA. Hospital - onset sepsis carried a 30 - day mortality of 6.9% when sepsis screening was lacking, compared with 1.1% for cases recognized with a screening tool in a timely matter. 5 This highlights the importance of the Phoenix Sepsis Score in coordinated escalation of care and tailored interventions for critically ill patients. 8 EQUITY AND ACCESSIBILITY IN SEPSIS DIAGNOSIS Pediatric sepsis is a time - critical condition and remains a major contributor to childhood mortality worldwide, especially in low - resource settings. Mortality rates in these settings can reach up to 58%, while in high - resource areas, pediatric sepsis mortality is generally below 20%. 8 Children living in socioeconomically disadvantaged areas are particularly vulnera ble, where early recognition and treatment are often delayed due to limited access to labs, fewer pediatric - trained providers, and under - resourced hospital systems. These disparities directly impact outcomes. Kaur et. al ( 2025 ) examined neighborhood - level social determinants of health using the Child Opportunity Index 3.0 and found that children admitted to the pediatric intensive care unit from lower - opportunity neighborhoods were more likely to die or experience organ dysfunction one week after a positive Phoenix Sepsis Score onset. 9 While adding Child Opportunity Index 3.0 data did not significantly improve predictive modeling beyond clinical EMR data, the results clearly showed that where a child lives matters. Children from underserved areas had worse o utcomes despite similar clinical presentations. This reinforces that environmental and systemic factors have a real influence on pediatric sepsis care, and that early recognition can be lifesaving. These insights call for targeted strategies to improve acc ess to sepsis diagnostics and timely interventions in vulnerable communities. Integrating tools such as the Phoenix Sepsis Score into frontline care, matched with provider education and institutional support, could help reduce disparities and improve outco mes for further at - risk pediatric populations. These disparities are also seen globally. Delayed diagnosis and treatment, due to poor laboratory access and lack of sepsis - specific training, contributed significantly to higher 9 mortality rates in pediatric septic shock, especially in under - resourced hospitals. 9 Early intervention is known to improve sepsis outcomes, but other systemic barriers often cause delays. Kaur et al. (2025) identified several likely issues and barriers: limited access to rapid diagn ostics, the absence of standardized triage tools, and low provider awareness of early sepsis signs. Most concerning, nearly one - third of the children who died during th is study had not received timely fluids or antibiotics, mainly due to delayed recognitio n and gaps in emergency care infrastructure. 9 These findings strongly support the use of the Phoenix Sepsis Score, which does not rely solely on labs and can help providers recognize and respond to sepsis more quickly, even in low - resource settings. This updated tool uses clinical signs like respiratory distress, mental status changes, and perfusion, making it practical in both large tertiary centers and small community hospitals. By enabling earlier escalation of care regardless of setting, the Phoenix Se psis Score has the potential to reduce disparities in pediatric sepsis outcomes. Implementing it in triage protocols, EMR alerts, and frontline training would be a major step toward making sepsis care more equitable both in the United States and globally, especially in high - risk, low - resource areas. LIMITATIONS AND AREAS FOR FUTURE RESEARCH Although the Phoenix Sepsis Score shows promising sensitivity and applicability across various healthcare settings, several limitations remain. Although the Phoenix Sepsis Score offers improved specificity over SIRS and qSOFA in pediatric populations, it is primarily validated in intensive care settings. The predictive performance outside of the pediatric intensive care unit , particularly in community or resource - limited environments, is still being evaluated. In fact, recent studies emphasize that the Phoenix Sepsis Score was not developed for early screening 10 originally, but rather for identifying life - threatening organ dysfunction once sepsis has already progressed. 1 0 The current criteria was created to focus on identifying children who already exhibit life - threatening dysfunctions spanning multiple organ systems. Although there are clear benefits to the Phoenix Sepsis Score in early detection, further re search is still needed to develop a clear pediatric sepsis definition. This is especially important in settings that are not equipped for life - threatening level of care. Outpatient providers, emergency departments, and emergency medical services should be able to recognize and diagnos e sepsis in pediatric patients before it progresses to shock. This underscores a significant gap in early sepsis recognition, particularly in outpatient and emergency department settings. To address the gap in screening tools, Georgette et al. (2025) evaluated several screening tools and found that the Phoenix Sepsis score demonstrated superior predictive accuracy for pediatric sepsis and septic shock when compared to traditional methods such as SIRS and qSOFA. 1 1 Furthermore, al though the Phoenix Sepsis Score allows for scoring with limited lab oratory data, full diagnostic accuracy is enhanced with access to organ - specific markers. This is an advantage to higher level care that is not consistently available in low - resource settin gs. 12 Using several biomarkers together is shown to help improve early detection of sepsis, but this method can be difficult to use outside of hospital settings due to the requirement of resources and complex testing. Clinical variability among pediatric p atients, such as age - related vital signs, developmental stage, neurologic baseline, and comorbidities, can complicate the accurate interpretation of an organ dysfunction score. 12 These factors reduce the reliability of a general pediatric diagnostic tool, as pediatric baselines are quite variable. This can lead to either over diagnosis or under diagnosis of sepsis, especially in diverse pediatric populations. With this, it is still necessary for providers to interpret scores from the Phoenix Sepsis Score wi thin the context of individual patient baselines . This does highligh t the need for 11 flexible, dynamic tools that accommodate pediatric ranges , although c ontinued studies need to be performed to find the most favorable outcome for diagnostic tools. ADVOCACY FOR RECOGNITION AND EQUITY IN PEDIATRIC SEPSIS CARE The development of the Phoenix Sepsis Score represents an important advancement in pediatric - specific sepsis diagnosis, but recognition alone is not enough. There remains a critical need to adv ocate for broader implementation of early recognition strategies that are both effective and accessible across diverse care environments. Policy makers, clinical leaders, and healthcare institutions must prioritize integration of pediatric focused sepsis t ools into electronic health records and emergency care protocols. Funding and support for training providers in t h e interpretation and use of tools such as the Phoenix Sepsis Score, especially when laboratory resources are limited, are essential. Pediatric patients, especially those with complex medical histories or living in underserved areas, deserve timely recognition and treatment based on tools tailored to their unique physiology. Advocacy at institution al , regional, and global levels is necessary to c lose the gap between sepsis recognition and equitable pediatric care. CONCLUSION Pediatric sepsis continues to be a leading cause of morbidity and mortality in children worldwide, and early recognition remains one of the most important factors in impr oving outcomes. As discussed, traditional tools like SIRS and qSOFA were not designed with pediatric physiology in mind and often fail to capture the subtle, rapidly progressing signs of sepsis in children. The Phoenix Sepsis Score represents a pivotal adv ancement by providing a pediatric - specific, flexible, and accessible scoring system that addresses these gaps. With its ability to 12 generate a positive score from both clinical signs and laboratory data, the Phoenix Sepsis Score offers a practical solution across a wide range of healthcare settings. It has been found that some children who screened positive using the Phoenix Sepsis Score were negative by the SIRS - based criteria, yet still experienced high in - hospital mortality. These cases of SIRS - negative s epsis highlight the gap between provider - based clinical judgement and standardized diagnostic tools, reinforcing the need for a pediatric - specific sepsis tool to improve early recognition and patient outcomes. 12 Clinically, the Phoenix Sepsis Score support s earlier intervention through risk stratification, guides decision making around triage and escalation of care, and allows for more accurate prediction of outcomes. Importantly, the score helps providers recognize sepsis before irreversible organ damage o ccurs, something previous tools often missed. By integrating the Phoenix Sepsis Score into routine care, providers can act sooner, treat more effectively, and ultimately improve survival for pediatric patients with sepsis. 13 APPENDIX: Table 1: D escribes the criteria for scoring of The Phoenix Sepsis Score in pediatric patients. The respiratory, cardiovascular, coagulation, and neurologic scores are broken down on different criteria. 4 14 Figure 1: Calibration of the Phoenix Sepsis Score across immediate and 24 - hour assessments. Mortality increased steadily with high score values, validating its use as a risk stratification tool. Both in - hospital and 1 - month mortality were strongly associated with sc ores greater than 6. 6 15 REFERENCES: 1. World Health Organization: WHO. Sepsis Fact Sheet . Published May 3, 2024. https://www.who.int/news - room/fact - sheets/detail/sepsis 2. Baddam S, Burns B. Systemic inflammatory response syndrome. StatPearls – NCBI Bookshelf. Published June 20, 2025. https://www.ncbi.nlm.nih.gov/books/NBK547669/ 3. Toker AK, Kose S, Turken M. Comparison of SOFA score, SIRS, qSOFA, and qSOFA + L criteria in the diagnosis and prognosis of sepsis. Eurasian J Med . 2021;53(1):40 - 47. doi:10.5152/eurasianjmed.2021.20081 4. SCMM Tast Force develops new criteria to identify pediatric sepsis. Society of Critical Care Medicine (SCCM) https://www.sccm.org/blog/sccm - task - force - develops - new - criteria - to - identify - pediatric - sepsis 5. Hakim H, Richardson T, Riggs R, et al. Sepsis mortality in ho spitalized children with cancer is associated with lack of a screening tool. Hosp Pediatr. doi:10.1542/hpeds.2024 - 007956 6. Han CH, Kim H, Park M, et al. Validation of the Phoenix criteria for sepsis and septic shock in a pediatric intensive care unit. Jour nal of Korean Medical Science . 2025;40(10). 7. Rusmawatiningtyas D, Rahmawati A, Makrufardi F, et al. Factors associated with mortality of pediatric sepsis patients at the Pediatric Intensive Care Unit in a low - resource setting. BMC Pediatrics . 2021;21(1):4 71. doi:10.1186/s12887 - 021 - 02945 - 0 8. Moore R, Chanci D, Brown SR, et al. Association of the child opportunity index with in - hospital mortality and persistence of organ dysfunction at one week after onset of Phoenix sepsis among children admitted to the pedi atric intensive care unit with suspected infection. PLOS Digital Health . 2025;4(4). doi:10.1371/journal.pdig.0000763 9. Kaur G, Kaushik JS, Vinayak N, Aamir M. Clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic sh ock from Rohtak, Haryana: A prospective observational study. Indian Journal of Critical Care Medicine 2014;18(7):437 - 441. doi:10.4103/0972 - 5229.136072 10. Esposito S, Mucci B, Alfieri E, Tinella A, Principi N. Advances and challenges in pediatric sepsis diag nosis: Integrating early warning scores and biomarkers for improved prognosis. Biomolecules . 2025;15(1):123. doi:10.3390/biom15010123 11. Georgette N, Michelson K, Monuteaux M, Eisenberg MA. Comparing Screening Tools for Predicting Phoenix Criteria Sepsis and Septic Shock Among Children. PEDIATRICS 2025;155(5). doi:10.1542/peds.2025 - 071155. 12. Sanchez - Pinto LN, Daniels LA, Atreya M, et al. Phoenix Sepsis Criteria in critically ill children: Retrospective validation using a United States nine - center dataset, 2012 – 2018. Pediatric Critical Care Medicine . 2025;26(2):155 - 165. doi:10.1097/pcc.0000000000003675