Sepsis


showing the audience a poignant painting by Luke Fildes depicting a doctor looking pensively at a sick child, while his mother and father look on with concerned expressions, in the background. “Everything I do in my practice is about this


triumvirate. It’s about the decision I make; it’s about the child, but it’s also about the caregivers. They are critical to the whole sepsis conundrum,” he asserted. “In an emergency department, we are


extremely busy and have to make rapid decisions all the time,” commented Prof. Roland. He highlighted the significant challenge of making decisions when fatigued – particularly, when undertaking 10-12-hour-long shifts. Industry is aiming to make the decision process easier with “gadgets and tools”, he pointed out, but when it comes to antimicrobial resistance, “there are significant challenges,” he asserted. He gave the example of an infant who is 51


days old, with no risk factors: “When he presents to an emergency department, he may or may not appear to be well; he may or may not have a fever. If he has a fever and he’s relatively well appearing, people will make a decision on the risk of having a bacterial infection and what they need to do about it. “If you ask a large group of clinicians what they think the child’s risk of having a serious bacterial infection is – from one to a hundred percent – and you match it to what actually happens, there is zero correlation,” he commented. This is according to the findings of a major study of thousands of infants, he explained, adding that, “These are experienced clinicians who know their game.” The clinician’s ‘gut feeling’ clearly isn’t


accurate, he pointed out, so we need diagnostic


Everything I do in my practice is about this triumvirate. It’s about the decision I make; it’s about the child, but it’s also about the caregivers.


They are critical to the whole sepsis conundrum Professor Damian Roland


tools, but there is also the issue of “loss aversion”, which needs to be understood and addressed. Loss aversion can be described as a prominent cognitive bias, by which we fear losses more than desire equivalent gains. There is a feeling that we don’t want to “miss things” or do something that “might cause harm”. “If you are faced with a decision over whether


to prescribe antibiotics or not, regardless of what the information says, you have a cognitive design to say, ‘it will be worse if I miss infection than if I save a patient from having antibiotics, successfully’. We are primed cognitively to think that way,” Prof. Roland explained. He went on to consider the probability of illness in paediatric patients in an emergency department: “If I go through a shift and I treat no one, and I choose to make no active decisions at all, I can go two to three shifts and I will never cause harm,” he explained. “That is the lack of incidence of problems in


children…We set our systems up to think that everybody has more illness; and we design our systems and our devices based on a probability that the incidence is much higher than it actually is.”


He added that, ““If you design a specific tool


to be used on a specific group, then someone decides to use that tool on ‘all-comers’, it’s never going to be as effective. People start using


Principal (Paediatric Patient) Social challenges


Delivering integrated care through greater engagement with vulnerable and disadvantaged groups


Intermediary (Parent/Carer) Delivering integrated care


through greater engagement with vulnerable and disadvantaged groups


Psychological challenges Putting “health” on the core curriculum Providing evidence-based suite at school


Systemic challenges of resources across a range of languages Re-shaping public debates about litigation


things in ways that weren’t intended,” he warned. He went on to talk about triage and the


decision to ‘not do anything at all’, giving an example of ‘infant one’ who has a temperature of 38.1 degrees and ‘infant two’ who has a temperature of 37.9 degrees. “Put your hands up if you think that these two


children might get different investigatory and treatment pathways?” (Many in the audience responded positively). He pointed out that arbitrary thresholds (such as 38°C vs 37.9°C for fever) lead to significantly different treatment paths – despite minimal clinical difference. “It is statistical nonsense that, on the basis


of a 0.2 degree centigrade difference in temperature (which is outside the limits of a digital thermometer and an ear thermometer), that we would choose to do that. We continue to do it because the guidelines say: ‘if you are 38 degrees you are at risk, and if you are 37.9 degrees, you are not. Just mull on that.” He highlighted the work of Professor Rick


Body, a Professor of Emergency Medicine in Manchester, and went on to consider where clinicians draw the line in their practice – a CRP of 51 versus 49? White cell count of 23.4 versus 16.2? “You need to understand your own cognitive


psychology, otherwise you’ll end up making mistakes,” he warned. Prof. Roland went to


Agent (Prescriber)


Organisational safety-netting to minimise individual prescriber risks for litigation


Providing targeted decision tools (e.g., treatment algorithms)


Improved testing of national guidance to ensure specificity and sensitivity and minimise unintended consequences


Diagnostic and treatment


Validating diagnostic tools challenges and evidence-based guidelines for paediatrics


Table 1. Recommendations for addressing key decision challenges across different stakeholders. (Source: ‘Decision challenges for managing acute paediatric infections: implications for antimicrobial resistance’4


) 16 www.clinicalservicesjournal.com I September 2025


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