Patient name.......................... PID ....................... Date .................. Ward ....................

dly
Sepsis
Sepsis
/ Severe
/ Trust
Severe
Sepsis
Sepsis
Screening
Screening
Tool
Tool
<<Insert
here>>
Sepsis
Screening
Tool
Are any 2 of the following SSI criteria present and new to your patient?

wAre any 2 of the following SSI criteria present and new to your patient?

Apply if MEWS is 4 or more, or if infection suspected

Are any 2 of the following SIRS* criteria present and new to your patient?
Obs:

Temperature <36 or > 38.3oC

Respiratory rate > 20/ min

Heart Rate > 90 bpm

Acutely altered mental state

Glucose > 7.7 mmol/l

Bloods: WCC < 4 x109/l or > 12 x109/l

(if patient is not diabetic)

If patient is neutropenic and any 1 present, follow yes and call Consultant
Follow standard MEWS
protocol

NO

Re-apply screening tool if

situation changes

YES

Tick
Tick
appropriate
appropriate
box
box
Call FY or CT doctor using SBAR
Situation: Suspected Sepsis

Patient has SIRS: Think SEPSIS!!!!

Is this likely to be due to an infection?

For example

Cough/ sputum/ chest pain

Dysuria

Abdo pain/ distension/ diarrhoea

Headache with neck stiffness

Line infection

Cellulitis/ wound infection/

septic arthritis

Endocarditis

NO
NO

Patient has SIRS*

Continue MEWS every 30 mins
Give oxygen to keep SpO2>92%

YES

Tick
Tick
appropriate
appropriate
box
box

This patient has SEPSIS

Ensure Doctor present within 30 mins
Immediately start Sepsis Six Pathway
(overleaf)

Consider fluid challenge

Look for other causes of SIRS
( pancreatitis, transfusion reaction, trauma,
burns, thromboembolism)

Re-evaluate for sepsis if MEWS

increases or condition changes

Time
Time of
of SBAR
SBAR call:
call:

Doctors
Doctors name:
name:

Referring
Referring staff
staff name:
name:

Discontinue screen

Sepsis ward tool v1.3i 0610

Patient name.......................... PID ....................... Date .................. Ward ....................

Sepsis / Severe Sepsis Screening Tool

(* SIRS
Response Syndrome)
Are any 2 of the following SSI criteria present
and= Systemic
new toInflammatory
your patient?

wAre any 2 of the following SSI criteria present and new to your patient?

Sepsis

Care Pathway (complete in 1 hour):

Is there a valid end-of-life care pathway or

advance directive in place which would
limit treatment?

Document limitations of treatment, consider

appropriateness of therapy, review
appropriately and document in notes

YES

NO

Document time ...... : ..... Staff name ...........................

Designation ......................

Ensure FY or CT doctor attend NOW and work together to achieve these tasks

1. Give high-flow oxygen

Time started

Name

Reason not done or result

Time given

Name

Reason not done or result

Time given

Name

Reason not done or result

Time given

Name

Reason not done or result

Time given

Name

Reason not done or result

Time given

Name

Reason not done or result

these patients are exempt from BTS guidelines

variance may be appropriate if SpO2 > 98%

Seek expert help if severe COPD or used for >4h

2. Take blood cultures

Unless already taken today

Consider also sputum, urine, CSF etc

Consider imaging to find source

3. Give IV antibiotics

According to Trust protocol

Dont just prescribe: give yourself or make sure
someone does!!!!!
BE CAREFUL of history of allergy to any agent

4. Give a fluid challenge

If Syst BP< 90: Stat 20ml/kg Hartmanns/ 0.9% Saline
Not hypotensive: At least 500ml Hartmanns/ 0.9% Saline
(alternatively use a colloid)

5. Measure lactate
If > 2mmol/l, give 20ml/kg crystalloid
(unless already given)

If > 4mmol/l, call Critical Care Outreach

6. Measure Urine Output

May need catheterising
Start fluid balance chart

Next: Is there any 1 high risk factor?

Continue MEWS every 30 mins
Reassess for high-risk factors each time condition changes

NO

This is SEVERE SEPSIS

FY or CT:
Nurse:

Call Registrar or Consultant to attend within

60 mins, document sepsis and action plan in
notes
Ensure Critical Care Outreach are aware of
need to attend urgently

Referred by:

YES

BP (post fluid)

Syst < 90 / Mean < 65

Lactate

> 4 mmol/l

INR

> 1.5

aPTT

> 60 s

Bilirubin

> 34 mol/l

O2

Needed to keep SpO2>90%

Platelets

< 100 x 109/l

Creatinine

> 177 mol/l

Urine output

< 0.5 ml/kg/hr for 2 hrs

Risk of neutropenic sepsis

Where SEVERE SEPSIS present, record of referral made

Call made to:
Time:
Signed: