SEPSIS/DETERIORATING PID: DOB: / / 1 PATIENT PATHWAY PATIENT NAME: (affix label) NURSE / DOCTOR NAME: TITLE / GRADE:

Screen if MEWS ≥4? Fever or other symptoms of infection? Unexplained deterioration?

Are any 2 of the following present? (TICK ALL THAT APPLY) CONSIDER ESCALATION TO Temperature <36°C or >38.3°C APPROPRIATE CLINICIAN +/- Respiratory rate >20/minute CRITICAL CARE OUTREACH TEAM Heart rate >90/minute NO (CCOT) AND REPEAT New onset confusion (delirium) or altered conscious level OBSERVATIONS Glucose >7.7mmol/L (unless DM) (according to MEWS protocol) White Cell Count (WCC) <4 or >12 (if available) CONSIDER OTHER CAUSES OF ACUTE DETERIORATION e.g. YES  Hypovolaemia, PE, ACS/LVF Does your patient have symptoms or signs suggestive Neuro Event, Addisonian of a new infection? Crisis, RESUSCITATE PATIENT NO If Yes please state (using an ABCDE approach)

source/ symptoms. INITIATE APPROPRIATE fromAdapted permission with UKScreening Trust andMaries Sepsis 2014 by Action Tool Tom and Caroline Heaps Adapted with permission from UK Sepsis Trust Screening and Action Tool 2014 by DPRG. E.g. UTI ; abdo pain, SOB, sputum, ?appendicitis, cellulitis etc. INVESTIGATIONS & TREATMENT CONSIDER TREATMENT & CPR YES: PATIENT HAS SEPSIS STATUS

Are there any immediate RED FLAGS? (TICK ALL THAT APPLY) Heart rate >130/min Contact appropriate clinician to Systolic BP <90mmHg or MAP <65mmHg review within 30 minutes and state Respiratory rate > 25/min NO ‘uncomplicated sepsis’

SpO2 <90% or (SpO2 only 90% with oxygen) Remember to use SBAR Responds only to Voice / Pain or Unresponsive Further Assessment YES Are there any other red flag

markers of severe sepsis? Contact appropriate clinician +/- CCOT to review (TICK ALL THAT APPLY) immediately and state ‘SEVERE (Red Flag) SEPSIS’ YES Remember to use SBAR Lactate >2.0mmol/L Urine output <0.5mL/kg for 2h or ACT NOW creatinine >177µmol/L TREAT FOR SEVERE (Red Flag) SEPSIS: Bilirubin >34µmol/L Platelets <100 x 109/L COMPLETE BUNDLE WITHIN 1 HOUR OF INR >1.5 or aPTT >60s RECOGNITION (TIME ZERO) THIS IS A MEDICAL EMERGENCY NO DO NOT DELAY MANAGEMENT FOR INVESTIGATIONS OR TREAT FOR RESULTS UNCOMPLICATED SEPSIS - Tillott Tillott SEPSIS TREATMENT PATHWAYS—TURN OVER THE PAGE

SEPSIS/DETERIORATING PATIENT SCREEN PATHWAY 2

MAKE A TREATMENT ESCALATION PLAN AND DECIDE ON CPR STATUS Time Type of Sepsis Date Zero Actions

Antibiotics for suspected focus as per Trust guidelines, other elements  Uncomplicated Sepsis / / : of ‘Sepsis 6’ as appropriate GRAB THE TROLLEY/EQUIPMENT AND  Severe (Red Flag) Sepsis / / : COMPLETE THE ‘SEPSIS 6 BUNDLE’ WITHIN 1 HOUR

Time Initials Reason NOT done or Result Sepsis Six® 60 MINUTES done

Oxygen titrate to achieve target SpO2 94-98% 1. : (88-92% if at risk of CO2 retention e.g. COPD)

Take Blood Cultures at least one set Attach yellow sticker from blood 2. peripherally (and separately from any : indwelling long lines/central venous catheters) culture pack here

3. IV Antibiotics according to trust guidelines : Adapted with permission from UK Sepsis Trust Screening and Action Tool 2014 by DPRG. Adapted with permission fromAdapted permission with UKScreening Trust andMaries Sepsis 2014 by Action Tool Tom and Caroline Heaps IV Fluid 30mL/kg bolus of 4. 0.9% Saline/Hartmann’s STAT if sBP <90mmHg : (500mL STAT if NOT hypotensive) Check Lactate and Hb VBG/ABG plus blood 5. Lactate = mmol/L for FBC, U&E, LFT, CRP, clotting :

Commence Fluid Balance Monitoring 6. consider urinary catheter :

REASSESS: repeat lactate, review observations (including hourly urine output), check blood results REPEAT RISK STRATIFICATION: are there any red flags or markers of organ dysfunction? (see over)

Severe (Red Flag) Sepsis Septic Uncomplicated Sepsis (lactate >4mmol/L Diagnosis: (lactate >2) (lactate <2) (where critical care input is not immediately Or systolic BP <90mmhg) required) Senior (ST3+) Discuss as condition dictates or as Review within 60 minutes of IMMEDIATELY Review: per MEWS protocol recognition Consultant Discuss as condition dictates or as SPR/Consultant review within 1 hour IMMEDIATE telephone call to Review: per MEWS protocol as per high MEWS escalation policy Consultant (if not present) Repeat Every 30 minutes until MEWS <4 Every 30 minutes until MEWS <4 IMMEDIATE referral to Critical Observations: Care Outreach Team (CCOT) and/ Lactate within 4 hours if clinically Repeat lactate within 2 hours; other or ITU Registrar

Repeat Bloods: indicated blood tests within 14 hours unless If there is any delay in medical E.g. fails to improve required sooner review, nurses should contact CCOT or Consultant directly Escalate IMMEDIATELY if markers of Escalate IMMEDIATELY if septic severe sepsis or shock (including cryptic shock) or *Or a fall of >40 mmHg from patient’s - Reassess: develop (including patients with organ dysfunction requiring critical usual systolic which Tillott ‘cryptic shock’ i.e. normal blood care (e.g. AKI, refractory persists AFTER delivery of ≥30 mL/kg body weight of IV fluids pressure but elevated lactate) hypoxaemia) develops

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