Use Patient ID label
Provider of services on behalf
of the NHS
Inpatient Sepsis
Screening Tool and
Care Pathway
Date/time screening commenced: ………………….
Commenced by (name/grade) ………………………
Complete all white boxes
Section 1: Sepsis screening tool
Heart rate >90bpm
Respiratory rate >20 breaths/min (fast breathing)
9
9
WCC <4x10 /L or >12x10 /L*
*May not apply in neutropenic sepsis
New altered mental state/reduced conscious level
Glucose > 7.7 mmol/l (unless DM)
OR
Unexplained hypotension/very lethargic
Mottled or pale colour/cold peripheries/cold to
touch
Central capillary refill > 3 seconds
Absent radial pulse
Purpuric rash that does not fade when pressed
Baby not feeding/vomiting/not passing urine
If yes , consider the following question
Sepsis is confirmed by 2 or more clinical signs (a)
AND
a) Are 2 or more of the following signs
present?
Yes
o
o
Temperature >38.3 C or <36.0 C (Feel very hot)
indication of infective source (b)
b) Indication of infective source
Yes
Could this be a severe infection? e.g.
positive microbiology, purulent sputum, CXR
changes, abscess, collections, WBCs in CSF
Specify likely source (if known):
Pneumonia
In-dwelling cannula, line or device
Central nervous system
Meningitis
Urinary tract infection
Abdomen/pelvic pain or distension
Cellulitis/septic arthritis/infected wound
Other (please specify)
……………………………………………………………….
OR unknown source
OR immunocompromised (organ transplant/chemotherapy)
If answers to (a) and (b) indicate sepsis commence „Section 2: immediate actions‟ and request senior review
Section 2: Immediate actions follow the Actions below
Target
Time
Performed by
Time
performed
Actions
1. Oxygen
Give 15L O2 via mask with reservoir bag
(In COPD adjust O2 to aim for target saturation 88-92%)
Give 500ml IV bolus 0.9% saline
If systolic BP (SBP) <90mmHg give further IV bolus of 0.9%
2. IV Fluids
saline
If SBP remains <90mmHg refer to acute Trust and escalate if
appropriate
Monitor input hourly
Take blood cultures (+/- wound swab, sputum and urine
3. Cultures
Samples as indicated).
To be given ASAP (ideally after cultures but do not delay
4. IV antibiotics
Administration). Given by IV bolus if appropriate for drug.
5. Blood tests
FBC, U&Es, clotting, CRP, LFTs, Glucose
Monitor urine output hourly, aim for 0.5mL/kg/hr.
6. Urine output Commence fluid balance chart
Consider urinary catheter, if essential
7. Screen for severe sepsis (see ‘Section 3: screening for severe sepsis’)
8. Refer for source control if relevant e.g. drainage of septic collection
Section 3: is Sepsis possible?
<1 hour
<1 hour
<1 hour
<1 hour
<1 hour
<1 hour
<1 hour
ASAP
Screening for severe sepsis
Are any of the following present and NEW to the patient?
Yes
SBP <90mmHg despite adequate fluid resuscitation
Supplemental oxygen required to achieve SpO2 > 90%
9
INR >1.5 or APTT >60 seconds or Platelets <100x10 /L
If YES to any of the above, patient has SEVERE
SEPSIS. Request the following:
Discuss with Consultant (+ on-call) and consider transfer to acute
hospital
Yes
Urine output <0.5mL/kg/hr
Immunocompromised
If none of the above present – treat as SEPSIS and
perform the following:
Regularly screen for severe sepsis
Review microbiology results
Plan medical review
Sepsis - care pathway, v2 Author: WUTH Sepsis Working Party Approved by Medicines Clinical Guidance Reviewed: March 16