Patient name ……………………………………………………………………………… NHS Number …………………………………….
Date of Birth……………………… Ward…………………………………….
Managing suspected sepsis in adults and young people aged 18 and over– in an inpatient
hospital setting
Date/time screening commenced: ………………….
Commenced by (name/grade) ……………………
MODERATE TO HIGH RISK CRITERIA
HIGH RISK CRITERIA








Objective evidence of altered behaviour or
mental state.
Respiratory Rate: 25 breaths per minute or
more OR new need for oxygen (more than 40%
FiO2) to maintain saturation more than 92% (or
more than 88% in known chronic obstructive
pulmonary disease)
Heart Rate: 130 beats per minute or above
Systolic blood pressure 90 mmHg or less or
systolic blood pressure more than 40 mmHg
below pts known normal BP
Not passed urine in previous 18 hours or for
catheterised patients , passed less than
0.5ml/kg of urine per hour
Mottled or ashen appearance
Cyanosis of the skin, lips or tongue
Non-blanching rash of skin









Any high risk criteria met
Arrange immediate review by senior
clinical decision maker (person
authorised to prescribe antibiotics)
Carry out venous blood test for the
following
 Blood gas including lactate
measurement
 Blood culture
 Full blood count
 C-reactive protein
 Urea and electrolytes
 Creatinine
 Clotting screen
Give intravenous antibiotics without delay,
and at least within one hour of identification
of high risk criteria.
Use an intravenous antimicrobial from
agreed local formulary and in line with local
or national guidelines
Discuss with consultant
Please Follow Red Care
Pathway
LOW RISK CRITERIA
History from patient, friend or relative of
new onset of altered behaviour or mental
state
History of acute deterioration of
functional ability
Impaired immune system (illness or drugs
including oral steroids)
Trauma, surgery or invasive procedures in
the last 6 weeks
Respiratory rate: 21-24 breaths per
minute unless this is the pts normal range
Heart Rate: 91-130 beats per minute (for
pregnant woman 100-130 beats per
minute) OR new onset arrhythmia.
Systolic blood pressure 91-100mmHg
Not passed urine in the past 12-18 hours,
or for catheterised patients passed 0.5-1
ml/kg of urine per hour
Signs of potential infection, including
redness, swelling or discharge at surgical
site or breakdown of wound
2 or more moderate
to high risk criteria
Or
SBP: 91-100mmHg
Review Condition & venous
lactate results within 1 hour
Carry out venous blood test for
the following
 Blood gas including
lactate measurement
 Blood culture
 Full blood count
 C-reactive protein
 Urea and electrolytes
 Creatinine
Lactate>2 mmol/L OR assessed as
having an acute Kidney Injury*
Escalate to High risk


Normal behaviour
No high risk or
moderate to high
risk criteria met.
Suspected sepsis
and no high risk
criteria met
Clinical
assessment and
manage according
to clinical
judgement
Only 1 moderate to high risk
criterion, clinician to review
within 1 hour and perform
blood tests if indicated
Lactate <2mmol/L and no
Acute Kidney Injury* Manage
definitive condition /
infection if diagnosed
If no definitive condition
identified Please Follow
Amber Care Pathway
*See Acute Kidney Injury
(NICE Guideline CG169)
Patient name ……………………………………………………………………………… NHS Number …………………………………….
Date of Birth……………………… Ward…………………………………….
Date/time screening commenced: ………………….
Commenced by (name/grade) ………………………
AMBER CARE PATHWAY
Actions
1.Blood Gas/
Lactate measurement
2. Repeat
Observations
3. Cultures
4. Blood tests
5. Urine output
If Lactate <2mmol / L and no definitive condition identified, repeat
structured assessment hourly. Or assessed as having no acute kidney
Injury (Manage definitive condition / infection if diagnosed refer to
MODERATE TO HIGH RISK CRITERIA)
Review by senior decision maker within 3 hours for consideration of
antibiotics
Systolic blood pressure: 91-100mmHg
Respiratory rate: 21-24 breaths per minute
Assess and monitor input and output hourly
Heart rate: 91-130 beats per minute (for pregnant woman 100-130
beats per minute) OR new onset arrhythmia.
Signs of potential infections
Take
blood cultures
(+/Temperature
>38.3C or
< wound
36C swab, sputum and urine
Samples as indicated).
FBC, U&Es, clotting, CRP, LFTs, Glucose
Monitor urine output hourly, aim for 0.5mL/kg/hr. If not
passed urine in the past urine in the past 12-18 hours, or
for catheterised patients passed 0.5-1 ml/kg of urine per
hour
Commence fluid balance chart including redness, swelling
or discharged at surgical site or breakdown of wound
6. If no definitive condition identified then repeat structured assessment at least
hourly. Ensure review by a senior decision maker within 3 hours for consideration of
antibiotics.
Target
Performed
Time
by
Time
performed
<1 hour
<1 hour
<1 hour
<1 hour
<1 hour
<1 hour
RED CARE PATHWAY
Actions
1. Oxygen and
respiratory rate
Give 15L O2 via mask with reservoir bag
<1 hour
(In COPD adjust O2 to aim for target saturation 88-92%)
25 breaths per minute or more OR new need for oxygen (more than
40% FiO2) to maintain saturation more than 92% (or more than 88% in
known chronic obstructive pulmonary disease)
Lactate > 4 Give 500ml IV bolus 0.9% saline over less than 15
minutes without delay and refer to critical care.
2. IV Fluids
If systolic BP (SBP) <90mmHg give further IV bolus of 0.9%
saline.
If SBP remains <90mmHg refer to acute Trust and escalate if
appropriate
Monitor input and carry out observations every 30 minutes
Take blood cultures (+/- wound swab, sputum and urine
3. Cultures
Samples as indicated).
To be given without delay (ideally after cultures but do not delay
4. IV antibiotics
Administration). Given by IV bolus if appropriate for drug.
5. Blood tests/
Lactate < 2 mmol/L consider i.v. fluids
Lactate levels
FBC, U&Es, clotting, CRP, LFTs, Glucose
Lactate >4 mmol/L OR SBP < 90mmHg
6. Urine output
7. Repeat
Systolic Blood
Pressure
Target
Time Performed by
Monitor urine output hourly, aim for 0.5mL/kg/hr.
Commence fluid balance chart
Consider urinary catheter, if essential
Systolic blood pressure 90 mmHg or less or systolic blood pressure
more than 40 mmHg below normal
8. Repeat Pulse 130 beats per minute or above
8. Carry out observations, as clinically indicated, at least every 15-30 minutes whilst
awaiting blue lighted transfer to Acute Hospital Setting
<1 hour
<1 hour
<1 hour
<1 hour
<1 hour
<1 hour
<1 Hour
ASAP
Time
performed