Admission & Discharge
3
2
<40
<8
1
41 - 50
<35.0
<70
71 - 80
<10mls per hour <30mls per hour
for two consecutive hours for two consecutive hours
0
51 - 100
9 - 14
35.0 - 38.4
81 - 100
ALERT
+ ORIENTATED
101 - 199
1
101 - 110
15 - 20
RESPONDS TO
VOICE AND/OR IS CONFUSED
2
111 - 129
21 - 29
>38.5
RESPONDS TO PAIN
>200
3
>130
>30
UNCONSCIOUS
Addressograph
Name:
Date of Birth:
Address:
Modifications to EWSS Parameters and
Hospital Number:
NHS Number:
Sepsis 6 Recognition
If physiological parameters outside of the EWSS
normal range are to be tolerated, write the acceptable
parameter to achieve an EWSS of 0.
If physiological parameters outside of the EWSS
normal range are to be tolerated, write the acceptable
parameter to achieve an EWSS of 0.
Doctor’s Name and
Signature
Respiratory Rate
Respiratory Rate
O2 Saturation
O2 Saturation
Systolic BP
Systolic BP
Heart Rate
Heart Rate
Temperature
Temperature
Consciousness
Date
/
2 Hour Urine Output
Time
Consciousness
Date
:
/
/
2 Hour Urine Output
Review Date Time
/
Doctor’s Name and
Signature
:
/
Review Date Time
:
/
Time
/
:
/
If physiological parameters outside of the EWSS
normal range are to be tolerated, write the acceptable
parameter to achieve an EWSS of 0.
Doctor’s Name and
Signature
Respiratory Rate
Do they meet >1 sepsis red flag criteria:
O2 Saturation
• New altered mental state
of
• Respiratory rate: * 25
Systolic BP
• Needs Oxygen to keep SP02 * 92%
Heart Rate
• Heart rate: *130 beats per minute
• Systolic BP ) 90 mmHg
Temperature
Consciousness
Date
/
2 Hour Urine Output
• Non-blanching rash, mottled,
ashen or cyanotic
Time
/
:
• Lactate* 2mmol/l
Review Date Time
/
/
If 1 or more above give IV antibiotics immediately and start IV fluids
:
$ATETime of recognition _________? Signature___________________
Antibiotics given at _______________
Printed Name________________
Doctor’s Name and
Signature
End of Life Care
Discontinue vital sign monitoring
YES
NO
Discontinue EWSS
YES
NO
If clinical condition changes, please review decision.
Date
/
Page 2 of 2
Time
/
:
© September 2016 Review date: September 2019 version