Sepsis Screening Action Tool To be applied to

Sepsis Screening & Action Tool To be applied to all non-pregnant patients over 12 years who have suspected infection, for whom staff or relatives are concerned, or who have clinical observations outside normal limits. Patient details (affix label): Date/Time: ………………. . . ……………… Staff member completing form: Name (print): …………………… Designation: …………………… Signature: …………………… Important: Is an end of life pathway in place/ is escalation clinically inappropriate? Yes Tick 1. Is individual NEWS 3 or overall ≥ 5? 2. Is there clinical concern? N Initials Stop pathway Low risk of sepsis Use standard protocols, review if deteriorates Y N 2. Could this be due to an infection? 4. Any Amber Flag criteria? Tick Yes, but source unclear at present Tick Relatives concerned about mental status Pneumonia Acute deterioration in functional ability Urinary Tract Infection Immunosuppressed Cellulitis/ septic arthritis/ infected wound Trauma, surgery or procedure in last 6 weeks N Device-related infection Meningitis Clinical signs of wound, device or skin infection Respiratory Rate 21 -24 or breathing hard Heart Rate 111 -130 or new arrhythmia Other (specify: ……………. . ) Abdominal pain/distension–refer for senior review Systolic BP 91 -100 mm. Hg surgical Not passed urine in last 12 -18 hours Temperature < 36 OC Y Rigors 3. Is any ONE red flag present? Tick Y Systolic BP ≤ 90 mm. Hg (or drop >40 from normal) Send bloods Lactate ≥ 2 mmol/l Time complete Initials To include FBC, U&Es, CRP, LFTs, clotting Respiratory Rate (RR)> 25 per minute Heart Rate (HR) > 130 per minute Contact senior doctor to review Responds only to voice, pain or is unresponsive N attended? Has clinician USE SBAR! Must review results within 1 hour Needs oxygen to keep Sp. O 2 ≥ 92% (88% in COPD) Non-blanching rash, mottled/ ashen/ cyanotic Is AKI present? (tick one) YES Oliguria (from history or less than 0. 5 ml/kg/hr) NO Recent chemotherapy (6 weeks) Y Y Clinician to make antimicrobial Prescribing decision within 3 h Time complete Red Flag Sepsis. Start Sepsis 6 pathway NOW (see overleaf) This is time critical, immediate action is required. Dr Name / Signature: Time Zero: Initials

Sepsis Six Pathway To be applied to all patients over 12 years of age with suspected or confirmed Red Flag Sepsis Make a treatment escalation plan and decide on CPR status Patient has Red Flag Sepsis Action (complete ALL within 1 hour) Time complete Time zero Signature Senior doctor & CCOT/ART* informed? Initials Comments 1. Administer oxygen Aim to keep saturations > 94% (88 -92% if at risk of CO 2 retention e. g. COPD) 2. Take blood cultures From *PICC/Hickman/central line too Remember to take blood cultures using an aseptic non touch technique Septic screen – sputum, urine & swabs 3. Give IV antibiotics According to Trust protocol Consider allergies and MRSA history prior to administration 4. Give IV fluids As per hospital protocol/NICE guidelines Titrate fluid boluses depending on lactate levels 5. Check serial lactates Not applicable- initial lactate <2 6. Measure urine output Ensure fluid balance chart commenced & completed hourly May require urinary catheter If after delivering the Sepsis Six, patient still has: • Systolic B. P <90 mm. Hg • Reduced level of consciousness despite resuscitation • Respiratory rate over 25 breaths per minute • Lactate not reducing Or if patient is clearly critically ill at any time Then Call Cons and CCOT/Acute Response team See Intranet for guidelines on sepsis management and antimicrobial policy – microguide. *Remember to take blood cultures peripherally and from all lumens and label correctly as per policy (see blood culture policy on intranet) *CCOT- Critical Care Outreach Team/ART- Acute Response Team For more copies of this document please contact Reprographics on 3778 and Quote: Print No. A 4 Colour 10 August 2016 Sepsis Six and Red Flag Sepsis are copyright to and intellectual property of the UK Sepsis Trust, registered charity no. 1158843. sepsistrust. org