SEVERE SEPSIS SCREENING TOOLS (adapted from Pat Posa (SJMHS) tool INFECTION Suspected or documented infection Antibiotic therapy Check blood glucose if any one above is checked AND proceed to STEP II: Blood sugar: If no checks above = NEGATIVE screen for sepsis: Initial _________ No need to proceed to Step II, however continue to assess resident for changes: STOP and WATCH early warning tool OR Using your Senses to Identify Sepsis SIRS Systemic Inflammatory Response Syndrome – Temperature greater than or equal to 101 or less than or equal to 96.8F HR greater than 90 beats/minute Respiratory rate greater than 20 breaths/minute Blood glucose greater than 140 in non-diabetics If less than 2 checked = NEGATIVE screen for sepsis: Initial _________ No need to proceed to Step III, however continue to assess resident. If 2 above are checked, PATIENT SCREENED POSITIVE FOR SEPSIS resident on I & O. Monitor and record urine output every shift Obtain order for LACTIC ACID and proceed to Section III ORGAN DYSFUNCTION Respiratory: SAO2 less than 90% OR increasing O2 requirements Cardiovascular: SBP less than 90mmHg OR 40mmHg less than baseline Renal: Urine output less than .5ml/kg over last 8 hours CNS: Mental status changes LABS: (Do not use lab results older than 24 hours) Platelets less than 100,000 INR greater than 1.5 Bilirubin greater than or equal to 4mg/dl Serum lactic acid greater than or equal to 2mEq/l If 1 above checked, PATIENT SCREENS POSTIVE FOR SEVERE SEPSIS. CALL PHYSICIAN AND FOLLOW SBAR SCRIPT BELOW. If no checks above = NEGATIVE screen for sepsis: Initial _________ Continue to assess. No further action at this time. SITUATION: Tell physician resident screened positive for Severe Sepsis BACKGROUND Describe positive SIRS; Inform physician if resident is currently being treated for a known infection; share which organ system has dysfunction ASSESSMENT Share VS and SaO2 (pulse ox) RECOMMENDATION: Blood cultures; CBC; IV Antibiotic REQUEST ORDER Decreased BP, fluid bolus 30ml/kg over 1 hour or faster until hypotension FOR FOLLOWING resolved. If resident does not respond to bolus, send to ER USING YOUR SENSES TO IDENTIFY SEPSIS (HOME INSTEAD)
SEVERE SEPSIS SCREENING TOOLS (adapted from Pat Posa (SJMHS) tool INFECTION Suspected or documented infection Antibiotic therapy Check blood glucose if any one above is checked AND proceed to STEP II: Blood sugar: If no checks above = NEGATIVE screen for sepsis: Initial _________ No need to proceed to Step II, however continue to assess resident for changes: STOP and WATCH early warning tool OR Using your Senses to Identify Sepsis SIRS – Systemic Inflammatory Response Syndrome Temperature greater than or equal to 101 or less than or equal to 96.8F HR greater than 90 beats/minute Respiratory rate greater than 20 breaths/minute Blood glucose greater than 140 in non-diabetics If less than 2 checked = NEGATIVE screen for sepsis: Initial _________ No need to proceed to Step III, however continue to assess resident. If 2 above are checked, PATIENT SCREENED POSITIVE FOR SEPSIS resident on I & O. Monitor and record urine output every shift Obtain order for LACTIC ACID and proceed to Section III ORGAN DYSFUNCTION Respiratory: SAO2 less than 90% OR increasing O2 requirements Cardiovascular: SBP less than 90mmHg OR 40mmHg less than baseline Renal: Urine output less than .5ml/kg over last 8 hours CNS: Mental status changes LABS: (Do not use lab results older than 24 hours) Platelets less than 100,000 INR greater than 1.5 Bilirubin greater than or equal to 4mg/dl Serum lactic acid greater than or equal to 2mEq/l If 1 above checked, PATIENT SCREENS POSTIVE FOR SEVERE SEPSIS. CALL PHYSICIAN AND FOLLOW SBAR SCRIPT BELOW. If no checks above = NEGATIVE screen for sepsis: Initial _________ Continue to assess. No further action at this time. SITUATION: Tell physician resident screened positive for Severe Sepsis BACKGROUND Describe positive SIRS; Inform physician if resident is currently being treated for a known infection; share which organ system has dysfunction ASSESSMENT Share VS and SaO2 (pulse ox) RECOMMENDATION: REQUEST ORDER FOR FOLLOWING Blood cultures; CBC; IV Antibiotic Decreased BP, fluid bolus 30ml/kg over 1 hour or faster until hypotension resolved. If resident does not respond to bolus, send to ER USING YOUR SENSES TO IDENTIFY SEPSIS (HOME INSTEAD)
SEVERESEPSIS%20SCREENINGTOOL.docx