Transcription of SEPSIS SCREENING TOOL ACUTE ASSESSMENT
1 SEPSIS SCREENING TOOL ACUTE ASSESSMENTSTART THIS CHART IF THE PATIENT LOOKS UNWELL OR NEWS2 IS 5 OR ABOVENO AMBER FLAGS = ROUTINE CARE / CONSIDER OTHER DIAGNOSISCOULD THIS BE DUE TO AN INFECTION?ANY RED flag PRESENT?SEPSISUNLIKELY,CONSIDEROTHERDIAG NOSISRED flag SEPSIS SEPSIS SIXRISK FACTORS FOR SEPSIS INCLUDE:PATIENT DETAILS:DATE: TIME:NAME:DESIGNATION:SIGNATURE:LIKELY SOURCE:STARTAge > 75 Impaired immunity ( diabetes, steroids, chemotherapy)Recent trauma / surgery / invasive procedureIndwelling lines / IVDU / broken skinRespiratory Brain Urine SurgicalObjective evidence of new or altered mental stateSystolic BP 90 mmHg (or drop of >40 from normal)Heart rate 130 per minuteRespiratory rate 25 per minuteNeeds O2 to keep SpO2 92% (88% in COPD)Non-blanching rash / mottled / ashen / cyanoticLactate 2 mmol/lRecent chemotherapyNot passed urine in 18 hours (< if catheterised)Skin / joint / woundOtherIndwelling device010203 ANY AMBER flag PRESENT?
2 FURTHER REVIEW REQUIRED:Relatives concerned about mental statusAcute deterioration in functional abilityImmunosuppressedTrauma / surgery / procedure in last 8 weeksRespiratory rate 21-24 Systolic BP 91-100 mmHgHeart rate 91-130 or new dysrhythmiaTemperature <36 CClinical signs of wound infection04 AGE 12+TIME OF REVIEW:ANTIBIOTICS REQUIRED: Yes No- SEND BLOODS AND REVIEW RESULTS- ENSURE SENIOR CLINICAL REVIEW within 1 HRYESYESNONOYESYES:UKST 2020 PAGE 1 OF 2 / UKST, REGISTERED CHARITY 1158843 SEPSIS SCREENING TOOL - THE SEPSIS SIXAGE 12+COMPLETE ALL ACTIONS WITHIN ONE HOURRED FLAGS AFTER ONE HOUR ESCALATE TO CONSULTANT NOWPATIENT DETAILS:DATE: TIME:NAME:DESIGNATION:SIGNATURE:NOT ALL PATIENTS WITH RED FLAGS WILL NEED THE SEPSIS 6 URGENTLY.
3 A SENIOR DECISION MAKER MAY SEEK ALTERNATIVE DIAGNOSES/ DE-ESCALATE CARE. RECORD DECISIONS BELOWNAME: GRADE:TIMETIMETIMETIMETIMETIMEMAXIMUM DOSE BROAD SPECTRUM THERAPYCONSIDER: LOCAL POLICY / ALLERGY STATUS / ANTIVIRALSSTART IF O2 SATURATIONS LESS THAN 92% - AIM FOR O2 SATURATIONS OF 94-98%IF AT RISK OF HYPERCARBIA AIM FOR SATURATIONS OF 88-92%GIVE FLUID BOLUS OF 20 ml/kg if age <16, 500ml if 16+NICE RECOMMENDS USING LACTATE TO GUIDE FURTHER FLUID THERAPYBLOOD CULTURES, BLOOD GLUCOSE, LACTATE, FBC, U&Es, CRP AND CLOTTING LUMBAR PUNCTURE IF INDICATEDUSE NEWS2. MEASURE URINARY OUTPUT: THIS MAY REQUIRE A URINARY CATHETER REPEAT LACTATE AT LEAST ONCE PER HOUR IF INITIAL LACTATE ELEVATED OR IF CLINICAL CONDITION CHANGESRECORD ADDITIONAL NOTES HERE: allergy status, arrival of specialist teams, de-escalation of care, delayed antimicrobial decision making, variance from SEPSIS Six::::::010402050306 ENSURE SENIOR CLINICIAN ATTENDSOXYGEN IF REQUIREDGIVE IV FLUIDSOBTAIN IV ACCESS, TAKE BLOODSGIVE IV ANTIBIOTICSMONITORUKST 2020 PAGE 1 OF 2 / UKST, REGISTERED CHARITY 1158843
