St.

Joseph Mercy Ann Arbor

St. Joseph Mercy Livingston

Patient Units Severe Sepsis Screening Tool

Severe Sepsis = Infection + SIRS + Organ Dysfunction

Directions: The screening tool is for use in identifying patients with severe sepsis. Screen each patient upon admission, once per shift and PRN with change in condition.
DATE:
TIME:
I. SIRS-Systemic Inflammatory Response Syndrome (two or more of the following):
Temperature greater than or equal to 101°F or less than or equal to 96.8°F
Heart Rate greater than 90 beats/minute
Respiratory Rate greater than 20 breaths per minute
WBC greater than or equal to 12,000/mm3 or less than or equal to 4,000/mm3 or greater than
0.5 K/uL bands
Blood glucose greater than 140 ml/dL in non-diabetic patient
Negative screen for severe sepsis (Please initial)
if check two of the above, move to II
II. Infection (one or more of following):
Suspected or documented infection
Antibiotic Therapy (not prophylaxis)
If check none of above – Negative screen for severe sepsis (Please initial) – answer infection question NO in I-View
If check one of the above – answer infection question YES in I-View, call physician for serum lactic acid order and move to III
III. Organ Dysfunction (change from baseline)
(one or more of the following within 3 days of new infection)
Respiratory: SaO2 less than 90% OR increasing O2 requirements
Cardiovascular: SBP less than 90mmHg OR 40mmHg less than baseline OR MAP less than 65mmHg
Renal: urine output less than 0.5ml/kg/hr; creatinine increase of greater than
0.5mg/dl from baseline
CNS: altered consciousness (unrelated to primary neuro pathology)
Glascow Coma Score less than or equal to 12
Hematologic: platelets less than 100,000; INR greater than 1.5
Hepatic: Serum total bilirubin greater than or equal to 4mg/dl
Metabolic: Serum lactic acid greater than or equal to 2mEq/L
Negative screen for severe sepsis (Please initial)
If check one in section III or a severe sepsis alert fires, patient has screened positive for severe
sepsis
1. Call rapid response team
2. Call physician, physician assistant or nurse practitioner and implement urgent measures protocol.
3. Initiate or ensure IV access (2 large bore IV’s if no central access)
4. Obtain a venous blood gas (peripheral draw), serum lactic acid, CBC (if it has been greater than
12 hrs since last test), two sets of blood cultures (if greater than 24 hours since last set)
5. If patient is hypotensive: Give crystalloid (NS) fluid bolus – 30ml/kg over one hour or as fast as possible
until hypotension resolved, unless known EF is less than 35% or active treatment for heart failure.

RN Signature, Initial Date & Time:

*AA1314* 292239 (02352) R 10/12 (M)D

 General Care Severe Sepsis Bundle Intermediate Care Severe Sepsis Bundle
For patients with 2 or more SIRS + known/suspected infection + For patients with 2 or more SIRS + known/suspected infection +
initial lactic acid 2-2.9 w/o additional organ dysfunction initial lactic acid 3-3.9 or had hypotension that responded to
fluid bolus
• Blood cultures x 2
• Blood cultures x 2
• Antibiotics w/in 1 hr of screening positive for sepsis. Ensure antibiotic is
ordered STAT (call Rx and notify of STAT order) • Antibiotics w/in 1 hr of screening positive for sepsis. Ensure antibiotic is
ordered STAT (call Rx and notify of STAT order)
• Vital signs: every 1 hr x 4, then every 4 hr x 2, then once per shift
• Vital signs: every 30 min x 4, then every 1hr x 2, then every 2hr x 4;
• Lactic acid every 4 hr x 24 hr
then every 4 hr
• I & O every 2 hr (if no void w/in 4 hr, bladder scan- if greater than
• Lactic acid every 4 hr x 24 hr
200 mL perform intermittent straight cath), call MD if less than
0.5 mL/kg/hr • I & O every 2 hr (if no void w/in 4 hr, bladder scan- if greater than
200 mL perform intermittent straight cath), call MD if less than
• Maintain/monitor for:
0.5 mL/kg/hr
– SBP greater than 90 mmHg
– Urine output greater than 0.5 mL/kg/hr • Continue to administer fluid boluses per physician order to achieve/
– Decrease in lactic acid x 3 results or normalization x2 within 12 hours maintain the following goals:
– SBP greater than 90 mmHg
**If unable to maintain these parameters or if pt has additional organ
– Urine output greater than 0.5 mL/kg/hr
dysfunction, call MD for possible transfer to IMC/ICU
– Decrease in lactic acid x 3 results or normalization x2 within 12 hours
• Continue sepsis screen every shift and prn change in patient condition
**If unable to achieve these parameters or if pt has increase in lactic
• Complete 0 to 1 hour interventions, below acid of 0.5 or more, increase in O2 requirements, mental status
change, or additional organ dysfunction, call MD for possible
transfer to ICU
• Complete 0 to 1 hour interventions, below

Date/Time: ____________________ to ____________________ Date/Time: ____________________ to ____________________

�������� If hypotensive, volume resuscitate: initial 30 mL/kg as fast as �������� If hypotensive, volume resuscitate: initial 30 mL/kg as fast as
possible, then additional boluses as needed per order possible, then additional boluses as needed per order
�������� Time 30 mL/kg fluid bolus infused �������� Time 30 mL/kg fluid bolus infused
�������� Broad spectrum antibiotic-start after obtaining blood culture �������� Broad spectrum antibiotic-start after obtaining blood culture
�������� Time antibiotic hung �������� Time antibiotic hung
�������� Initial Labs: serum lactate, additional labs as ordered by �������� Initial Labs: serum lactate, additional labs as ordered by
physician physician
Yes No Serum lactic acid drawn Yes No Serum lactic acid drawn
Yes No Blood Cultures x 2 Yes No Blood Cultures x 2
�������� Time 1: _______________ Time 2: _______________ �������� Time 1: _______________ Time 2: _______________
�������� Other cultures: �������� Other cultures:
�������� Establish IV access (2 large bore IVs) �������� Establish IV access (2 large bore IVs)
Signature:________________________________________________Date/Time:__________________ Signature:________________________________________________Date/Time:__________________