ED Sepsis Screening Tool
SIRS Screen
 ‘None seen’
defaults in
‘Negative
Sepsis Screen’.
 1 or more SIRS
criteria will open
the Infection
Screen field
If patient is a “Negative Sepsis screen”, you will receive a
Task in 2 hours to re-evaluate.
Infection Screen
 ‘None’ defaults
in ‘Negative
Sepsis Screen’
 1 or more
infection criteria
will open
‘Positive Sepsis
Screen’
If patient is a ‘Negative Severe Sepsis Screen” you will
receive a Task in 2 hours to re-evaluate.
If patient is a “Positive Severe Sepsis Screen” you are done
with the screening process.
Organ Dysfunction
Screen
 Field opens if the
patient has a
‘Positive Sepsis
Screen.
 ‘None’ defaults in
‘Negative Severe
Sepsis Screen’
 1 or more organ
dysfunction will open
‘Positive Severe
Sepsis Screen’
ED Sepsis Screening Tool
ED Sepsis Screening Tool
Documented or suspected infection as evidenced by any of the following:
* New symptoms of infection (e.g. weakness, fever/chills, lethargy, new purulent drainage, etc.)
* Current or recent antibiotic therapy (NOT PROPHYLACTIC)
List of potential areas for suspected sepsis:
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Pneumonia, empyema, cough
Symptoms of Urinary Tract infection
Acute abdominal infection
Meningitis
Skin/soft tissue infection
Bone/joint infection
Wound infection
Blood stream catheter infection
Endocarditis
Implantable device infection
Unknown source
Nursing Care Guidelines for Positive Sepsis Screen ED
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Cardiac Monitor, pulse ox, NBP
O2 per protocol to keep sats > 92%
Establish large bore IV
Anticipate the following labs: BC x2, CMP, lactate, CRP. ESR, Cortisol, U/A, sputum
Anticipate antibiotic orders and STAT administration
Vital Signs q 15 minutes until stable, then hourly
Nursing Care Guidelines for Positive Severe Sepsis Screen ED
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Notify physician immediately
Above Nursing Care Guidelines, plus the following:
Establish 2nd large bore IV site
Labs per sepsis protocol if not already done (I-Stat labs at MMC)
Anticipate the following orders per facility specific protocol (ED Sepsis Power Plan at MMC)
 Fluid bolus for BP support or lactic acidosis
 Consider central line placement and additional invasive monitoring, (CVP and Arterial Line)
 Antibiotic administration within one hour of positive severe sepsis screen
Vital Signs q 15 minutes until stable, then hourly