DRAFT
Sepsis Study – Clinician questionnaire
(Please feel free to modify, comment)
NB - Based on the AKI template, I have skipped page 1 and 2 assuming that they
are part of standard format and will be included anyway. I have made suggestions
in italics about how each data item is collected - again feel free to change.
A. Patient details
1. Date of birth
2. Age
3. Gender
B. Pre-hospital care
4. Before hospital admission did this patient access healthcare - tick box
i. GP
ii. Urgent care centre
iii. Community nurse
iv.
111
v.
Hospital A&E
C. The admission
5. Date of admission
6. Time of admission
7. Was the admission – tick box
i. Planned
ii. Self presented to hospital A&E department
iii. Emergency admission by ambulance
iv.
Hospital transfer
v.
Referred by GP
vi.
Referred from Urgent care/ 111/ community nurse
8. The primary complaints at admission were 9. Diagnosis at admission – free text box
10. Final diagnosis at discharge or death – free text box
11. First assessment at admission done by – tick boxes that should include all
grades of doctors; and also Nurse/ triage nurse
i. Was sepsis suspected/ identified – Yes/ No / Not applicable
12. Initial clerking done by – grade of doctor – tick box
i. What sepsis suspected/ identified – Yes/ No / Not applicable
13. Specialty of consultant patient was admitted under – national codes
14. First blood tests at admission (add box for date)
i. White cell count
ii. CRP (if done)
15. Did the patient have evidence of sepsis at admission – Y/N
16. Please say why you think so – free text box
17. What was the likely cause of sepsis – tick box; Lungs, skin, gastro-intestinal,
genito-urinary, others (with free text box)
18. Please say why you think so – free text box
19. Were comorbidities recorded in the initial assessment – tick box. Diabetes,
COPD, steroid use, other immunosuppressive drugs,
20. If the patient developed sepsis in hospital was it recognised in time – Y/N
i. How was it diagnosed – tick box of clinical signs; infected lines, devices,
catheter, EWS system
ii. What investigations were used to make diagnosis – tick box of x-ray,
CT scan, blood tests, blood gas
iii. Was diagnosis made after surgery – Y/N. If yes, how many days postop; did the patient receive peri-operative antibiotics (details)
iv.
Was sepsis diagnosed after an invasive procedure – Y/N. If yes, how
many days post-procedure; did the patient receive peri-operative
antibiotics (details)
v.
Who made the initial diagnosis – tick box on nurse, doctor by grade
vi.
How severe was sepsis – tick box of pulse, BP, ABG, lactate, response to
initial treatment.
21. Was an attempt made to identify the cause of sepsis – Y/N
i. Clinical examination findings documented
ii. Imaging undertaken
iii. Blood cultures
iv.
Other investigations – please specify
22. Initial management – tick box of what was done; fluids, catheter, ABG, O2,
frequency of monitoring, drugs, antibiotics, review of patients previous
medication etc
23. After diagnosis of sepsis was considered
i. When was the first blood culture taken
ii. When was the first dose of antibiotic given
24. How was the choice of first antibiotic made
i. Hospital antibiotic policy
ii. Discussion with microbiologist/ ID specialist
iii. Previous culture results
iv.
Discretion of treating doctor
25. Does the hospital have a critical care outreach team – Y/N
26. If yes was the critical care outreach team involved – Y/N
i. If no, was this due to lack of 24/7 service
ii. Lack of escalation from treating team
iii. Lack of response from CCOT despite escalation based on EWS
27. Did involving the CCOT improve management of sepsis – Y/N
28. Was a surgical/ interventional (??better word) cause found for sepsis – Y/N
i. If yes, was appropriate intervention carried
ii. Was the procedure carried out in time
29. Outcome
i. What additional steps were carried out in ICU
ii. Did the patient develop complications – y/n
iii. If yes, list in tick box
30. Did the patient survive - Y/N
i. If no what was the final diagnosis
ii. In your opinion, could this death be prevented
31. If the patient survived
i. What was the final diagnosis at discharge
ii. Was any follow up made
iii. were there any disabilities at 30 days from discharge, y/n
iv.
If yes, could they have been prevented