PLACE LABEL HERE
SEPSIS ADMISSION ORDERS
NON-ICU
The following orders will be implemented. Orders with a “  ” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
CRITERIA RECOMMENDATION
SEPSIS

Fever > 38°C (100.4°F), Hypothermia < 36°C (96.8°F)

Tachypnea > 20 bpm or pCO2 < 32 mmHg

Tachycardia > 90 bpm

Leukocytosis > 12,000 or Leukopenia < 4,000 or > 10% immature neutrophils
SEVERE SEPSIS / SEPTIC SHOCK

Sepsis-induced hypotension (MAP < 65 or requiring vasopressor support)

Lactate > 4

Urine output < 0.5 ml/kg/hr for more than 2 hrs despite adequate fluid resuscitation or no urine ou t put in ≥ 4 hours

Acute lung injury with PaO
2
/FiO
2
< 250 in the absence of pneumonia as infection source

Acute lung injury with PaO
2
/FiO
2
< 200 in the presence of pneumonia as infection source

Creatinine > 2 mg/dL or elevated > 0.5 mg/dL from baseline

Bilirubin > 2 mg/dL

Platelet count < 100,000

Coagulopathy (INR > 1.5)
IMCU/PCU, Medical floor (with or without telemetry)
ICU Admission if any of the following are present:

Hemodynamic instability requiring vasopressors (ICU required)

Sepsis induced hypotension

Lactate > 4

Respiratory compromise due to sepsis with either o Requiring greater than >50% oxygen
PF Ratio of <200= PaO
2
/FiO
2
Copy to pharmacy
Order writer’s initials___________
*3-20273*
FORM 3-20273 REV. 07/2015 Page 1 of 6

PLACE LABEL HERE
SEPSIS ADMISSION ORDERS
NON-ICU


2.
The following orders will be implemented. Orders with a “  ” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
DIAGNOSIS:  SEPSIS  SEVERE SEPSIS
EMERGENCY DEPARTMENT DOWNTIME ORDERS Pat ient’s Weight: _________ kg
1. Diagnostics:
CBC, CMP, Magnesium, DIC Profile, Serum lactate, Urine Analysis, Urine culture
Lactate in 4 hours
Blood culutres now x 2 sites, 15-20 minutes apart prior to antibiotics, if severe sepsis:
 Sputum gram stain and C&S
 CXR, Reason__________________  ABG
 Quantitative hCG ( menustrating female ≥ 12 yrs old)
O
2
per Protocol (form # 34431)
3. Continuous cardiac & pulse ox monitoring
4.
5.
Hourly vital signs
 Place Foley catheter
6. Place two large bore IVs, if possible
7. Notify physician for: MAP < 65 mm Hg or urine output < 0.5 ml/kg/hr or no urine out put in ≥ 4 hours
FLUID RESUSCITATION
8. IV Fluids:
MAP < 65: NS 30 ml/kg IV bolus PRN fluid challenge (max fluids 3 liters), If MAP continues to be < 65 or urine output < 0.5 ml/kg/hr or no urine output in > 4 hrs, Notify physician.
9. Antibiotic therapy: administer first dose within 1 hour per ED physician order
______________ _____________
Date Time
_________________________________
ED Physician Signature
___________
PID Number
Copy to pharmacy Order writer’s initials___________
FORM 3-20273 REV. 07/2015 Page 2 of 6

PLACE LABEL HERE
SEPSIS ORDERS
NON ICU
The following orders will be implemented. Orders with a “  ” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
 SEPSIS  SEVERE SEPSIS
1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?
 Yes, admit as inpatient, proceed to # 2   No, place in observation
2. If admitted as inpatient, Inpatient Physician Certification:
Diagnosis _______________________________________________
Level of Care:  Intermediate Care  Acute Care Location/Specialty Unit Preference: ________________
3.  Telemetry: Medical/Surgical Acute Care complete form # 36084
4.  Isolation  Contact  Airborne  Droplet For: ________________
5. Consult(s): _______________________________________________ If physician:  STAT or  Routine
6. STAT Diagnostics, IF NOT DONE IN ED:
CBC, CMP, Magnesium level, DIC Profile, Serum lactate
Quantitative hCG for any menustrating female ≥ 12 years of age if not done in ED
 HgbA1C
 Sputum collection for culture and gram stain
Blood Cultures:
Blood culutres now x 2 sites, 15-20 minutes apart prior to antibiotics, if severe sepsis:
Urine culture, Urine Analysis, Other culture: ______________________________________________________
7. Other Diagnositics:
 Portable CXR,  In am  Routine  STAT Reason ___________________
 ABG now  Routine  STAT
Nasal staph screen
CT Imaging:
 Head  with contrast Reason: ______________  Chest:  with contrast Reason __________
 Abd/Pelvis with contrast Reason: ______________  Other: ____________ Reason _________
AM labs:  CBC  CMP  Serum lactate  Magnesium level  Phosphorous level
8.
9.
Other: ________________________________________
O
2 per protocol (form #34431)
VITAL SIGNS:
Intermediate level of care: q 2 hrs x 24 hrs, then q 4 hrs, Notify physician for: MAP < 65
Acute level of care: per unit routine, Notify physician for: MAP < 65
10.  Place Foley catheter.
Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
11. INTAKE/OUTPUT
Intermediate level of care: Strict I&O q 4 hrs x 24 hrs, notify physician if urine output < 0.5 ml/kg/hr
Acute level of care: per unit routine, notify physician if no urine out put in ≥ 4 hrs
Place two large bore IVs, if possible 12.
Copy to pharmacy Order writer’s initials___________
FORM 3-20273 REV. 07/2015 Page 3 of 6

PLACE LABEL HERE
SEPSIS ORDERS
NON ICU
13.
The following orders will be implemente d. Orders with a “  ” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
14.
NPO or  Regular  Cardiac  Diabetic ______ calorie  Renal
Oral Nutrition Supplement Standing Orders (form # 31417), initiate if patient meets criteria
15. Activity (advance as tolerated):  Bed rest  BSC  BRP  Up ad lib  May shower
16. Initiate PT/OT Protocol (form # 32655) if patient has a substantial decrease from base line function
(that is unlikely to resolve within 48 hrs), or needs placement and disposition.
17. Maintenance fluids: _______________________________________________________________
18. VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)
 Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg OR age > 75) or  Lovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30 ml/min)
Mechanical devices:
19. Glucose control:
 SCDs
If glucose > 180, recheck in 1 hr. If still > 180, start glucose checks q 6 hrs or AC/HS with SSI: BS-100/30 = # units HumaLOG subcutaneously for BG > 180.
For Intermediate Care patients: Initiate Critical Care Insulin Standing Orders (form # 21386)
If patient receiving insulin, initiate Hypoglycemia Treatment Standing Orders (form # 2513)
20. Antibiotic therapy :
RECOMMEND THAT ANTIBIOTICS BE ASSESSED 48 HOURS AFTER INITIAL ADMINISTRATION
Antibiotic therapy: Administer first dose within 1 hr for severe sepis/sepsis shock if not already done in ED
 Sepsis due to UTI**: Gentamicin 5 mg/kg IV STAT, pharmacy to dose x 1 dose
**Consider using a carbepenem until known
ESBL negative and
 Fortaz (ceftazidime) 1 gm IV STAT,then q 8 hrs or
 Rocephin (ceftriaxone) 1 gm IV STAT, then q 24 hrs or
 Intra-abdominal sepsis/ unknown source:
 Zosyn (piperacillin/tazobactam) 3.375 gms IV STAT, then q 8 hrs or
 Invanz (ertapenem) 1 gm IV STAT, then q 24 hrs or
 Rocephin (ceftriaxone) 1 gm IV STAT, then q 24 hrs and
Flagyl (metronidazole) 500 mg IV STAT, then q 8 hrs or

Skin and soft tissue infections**:
**Consider using
Vancomycin until culture results are available
 or
Unasyn (ampicillin/sulbactam) 3 gms IV STAT q 6 hrs
 If patient is penicillin allergic, use Ancef (cefazolin) 1 gm IV STAT q 8 hrs and
 MRSA Risk as sepsis source
 Pharmacist to dose Vancomycin IV STAT and follow X 72 hrs
Copy to pharmacy Order writer’s initials___________
FORM 3-20273 REV. 07/2015 Page 4 of 6

PLACE LABEL HERE
SEPSIS ORDERS
NON ICU
The following orders will be implemented. Orders with a “  ” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
 SEPSIS DUE TO PNEUMONIA: 
 Community Acquired
Pneumonia with no additional pseudomonal risk
 Rocephin (ceftriaxone) 1 gm IV
STAT, then q 24 hrs
AND
 Avelox (moxifloxacin) 400 mg
STAT, then q 24 hrs
OR
 IV  po
Zithromax (azithromycin) 500 mg IV STAT, then q 24 hrs or
 Pseudomonas Pneumonia
(Suspected/ Possible/ Probable)
Check one:

Bronchiectasis

Structural lung disease with chronic steroid use or repeated antibiotic use
 HCAP


 Zosyn (piperacillin/tazobactam)
Documented Penicillin Allergy
 Merrem (meropenem) 1 gm
3.375 gm IV STAT, then q 6 hrs
AND
OR
IV STAT, then q 8 hr
 AND
Cipro (ciprofloxacin) 400 mg
Cipro (ciprofloxacin) 400 mg IV
IV STAT, then q 8 hrs
STAT, then q 8 hrs
Consider MRSA coverage if risk factors exist or
 Aspiration
Pneumonia:
(Suspected/ Possible/ Probable)
Risk factors (eg: CVA, alcoholism, altered mental status)


 Zosyn (piperacillin/tazobactam)
3.375 gm IV STAT, then q 8 hrs
Documented Penicillin Allergy

 Rocephin (ceftriaxone) 1 gm
IV STAT, then q 24 hrs
OR
AND
Flagyl (metronidazole) 500 mg
IV STAT, then q 8 hrs
Consider MRSA coverage if risk factors exist and
 MRSA
Pneumonia:
(Suspected/ Possible/ Probable)
Risk factors (eg: indwelling venous catheter, hemodialysis,
IV drug abuse )

 Vancomycin IV STAT, Pharmacist to dose and follow x 72 hrs
Copy to pharmacy Order writer’s initials___________
FORM 3-20273 REV. 07/2015 Page 5 of 6

SEPSIS ORDERS
NON ICU
PLACE LABEL HERE
The following orders will be implemented. Orders with a “  ” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
PRN MEDICATIONS (See policy 520-06 for range orders and pain intensity guidelines)
21. NS 250 ml bolus prn x 1 if MAP <65, SBP < 90, or UOP < 0.5 ml/kg/hr
22.  Electrolyte Replacement Protocol (form # 21340)
23. Mild Pain, Temp >100.5

F, HA:  Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
24. Moderate Pain:
 Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.
or  If patient cannot take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn instead of Norco. DC if Percocet ordered.
 or  Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered. and/or  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o old or
< 50 kg) or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30.
25. Severe Pain (Begin when Epidural or PCA has been discontinued)
 Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered. or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for excessive sedation. DC if Morphine ordered.
26. Nausea/Vomiting:  Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
27.
28.
Sleep :
Indigestion:
 If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)
 Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
 Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
29. Stool Softener:  Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
30. Constipation:  Milk of Magnesia (MOM) 30 ml po daily prn
If no BM after 48 hrs ,  Dulcolax (biscodyl) 10 mg per rectum daily prn
 and/or   Senokot-S (docusate/senna) 2 tablets po at bedtime nightly
31.
32.
Cough:
Sore Throat:
 Robitussin (guaifenesin) 15 ml po q 4 hrs prn
 Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________ ______________ _________________________________ ___________
Date Time Physician Signature PID Number
Copy to pharmacy
FORM 3-20273 REV. 07/2015 Page 6 of 6