Sepsis screening tool

Question 1

Acute assessment: step 1

Answer 1

start this chart if the patient looks unwell or NEWS2 is ≥5

Question 2

Risk factors for sepsis

Answer 2

age >75
recent trauma / surgery / invasive procedure
impaired immunity (e.g. diabetes, steroids, chemotherapy)
indwelling lines / IVDU / broken skin

Question 3

Acute assessment: step 2

Answer 3

Could this be due to an infection?

Question 4

Likely sources of infection

Answer 4

respiratory, urine, skin/joint/wound, indwelling device, brain, surgical, other

Question 5

Acute assessment: step 3

Answer 5

Any red flag present?
Yes = start Sepsis 6

Question 6

Red flags for sepsis

Answer 6

RR ≥25 per minute
needs O2 to keep SpO2 ≥92% (88% in COPD)
HR ≥130 per minute
systolic BP ≤90 mmHg (or drop of >40 from normal)
not passed urine in 18 hours (<0.5 ml/kg/hr if catheterised)
lactate ≥2 mmol/L
objective evidence of new or altered mental state
non-blanching rash / mottled / ashen / cyanotic
recent chemotherapy

Question 7

Acute assessment: step 4

Answer 7

Any amber flag present?
Yes = send bloods and review results; ensure senior clinical review within 1 hr
No = routine care / consider other diagnosis

Question 8

Amber flags for sepsis

Answer 8

RR 21-24
HR 91-130 or new dysrhythmia
systolic BP 91-100 mmHg
relatives concerned about mental status
acute deterioration in functional ability
immunosuppressed
temperature <36°C
clinical signs of wound infection
trauma / surgery / procedure in last 8 weeks

Question 9

Sepsis 6: step 1

Answer 9

ENSURE SENIOR CLINICIAN ATTENDS
not all patients with red flags will need the ‘Sepsis 6’ urgently
a senior decision maker may seek alternative diagnoses / de-escalate care

Question 10

Sepsis 6: step 2

Answer 10

OXYGEN IF REQUIRED
start if SpO2 <92%
aim for SpO2 94-98% (88-92% if at risk of hypercapnia)

Question 11

Sepsis 6: step 3

Answer 11

OBTAIN IV ACCESS, TAKE BLOODS
blood cultures, blood glucose, lactate, FBC, U&Es, CRP and clotting
lumbar puncture if indicated

Question 12

Sepsis 6: step 4

Answer 12

GIVE IV ANTIBIOTICS
maximum dose broad spectrum therapy
consider: local policy / allergy status / antivirals

Question 13

Sepsis 6: step 5

Answer 13

GIVE IV FLUIDS
give fluid bolus of 20 ml/kg if age <16, 500 ml if 16+
NICE recommends using lactate to guide further fluid therapy

Question 14

Sepsis 6: step 6

Answer 14

MONITOR
use NEWS2
measure urine output (this may require a urinary catheter)
repeat lactate at least once per hour if initial lactate elevated or if clinical condition changes

Question 15

Red flags after one hour

Answer 15

escalate to consultant now