National Early Warning Score Adult Patient Observation Chart - Health Service Executive Page 3
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3ADULT PATIENTS
Sepsis Screening Pathway
There is separate sepsis criteria
for women in pregnancy
(ALWAYS USE CLINICAL JUDGEMENT)
Use this Sepsis Screening Pathway if the National Early Warning Score (NEWS) is ≥ 4
(5 on supplementary O 2 ), or if infection is suspected
Doctor must review within 30 mins (use ISBAR)
Are any 2 or more modi ed Systemic In ammatory Response Syndrome (SIRS) criteria present
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• Respiratory rate > 20
• WCC < 4 or > 12 x 10
/L
• Acutely altered mental status
(bpm)
• Heart rate > 90
• Temperature <36 or >38.3
( o C)
• Bedside glucose >7.7mmol/L
(bpm)
+
(in the absence of diabetes mellitus)
INFECTION SUSPECTED
Note: Some groups of patients, such as older people, may not meet the modified SIRS criteria, even though infection is suspected.
Where this occurs check for signs of organ dysfunction and raised biomarkers such as C-reactive protein (CRP)
Following a history and examination, and in the absence of suspected infection, sta may
NO
proceed with using the NEWS protocol
YES.
THIS IS SEPSIS
Sepsis Six Regimen must be completed within 1 hour
NO
YES
Has a decision been made NOT to escalate care (excluding further treatment)?
proceed
do not proceed
SEPSIS SIX –
aim to complete within 1 hour
TAKE 3
GIVE 3
1. Blood cultures before giving antibotics
4. O
(94-98% SpO
or 88-92% in COPD patients)
2
2
Do not delay antibiotic administration >1 hour if blood cultures
5. IV uid resuscitation
are di cult to obtain. Send samples from potentially infected
(500ml bolus - give up to 30ml/kg) & reassess
sites eg. sputum, urine, wounds, IVC/CVC. Consider source control.
(target systolic BP>90/MAP>65)
2. Lactate and FBC
Monitor response to IV uids and titrate to e ect
3. Urine output measurement
6. IV antibotics according to local guidelines
Laboratory tests must be requested as EMERGENCY and aim to have results available and acted on within the hour
Look for signs of organ dysfunction:
Look for signs of septic shock
(following administration of fluid bolus)
• Systolic BP < 90 or Mean Arterial Pressure
< 65 or Systolic BP more than 40 below patient’s normal
• Lactate > 4 mmol/L
• New need for oxygen to achieve saturation > 90%
• Hypotensive (Systolic BP < 90 or MAP < 65)
• Lactate > 2 mmol/L
(following administration of fluid bolus)
If either present:
THIS IS SEPTIC SHOCK
• Urine output < 0.5ml/kg for 2 hours – despite adequate
Critical care consult required
uid resuscitation
• Acutely altered mental status
• Consultant referral
• Glucose > 7.7 mmol/L (in the absence of diabetes)
• Consider transfer to a higher level of care
• Creatinine > 177 micromol/L
• Critical care consult requested
• Bilirubin > 34 micromol/L
A critical care review may be requested at any point during this assessment,
• PTR > 1.5 or aPTT > 60s
but is required for patients with Septic Shock. In a hospital with no critical
care unit, a critical care consult must be made and transfer to a higher level
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• Platelets < 100 x 10
/L
of care considered, if appropriate, following the consult.
THIS IS SEVERE SEPSIS
Any organ dysfunction:
Registrar or Consultant to review immediately.
Pathway Modification
Reassess frequently in 1st hour.
Not all patients meeting modi ed SIRS criteria have sepsis,
Consider other investigations and management
OR there may be additional problems requiring di erent management
(current Congestive Cardiac Failure (CCF), Diabetic Ketoacidosis (DKA),
Myocardial Infarction (MI), Gastro-Instinal (GI) Bleed etc)
OR patient may be receiving chemotherapy
OR be palliated.
File this document in patient notes - Document management plan.
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