DEPARTMENT/MANUAL: HOSPITAL WIDE POLICY
ORIGINAL/REVISED DATE: / REVIEWED DATE: / PAGE NUMBER:
Page 1 of 3
SUBJECT:
Sepsis
Standard of Care
/ PREPARED BY:
POLICY NUMBER:
DRAFT / APPROVED BY:
CNO:______
MEC:______
GB:______

Scope

Emergency Department, Intensive Care Unit, Acute and Non-Acute Patient Care Areas

Purpose

To facilitate rapid identification and treatment of patients who are experiencing severe sepsis or septic shock and to provide early goal directed therapy in a safe and efficient manner. Organization and anticipation of potential problems are essential.

Policy

At minimum, the following parameters and care will be implemented upon identification of the septic patient.

Procedure

A patient who arrives in the Emergency Department with sepsis symptoms will receive the following care:

A.  Registration

Patients with two or more of the following symptoms and signs require immediate assessment by the triage nurse:

·  Temp > 38.3 C (100.9 F) or < 36.0 C (96.8 F)

·  Heart rate > 90

·  Respiratory rate > 20

·  Altered mental status (observed or reported by family)

·  Hyperglycemia ( glucose > 120 mg/dl) in the absence of diabetes

·  SBP < 90 mmHg, MAP < 70, or SBP decrease > 40 mmHg

DEPARTMENT/MANUAL: HOSPITAL WIDE POLICY
ORIGINAL/REVISED DATE: / REVIEWED DATE: / PAGE NUMBER:
Page 2 of 3
SUBJECT:
Sepsis
Standard of Care
/ PREPARED BY:
POLICY NUMBER:
DRAFT / APPROVED BY:
CNO:______
MEC:______
GB:______

B.  Triage

Patients with the following symptoms require initiation of the “Stop Sepsis Bundle”

(refer to attachment “A”) to facilitate rapid identification and treatment of patients who are experiencing severe sepsis or septic shock:

·  Two or more of the following symptoms:

o  Temp > 38. 3 C (100.9 F) or < 36.0 C (96.8 F)

o  Heart rate > 90

o  Respiratory rate > 20

o  Altered mental status

o  Hyperglycemia (glucose 120 mg/dl) in the absence of diabetes

o  SBP < 90 mmHg, MAP < 70, or SBP that has decreased > 40 mmHg from patient’s reported normal

·  Place patient in a monitored bed immediately and initiate the “Stop Sepsis Bundle”

C. Medical – Surgical patients will be assessed for sepsis signs & symptoms as outlined

Under “B” Triage.

D. Emergency Department and/or Intensive Care Area and/or Acute and Non-Acute

·  If suspected infection is assessed by ER MD, obtain IV access with large bore needle, blood cultures, WBC, Chemistry panel, serum lactate and IV antibiotics ASAP.

·  If patient’s SBP remains < 90 after fluid challenge and/or serum lactate ≥ 4 mmol/L, patient is at HIGH risk for severe sepsis. Central line placement of the Edwards Lifesciences’ Central Venous Oximetry Catheter Kit via subclavian or jugular approach and transfer to Intensive Care Unit is essential for optimal outcome.

·  Also reference: ICU policy 6015-301 Admission/Discharge/Transfer Criteria

·  Once the patient is transferred to ICU, assess patient for symptoms (noted above in Triage

DEPARTMENT/MANUAL: HOSPITIAL WIDE POLICY
ORIGINAL/REVISED DATE: / REVIEWED DATE: / PAGE NUMBER:
Page 3 of 3
SUBJECT:
Sepsis
Standard of Care
/ PREPARED BY:
POLICY NUMBER:
DRAFT / APPROVED BY:
CNO:______
MEC:______
GB:______

·  section) that require initiation of the “Stop Sepsis Bundle” (Reference: Sepsis Standard of Care policy). Expedite physician evaluation.

·  If not already in place, connect patient to the Edwards Vigileo continuous central venous oxygen

saturation monitor. If arterial line is in place, connect patient to the aterial pressure cardiac output monitor (apart of the Edwards Vigileo Monitoring System). Reference: ICU Policy on Continuous Central Venous Oxygen Saturation & Continuous Arterial Pressure Cardiac Output Monitoring.

·  Maintain a patent airway and place on oxygen if indicated.

·  Place on cardiac monitor, ascertain baseline rhythm and chart vital signs per ICU policy. Reference: ICU-CCU policy 6015-325-10.

·  Perform physical assessments and document as outlined in ICU –CCU policy 6015-325-10.

·  Also reference: Critical Care Policy – Monitoring Vasoactive or Antiarrhythmic Drips In Critcal Care – Policy 6015-1903 (if applicable)

·  Also reference: Critical Care Policy – Arterial Line Monitoring – Policy 6015-2409-04 (if applicable)

·  Patients must be assessed by APACHE II Calculator located on internet @ www.globalrph.com prior to administration of Drotrecogin alfa activated (Xigris) (refer to attachment “B”)