STAG Audit: Sepsis Phase 2
Family name: ______First name: ______
Case note number: CHI number: Audit no.
ÿðÿðÿðÿðÿð ÿðÿðÿðÿðÿð ððÿðÿðÿ
STAG Audit: SEPSIS Phase 2
Hospital code: ÿðÿÿð Audit no:ðÿÿðÿðð
Postcode: ðÿðÿ ÿ Sex: ð 1 = Male 2 = Female Age: ðÿð yrs
Pre-hospital Care (Note: not yet discussed with SAS)
Mode of Arrival: ð Not known = 0 Self = 1 Ambulance = 2 Air = 3
SAS Incident Number: ðÿÿðÿðððððð.ððð
Inter-hospital :ð not known = 0 Yes = 1 No = 2
Enter ED Date: ðð.ðð.ðð Time: ðð:ðð Arrived Intubated: ð not known = 0 Yes = 1 No = 2
Information On Admission Initial Area in ED: ð Resus = 1 Monitored Area = 2 Major = 3 Minor = 4
Initial triage category: ð Categories 1(red), 2(orange) ,3(yellow), 4(green), not known = 0 Time of admission values: ðð:ðð Source of Admission Values : ED = 1 SAS = 2 Values Source
Temperature: ðð.ð oC ð
Heart rate: ððð beats/min ð
Respiratory Rate: ððð breaths/min ð
Systolic BP: ððð mm.Hg Diastolic BP: ððð mm.Hg ð
O2 Saturation: ððð % on: ððLitres O2 and/or %age: ððð % ð
Eye Opening: ð Motor Response: ð Verbal Response: ð Total GCS ðð ð
AVPU Score (if available): ð Alert = 0 Verbal =1 Pain = 2 Unresponsive = 3 ð
BM: ðð.ðmmol/l (HI/high > 30 LO/low < 4) ð
Total SEWS Score on chart: ð Type of chart: ð SEWS = 1 MEWS = 2 Modified Mews = 3 not applicable = 4
Lactate level recorded: ð Yes = 1 No = 2 1st Lactate level: ðð.ðmmol/l Time Lactate was taken: ðð:ðð
Admission Diagnoses/Presenting Complaints by Group Yes = 1 No = 2
Trauma (1): ð Neurological (2): ð Cardiac (3): ð Respiratory (4): ð
Toxicology (5): ð GI (6): ð Vascular (7): ð Sepsis (8): ð
Metabolic/Endocrine (9): ð Cardiac Arrest (10): ð Environmental(11):ð Other/Unknown(12):ð
None Documented (13): ð Specify:
Mention of sepsis or infection in notes? ð Were IV antibiotics given in ED? ð not known = 0 Yes = 1 No = 2
If yes, time given: ðð:ðð
Resuscitation Room Time into Resus:ðð:ðð Re-triaged to Resus?: ð Yes = 1 No = 2
Any Area Dr GradeEM Dr Grade2 Specialty2
Most senior doctor present: ð ð ð other specify:
Doctor: Consultant = 1, ST/FTSA = 2, Foundation Doctor = 3, Other Career Grade = 4, No otherdoctor/ specialty = 0
Specialty: EM = 1, Ortho = 2, Anaesthesia = 3, ICM = 4, General Surgery = 5, General Medicine = 6, Specialty = 7, Radiology = 8 Other = 9
Final Values in ED
Temperature: ðð.ð oC Heart rate: ððð beats/min Respiratory Rate: ððð breaths/min
Systolic BP: ððð mm.Hg Diastolic BP: ððð mm.Hg
O2 Saturation: ððð % on: ððLitres O2 and/or %age: ððð %
Glasgow Coma Scale: E:ð M: ð V: ð Total GCS: ðð AVPU Score: ð (if available)
Final Total Score on chart: ð Type of chart: ð 1 = SEWS 2 = MEWS 3 = Modified Mews 4 = not applicable
Urine Output: Catheterised? ð Yes=1 No=2 If yes, hourly measurements? ðYes=1 No=2 and volume: ðððml
If no, output documented? ð Yes = 1 No = 2 If documented, volume: ððð mls
Bloods: WBC count: ððð.ðð cells/litre ABGs done: ð Yes=1 No=2 If yes, Time taken ðð:ðð
Poorest Values during ED Stay
Highest HR: ððð beats/min Lowest HR: ððð beats/min
Highest RR: ððð breaths/min Lowest RR: ððð breaths/min
Highest Sys BP: ððð mm.Hg Paired diastolic: ððð mm.Hg
Lowest Sys BP: ððð mm.Hg Paired diastolic: ððð mm.Hg
Lowest O2 Saturation: ððð % on: ððLitres O2 and/or %age: ððð %
O2 Saturation: ððð % on highest:ððLitres O2 and/or %age: ððð %
Lowest Glasgow Coma Scale: E: ð M: ð V: ð Total GCS: ðð Highest AVPU score: ð (if available)
Highest Lactate: ðð.ðmmol/l
Intubated in resus: ð not known = 0 Yes = 1 No = 2 Time intubated in resus: ðð:ðð
Time left Resus: ðð:ðð Extubated before departure from resus: ð not known = 0 Yes = 1 No = 2
Patient Disposal From ED
Date left ED: ðð.ðð.ðð Time left ED: ðð:ðð
Primary Diagnosis in ED: ðð Use numerical value Patient’s Weight: ððð.ðð
Destination: ðð Ward = 1 Radiology/PCI = 2 HDU = 3 ICU = 4 Theatre = 5 Mortuary = 6 Other Hospital = 7
Neuro = 8 SIU = 9 CCU = 10 SSW = 11 Home = 12 Irregular discharge = 13 did not wait = 14
If discharged to Other Hospital, was it to ICU? ð Not known = 0 Yes = 1 No = 2 If yes, complete discharge information
Ultimate Destination from ED for patients whose initial destination was radiology or theatre: ðð
Patient Discharge From Hospital
Highest level of care: ð not applicable = 0 Ward = 1 HDU = 2 ICU = 3
Outcome: ð Dead = 0 Alive = 1 Discharge Date: ðð.ðð.ðð Total in-patient days: ðð
Ward diagnosis: ðð Use numerical value Patient still inpatient at 28 days? ð Yes = 1 No = 2
Patient for Audit? ð ð No = 0 ED = 1 Post ED = 2 Transfer = 3 Other = 4
Reason for Audit: