Severe Sepsis/Septic Shock Patient Data Collection Tool Patient ______

Time of D/C______

Date/Time of presentation of Severe Sepsis ______3 hours=______6 hours=______

Date/Time of presentation of Septic Shock______6 hours =______

  • Use the time the last sign of Severe Sepsis/Septic Shock is noted or last lab value was reported or if time was documented by Dr use that time. If multiple dates/times use earliest one
  • Time Dr documented by provider of severe sepsis:
  • Time Dr documented septic shock:

Criteria for Severe SEPSIS: Must have(A) and 2 criteria in (B) and criteria (C) to meet Severe Sepsis Criteria

(A) Physician/APN/PA documentation of a known or suspected infection. Time of documentation of infection:

AND (B) Two or more signs of infection according to the Systemic Inflammatory Response Syndrome (SIRS) met within 6 hours of eachother:

Value Time Value Time

Heart rate > 90 / Temperature > 101F/38.3C or < 96.8F/36C
Respirations > 20 / WBC count >12,000 or <4,000 or >10% bands

(C) Organ dysfunction- 1 of the following:

Value/time if avail. Value/time if avail. Value/time if avail.

Systolic blood pressure < 90,
mean arterial pressure < 65,
a systolic blood pressure decrease of > than 40 / Creatinine > 2.0, or urine output < 0.5 mL/kg/hour for 2 hours / Platelet count < 100,000
Bilirubin > 2 mg/dL / Lactate 2 mmol/L / INR > 1.5 or PTT > 60 sec

Criteria for SEPTIC SHOCK Severe Sepsis present AND Tissue hypoperfusion persists after crystalloid fluid administration, evidenced by either:

Value/time if avail

Systolic blood pressure < 90,
mean arterial pressure < 65
a systolic blood pressure decrease of > than 40
Lactate level is 4mmol/L

Severe Sepsis Bundle Data - First 3 Hours

Was a new broad spectrum antibiotic initiated 24 prior to or 3 hrs following this episode of severe sepsis? / Y / N / Drug:
Date and Time of initial broad-spectrum antibiotic? / In guidelines? Y N
Was initial Lactic acid measured within 6 hours prior and 3 hours after meeting severe sepsis criteria? / Y / N / Result:
Date and Time lactic acid or lactate was measured?
Was Lactic acid Remeasured within 6 hours after severe sepsis if initial result 2 / Y / N
Date and Time lactic acid or lactate was Remeasured?
Was a Blood Culture collected in the time window 48 hours prior to and 3 hours following the presentation of severe sepsis? / Y / N / Not done
Date and Time of Blood Culture?

Septic Shock Bundle Data – Within 6 hours

Wasminimum of 30 ml/kg of IV fluid bolusNS or LR ordered and administered after Septic shock identification? (must include rate and duration in order)
Wt ______Fluids Req ______
Earliest Date/Time initiated? / Y / N
Was persistent hypotension noted within one hour of conclusion of fluids? / Y / N
Was a Vasopressor administered at the time of or after septic shock? / Y / N / Name:
Date and Time of Vasopressor?
Must do Focused exam or 2 of the following below it within fluids initiation to 6 hours after septic shock?
Was Focused examdone by Dr including all elements done within fluids initiation to 6 hours afterseptic shock? / Y / N
Date and Time of each element of Focused exam
vital signs
cardiopulmonary eval
cap refill
peripheral pulse
skin exam
Focused exam or 2 of the following done:
Was a CVP measurementdone within 6 hours of meeting septic shock criteria?
Earliest date and time ______/ Y / N
Was ScvO2/central venous oxygen measurementdone within 6 hours of meeting septic shock criteria?
Earliest date and time ______/ Y / N / ScvO2/mixed venous blood gas
Was bedside cardiovascular ultrasound done within fluids initiation to 6 hours after septic shock?
date and time ______/ Y / N / Echocardiogram • Trans-thoracic echo • TTE • Trans-esophageal echo • TEE • IVC Ultrasound • Inferior Vena Cava Ultrasound • 2D echo • Cardiac echo • Doppler echocardiogram • Echocardiogram with Doppler • Doppler ultrasound of the heart • Bedside cardiac echo
Was passive leg raise done within fluids initiation to 6 hours after septic shock?
date and time ______/ Y / N / Passive leg raise examination result • PLR result • Leg raise
OR Was fluid challenge done within fluids initiation to 6 hours after septic shock?
date and time______
__ / Y / N / 500cc in 15 minutes or 1L in 30 minutes