1. or who have clinical observations outside normal limits.
Sepsis Screening
& Action Tool
To be applied to all non-pregnant patients over 12 years who have suspected infection, for whom staff or relatives are concerned,
or who have clinical observations outside normal limits.
Patient details (affix label):
Date/Time:
Staff member completing form:
Name (print):
Designation:
Signature:
……………………………...
………………………………
…………………………………………
Important: Is an end of life pathway in place/ is escalation clinically inappropriate? Yes Initials Stop pathway
1. Is individual NEWS 3 or overall ≥5?
2. Is there clinical concern?
Tick
Low risk of sepsis
Use standard protocols, review if deteriorates N Y N
2. Could this be due to an infection?
Yes, but source unclear at present
Pneumonia
Urinary Tract Infection
Cellulitis/ septic arthritis/ infected wound
Device-related infection
Meningitis
Other (specify: ………………………..)
Abdominal pain/distension–refer for senior surgical review
4. Any Amber Flag criteria?
Relatives concerned about mental status
Acute deterioration in functional ability
Immunosuppressed
Trauma, surgery or procedure in last 6 weeks
Clinical signs of wound, device or skin infection
Respiratory Rate or breathing hard
Heart Rate or new arrhythmia
Systolic BP mmHg
Not passed urine in last hours
Temperature < 36OC
Rigors
Tick
Tick N Y
3. Is any ONE red flag present?
Systolic BP ≤ 90 mmHg (or drop >40 from normal)
Lactate ≥ 2 mmol/l
Respiratory Rate (RR)> 25 per minute
Heart Rate (HR) > 130 per minute
Responds only to voice, pain or is unresponsive
Needs oxygen to keep SpO2 ≥92% (88% in COPD)
Non-blanching rash, mottled/ ashen/ cyanotic
Oliguria (from history or less than 0.5 ml/kg/hr)
Recent chemotherapy (6 weeks)
Tick Y
Send bloods
To include FBC, U&Es, CRP, LFTs,
clotting
Contact senior doctor to review
USE SBAR! Must review results within 1 hour
Has clinician attended?
Time complete Initials N
Is AKI present? (tick one) YES NO
Clinician to make antimicrobial
Prescribing decision within 3h
Time complete Initials Y Y
Red Flag Sepsis. Start Sepsis 6 pathway NOW (see overleaf)
This is time critical, immediate action is required.
Dr Name / Signature:
Time Zero:
Sepsis Six and Red Flag Sepsis are copyright to and intellectual property of the UK Sepsis Trust, registered charity no sepsistrust.org

2. Sepsis Six Pathway 1. Administer oxygen 2. Take blood cultures
To be applied to all patients over 12 years of age with suspected
or confirmed Red Flag Sepsis
Make a treatment escalation plan and decide on CPR status
Patient has Red Flag Sepsis
Senior doctor & CCOT/ART* informed?
Time zero
Initials
Action (complete ALL within 1 hour) Time complete Signature Comments
1. Administer oxygen
Aim to keep saturations > 94%
(88-92% if at risk of CO2 retention e.g. COPD)
2. Take blood cultures
From *PICC/Hickman/central line too
Remember to take blood cultures using an aseptic non touch technique
Septic screen – sputum, urine & swabs
3. Give IV antibiotics
According to Trust protocol
Consider allergies and MRSA history prior to administration
4. Give IV fluids
As per hospital protocol/NICE guidelines
Titrate fluid boluses depending on lactate levels
5. Check serial lactates
6. Measure urine output
Ensure fluid balance chart commenced & completed hourly
May require urinary catheter
Not applicable- initial lactate <2
If after delivering the Sepsis Six, patient still has:
Systolic B.P <90 mmHg
Reduced level of consciousness despite resuscitation
Respiratory rate over 25 breaths per minute
Lactate not reducing
Or if patient is clearly critically ill at any time
Then Call Cons and CCOT/Acute Response team
See Intranet for guidelines on sepsis management and antimicrobial policy – microguide.
*Remember to take blood cultures peripherally and from all lumens and label correctly as per policy (see blood culture policy on intranet)
*CCOT- Critical Care Outreach Team/ART- Acute Response Team
For more copies of this document please contact Reprographics on 3778 and Quote: Print No. A4 Colour August 2016
Sepsis Six and Red Flag Sepsis are copyright to and intellectual property of the UK Sepsis Trust, registered charity no sepsistrust.org