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| Instructions: Use this screening tool to screen patients for sepsis. |
| (1) Is the patient’s history suggestive of a new infection: |
| □ no |
| □ yes, if yes suspected source |
| □ Pneumonia, empyema |
| □ Urinary tract infection |
| □ Acute abdominal infection |
| □ Meningitis |
| □ Skin/soft tissue infection |
| □ Bone/joint infection |
| □ Wound infection |
| □ Bloodstream catheter infection |
| □ Endocarditis |
| □ Implantable device |
| □ Other |
| (2) Are any two signs and symptoms of infection present AND new to the patient? |
| □ Hyperthermia (>101°F or 38.3°C) |
| □ Hypothermia (<96.8°F or 36°C) |
| □ Tachycardia (>90 bpm) |
| □ Tachypnea (>20 bpm) |
| □ Acutely altered mental status |
| □ Leukocytosis (WBC count >12,000) |
| □ Leukopenia (WBC count <4,000) |
| □ >10% immature neutrophils |
| If the answer is yes to both questions 1 and 2, suspicion of infection is present: |
| □ Obtain: serum lactate, blood cultures, CBC with diff, basic chemistry labs, bilirubin |
| □ Pertinent diagnostic tests ___________________________________ |
| (3) Are any of the following organ dysfunction criteria present AND acute: |
| □ SBP < 90 mmHg or MAP < 65 mmHg |
| □ SBP decrease >40 mmHg from baseline |
| □ Bilateral pulmonary infiltrates with a new (or increased) oxygen requirement to maintain SpO2 > 90% |
| □ Creatinine > 2 mg/dL or Urine Output < 0.5 mL/kg/hr for more than 2 hours |
| □ Bilirubin > 2 mg/dL |
| □ Platelet count <100,000 |
| □ Coagulopathy (INR > 1.5 or aPTT > 60 secs) |
| □ Serum lactate > 2 mmol/L |
| ➢If suspicion of infection is present AND organ dysfunction is present, the patient meets criteria for Severe sepsis. |
➢If patient meets Severe sepsis criteria, AND has refractory hypotension (>60 min AND/OR unresponsive to fluid bolus of
20 mL/kg), the patient meets criteria for Septic shock. |
| Initiate and complete the severe sepsis protocol. |
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