Severe Sepsis Screening Tool: A Case Study

Evaluation for Severe Sepsis Screening Tool

Instructions: Use this optional tool to screen patients for severe sepsis in the emergency department, on the wards, or in the ICU.
1. Is the patient’s history suggestive of a new infection?
_ Pneumonia, empyema _ Bone/joint infection
_ Urinary tract infection _ Bloodstream catheter infection
_ Acute abdominal infection _ Wound infection
_ Meningitis _Implantable device infection
_ Skin/soft tissue infection _ Endocarditis
_ Other ____________
___ Yes ___No
2. Are any two of following signs & symptoms of infection both present and new to the patient? Note: laboratory values may have been obtained for inpatients but may not be available for outpatients.
_ Hyperthermia > 38.3 °C (101.0 °F) _ Acutely altered mental status
_ Hypothermia < 36 °C (96.8°F) _ Tachycardia > 90 bpm
_ Leukocytosis (WBC count >12,000 μL–1) _ Tachypnea > 20 bpm
_ Leukopenia (WBC count < 4000 μL–1)
_ Hyperglycemia (plasma glucose >120 mg/dL) in the absence of diabetes
___ Yes ___No

If the answer is yes to both either question 1 and 2, suspicion of infection is present: Obtain: lactic acid, blood cultures, CBC with differential, basic chemistry labs, bilirubin.
At the physician’s discretion obtain: UA, chest x-ray, amylase, lipase, ABG, CRP, CT scan.

3. Are any of the following organ dysfunction criteria present at a site remote from the site of the infection that are not considered to be chronic conditions? Note: the remote site stipulation is waived in the case of bilateral pulmonary infiltrates.
_ SBP < 90 mmHg or MAP < 65
mmHg
_ SBP decrease > 40 mm Hg from baseline
_ Bilateral pulmonary infiltrates with a new (or increased) oxygen requirement to maintain SpO2 > 90%
_ Bilateral pulmonary infiltrates with PaO2/FiO2 ratio < 300
_ Creatinine > 2.0 mg/dl (176.8 mmol/L) or Urine Output < 0.5 ml/kg/hour for > 2 hours
_ Bilirubin > 2 mg/dl (34.2 mmol/L)
_ Platelet count < 100,000
_ Coagulopathy (INR >1.5 or aPTT >60 secs)
_ Lactate > 2 mmol/L (18.0 mg/dl)
___ Yes ___No
If suspicion of infection is present AND organ dysfunction is present, the patient meets the criteria for SEVERE SEPSIS and should be entered into the severe sepsis protocol.

Version 7.12.2005 © 2005 Surviving Sepsis Campaign and the Institute for Healthcare Improvement