Emergency Department Adult Sepsis Clinical Pathway

Canberra Hospital and Health Services

Clinical Procedure

Emergency Department Adult Sepsis Clinical Pathway

Contents

Contents1

Purpose2

Alerts2

Scope2

Section 1 – Adult Sepsis Screening and Action Plan2

Section 2 – Risk Factors and Criteria3

Section 3 – Sepsis Bundle3

Section 4 – Escalation4

Implementation5

Related Policies, Procedures, Guidelines and Legislation5

References5

Definition of Terms6

Search Terms6

Purpose

The procedure guides clinicians on the initiation and use of the Adult Sepsis Clinical Pathway using the Adult Sepsis Screening and Action Plan.

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Alerts

Early identification and Treatment of Sepsis is a Medical Emergency.

All interventions and treatments in the Adult Sepsis Bundle should be delivered within 1 hour of recognition of sepsis.

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Scope

This document pertains to Adults cared for by Canberra Hospital and Health Service (CHHS) staff in the Emergency Department.

This document applies to the following staff working within their scope of practice:

Medical Officers

Nurses and Midwives

Student Medical Officers and Nurses under direct supervision.

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Section 1 – Adult Sepsis Screening and Action Plan

Equipment

Adult Sepsis Screening and Action Plan

Adult Medication Chart

Intravenous Fluid Additive Orders

Daily Fluid Balance Chart

General Observation Chart (MEWS)

Procedure

When patients present to the Emergency Department the staff assessing the patient should consider if they think the patient’s presentation is suspicious of Sepsis. In the event that they suspect Sepsis or the patient looks unwell then commencement of the Adult Sepsis Screening and Action Plan should occur and a Senior Medical Officer should be alerted to review the patient.

In commencing the procedure please consider if there are any current Resuscitation Plans or Advance Care Directives that will limit treatment. Please ensure any Resuscitation Plans are documented in the patient record. In the event that these plans are not known or clear then treatment should commence.

In regards to Obstetric patients continue with the screening process and consult the Obstetric team.

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Section 2 – Risk Factors and Criteria

Commence screening form and tick if the patient has the following risk factors:

CHHS18/215

Doc Number

Version

Issued

Review Date

Area Responsible

Page

CHHS18/215

1

21/08/2018

01/082019

Critical Care - ED

1 of 6

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

· Age > 65 Years

· Fever or rigors

· Had a fall

· Immunocompromised

· Recent Surgery/procedure

· Re-presentation within 48 hours of being discharged from hospital

· Indwelling Medical Device (IVC)

· Acute Deterioration

· Lung: Cough, Shortness of breath

· Neurological: Altered level of consciousness or new confusion

· Recent post-partum and or breastfeeding

· Skin: wound, cellulitis

· Urine: Dysuria, frequency, odour

· Abdomen: Pain, peritonitis

On the screening form tick the relevant criteria:

· Respirations < 10 or > 25 per minute

· Oxygen Saturation < 95% on any oxygen

· Heart Rate < 50 or > 120 per minute

· Systolic BP < 90mmHg

· Temperature < 35.5oC or > 38.5oC

· Altered Level of Consciousness or new confusion

· Lactate ≥ 2mmol/L

· Base excess < -5.0 (if known)

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Section 3 – Sepsis Bundle

If patient is screened as being likely to have sepsis and they:

1. Look unwell

2. Have no Resuscitation plan limiting treatment

3. Have risk factors for sepsis

4. Have two or more of the Sepsis Criteria

Then the Sepsis Bundle treatments should commence.

Note: Sepsis is a Medical Emergency and a Consultant or Registrar should be consulted.

Investigations should be completed per the Sepsis Bundle:

· Bloods ordered from EDIS order sets:

· Source Clear (FBC, EUC, CRP, LFTs, COAGS)

· Source Unclear (FBC, EUC, CRP, LFTs, COAGS, Lipase)

· Blood Cultures: taken from two sites at least one from a peripheral site, if patient has a central access device take one set from the central line.

· Measure serial lactates: > 4 mmol/L is significant

· Other swabs, midstream urine and sputum as clinically indicated.

Treatment:

· Apply Oxygen to maintain oxygen saturations > 94% (88-92% for a patient with COPD)

· Within 60 minutes, administer antibiotics per the Therapeutic Guidelines (https://tgldcdp.tg.org.au/etgAccess ). Consider allergies prior to choice of antibiotic. Any restricted antibiotics are to be ordered in line with the CHHS Antimicrobial Stewardship (AMS) Procedure

· If hypotensive and/or the Lactate is > 2 mmol/L administer a fluid bolus 20 mL/kg of 0.9% Sodium Chloride

· Reassess Lactate after each 20 mL/Kg fluid bolus

· Reassess and repeat fluid bolus as clinically indicated

· If no improvement post fluid challenge request ICU Outreach referral

· Commence a strict fluid balance chart with hourly measures

· Consider insertion of indwelling urinary catheter if clinically indicated

· All treatments should be documented in the patient record including the Adult Sepsis Screening and Action Plan.

Vital Signs:

· A full set of vital signs (Respiratory rate, Oxygen Saturation, Heart Rate, Blood Pressure, Temperature and Sedation Score) should be documented every 30 minutes or more frequently as indicated until the MEWS is < 4.

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Section 4 – Escalation

If after delivering the Sepsis Bundle Interventions, the patient still has any of the following:

· Respiratory Rate > 25 breaths per minute

· Systolic BP < 90 mmHg

· Reduced level of consciousness despite resuscitation

· Lactate not reducing

Then the following actions should be taken:

ED Consultant review immediately

Infectious diseases referral should be made

Consider ICU Outreach referral

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Implementation

Adult Sepsis Pathway will be included in orientation for medical and nursing staff. Education will also be repeated in the ED Nursing education calendar.

Regular audits will be conducted relating to compliance of the tool and treatments. These results will be monitored at the ED Quality Assurance Committee and reported to the Standard 3 AMS sub group.

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Related Policies, Procedures, Guidelines and Legislation

Procedures

· CHHS Healthcare Associated Infections Clinical Procedure

· CHHS Patient Identification and Procedure Matching Policy

· CHHS Vital Sign Early Warning Score Procedure

· CHHS Consent and Treatment Policy

Procedures and Guidelines

· CHHS Code Blue Emergency Management Plan

· CHHS Pathology Requests and Specimens Procedure

· CHHS Patient Identification – Pathology Specimen Labelling Procedure

· CHHS Venepuncture Blood Specimen Collection Procedure

· CHHS Peripheral Intravenous Cannula, Adults and Children (Not Neonates)

· CHHS Central Venous Access Device (CVAD) Management – Children, Adolescents and Adults (NOT Neonates)

· CHHS Goals of Care and Resuscitation Plan Guideline

Legislation

· Health Records (Privacy and Access) Act 1997

· Human Rights Act 2004

· Work Health and Safety Act 2011

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References

1. Clinical Excellence Commission, Sepsis Kills Patient Safety Program, http://www.cec.health.nsw.gov.au/patient-safety-programs/adult-patient-safety/sepsis-kills/governance, NSW Health.

2. The UK Sepsis Trust, Sepsis 6 Screening and action tool, https://sepsistrust.org/wp-content/uploads/2017/08/ED-adult-NICE-Final-1107.pdf .

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Definition of Terms

AMS – Antimicrobial Stewardship

COAGS – Coagulation studies

COPD – Chronic Obstructive Pulmonary Disease

CRP – C reactive protein – inflammation marker

ED – Emergency Department

EDIS - Emergency Department Information System

EUC – Electrolytes, Urea and Creatinine

FBC – Full Blood Count

ICU – Intensive Care Unit

Kg – Kilograms

LFT – Liver function test

MEWS – Modified Early Warning Score

mL – Millilitres

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Search Terms

Emergency Department, Sepsis, clinical pathway,

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:

Date Amended

Section Amended

Divisional Approval

Final Approval

18 July 2018

New Document

Narelle Boyd, ED Crit Care

CHHS Policy Committee

This document supersedes the following:

Document Number

Document Name