Sepsis Alliance Clinical Community



4333875-89981Visit ID #__________________________ Pt Wt________ Age_____ M___ F___Admit Date __________ Time _________ Transfer from another facility: Y/ND/C Date ____________ Time _________ Pt AdmCI: Y/N D/C Disposition ________ED Physician ______________________ IM Physicians ____________________________Power Plan ___________ HIN _________________ Race ______________ Loc ______00Visit ID #__________________________ Pt Wt________ Age_____ M___ F___Admit Date __________ Time _________ Transfer from another facility: Y/ND/C Date ____________ Time _________ Pt AdmCI: Y/N D/C Disposition ________ED Physician ______________________ IM Physicians ____________________________Power Plan ___________ HIN _________________ Race ______________ Loc ______25146015240POA Y___ No ___ Severe SepsisALL THREE OF THE FOLLOWING MUST BE MET WITHIN 6 HOURS OF EACH OTHERQ1. SIRS CRITERIA ANY OF THE FOLLOWING TWOPt ValueDATETIMEHeart Rate: > 90Temperature: > 38.3 C (100.9 F) or < 36.0 C (96.8 F)Respiration: > 20/minWBC: >12,000 or < 4,000 or > 10% bandQ1 Met: Y / N Q2. SEPSIS - Documentation of suspected source of clinical infectionSiteDateTimePossible Infection: Q2 Met: Y / N Q3. SEVERE SEPSIS: Organ Dysfxn - ANY ONE OF THE FOLLOWINGPt ValueDateTimeSBP < 90, or MAP < 65, or SBP ↓ of >40 points (within 3 hours of each other)SBP < 90, or MAP < 65, or SBP ↓ of >40 points (within 3 hours of each other)Cr > 2.0, or urine output < 0.5 ml/kg/hr for 2 hoursBilirubin > 2 mg/dl (34.2 mmol/L)Platelet Count < 100,000INR >1.5 or aPTT > 60 secsLactate > 2 mmol/L (18.0 mg/dl)Acute Respiratory Failure & Mech VentQ3 Met: Y / N-OR-PHYSICIAN/APN/PA DOCUMENTS:SEVERE SEPSIS, R/O or POSS SEVERE SEPSIS or SEPTIC SHOCK, R/O or POSS SEPTIC SHOCKDateTimeSEVERE SEPSIS PRESENTATIONDateTime00POA Y___ No ___ Severe SepsisALL THREE OF THE FOLLOWING MUST BE MET WITHIN 6 HOURS OF EACH OTHERQ1. SIRS CRITERIA ANY OF THE FOLLOWING TWOPt ValueDATETIMEHeart Rate: > 90Temperature: > 38.3 C (100.9 F) or < 36.0 C (96.8 F)Respiration: > 20/minWBC: >12,000 or < 4,000 or > 10% bandQ1 Met: Y / N Q2. SEPSIS - Documentation of suspected source of clinical infectionSiteDateTimePossible Infection: Q2 Met: Y / N Q3. SEVERE SEPSIS: Organ Dysfxn - ANY ONE OF THE FOLLOWINGPt ValueDateTimeSBP < 90, or MAP < 65, or SBP ↓ of >40 points (within 3 hours of each other)SBP < 90, or MAP < 65, or SBP ↓ of >40 points (within 3 hours of each other)Cr > 2.0, or urine output < 0.5 ml/kg/hr for 2 hoursBilirubin > 2 mg/dl (34.2 mmol/L)Platelet Count < 100,000INR >1.5 or aPTT > 60 secsLactate > 2 mmol/L (18.0 mg/dl)Acute Respiratory Failure & Mech VentQ3 Met: Y / N-OR-PHYSICIAN/APN/PA DOCUMENTS:SEVERE SEPSIS, R/O or POSS SEVERE SEPSIS or SEPTIC SHOCK, R/O or POSS SEPTIC SHOCKDateTimeSEVERE SEPSIS PRESENTATIONDateTime4333875197539SEVERE SEPSIS TREATMENT BUNDLEWithin 3 hours of Presentation:DateTimeResultMet: Y/NInitial Lactate Level (time drawn)(6 hours prior to and 3 hours following presentation time highest level) IV Antibiotics administered (24hrs prior to and 3 hours following presentation)IV access Issue/delay: Y/NHung:Antibiotic:Blood Cultures drawn prior to abx(48 hrs prior to and 3 hrs following presentation) or:Documented reason for delay (All g preen SHOCK __________ (All g presen SHOCK __________ Drawn:Within 6 Hours of Presentation:IF initial Lactate is > 2 mmol/L:REPEAT LACTATE LEVEL ED Note:H & P:IVF: Cultures00SEVERE SEPSIS TREATMENT BUNDLEWithin 3 hours of Presentation:DateTimeResultMet: Y/NInitial Lactate Level (time drawn)(6 hours prior to and 3 hours following presentation time highest level) IV Antibiotics administered (24hrs prior to and 3 hours following presentation)IV access Issue/delay: Y/NHung:Antibiotic:Blood Cultures drawn prior to abx(48 hrs prior to and 3 hrs following presentation) or:Documented reason for delay (All g preen SHOCK __________ (All g presen SHOCK __________ Drawn:Within 6 Hours of Presentation:IF initial Lactate is > 2 mmol/L:REPEAT LACTATE LEVEL ED Note:H & P:IVF: Cultures433578026035Consults: PMH: (CRF, afib, Chr Liver dis, anticoag use, coagulopathy, leukemia, SVT, COPD)00Consults: PMH: (CRF, afib, Chr Liver dis, anticoag use, coagulopathy, leukemia, SVT, COPD)SEPSIS BUNDLE COMPLIANCE FEEDBACKPATIENT INFORMATIONFirst Name: Click here to enter text.Last Name:Click here to enter text.MRN:Click here to enter text.Admit Date:Click here to enter a date.Unit:Click here to enter text.Provider:Click here to enter text.SIRsClick here to enter text.End Organ DysfunctionClick here to enter text.Time Zero:Click here to enter text.Chart Reviewed for:Choose an AN DYSFUNCTION PRESENTMeasureYESNOCommentsRequirementBP??Click here to enter text.SBP < 90 or MAP < 65 or SBP dec > 40 BP x 2??Click here to enter text.Init Hypotension = 2 low BP within 6 H prior/after SS presentationCreatinine??Click here to enter text.2.0, or urine output < 0.5 ml/kg/hr x 2 HBilirubin??Click here to enter text.2 mg/dLPlatelet Count??Click here to enter text.< 100,000INR or aPTT??Click here to enter text.INR > 1.5 or aPTT > 60 sec (no anticoag Rx)Lactate??Click here to enter text.2 mmol/LResp Failure??Click here to enter text.AEB new need for mechanical ventilationBUNDLE ELEMENTSMeasurePASSFAILCommentsRequirement(Time requirements are relative to Time 0 noted above)Blood Culture??Click here to enter text.Collected 48hr prior – 3 hrAntibiotics??Click here to enter text.Given 24hr prior – 3hrLactate??Click here to enter text.Collected 6hr prior – 3 hrRepeat Ladctate??Click here to enter text.Collected within 6hr If initial lactate > 2Fluids??Click here to enter text.30cc/kg administered within 3hrVasopressors??Click here to enter text.Administered within 6hr if persistently hypotensive (i.e. Two BP <90 systolic or two MAP <65, consecutively)Reperfusion Assessment??Click here to enter text.Documented within 6hr post IVF administration488442099060SEPTIC SHOCK 6 HOUR BUNDLEWithin 6 hours of Presentation of Septic ShockDateTimeMet:IF hypotension persists after fluid resuscitation:Administer VasopressorMedication: ______________________From crystalloid fluid admin to 6 hours after Presentation of Septic ShockDateTimeMet:IF persistent hypotension-or- initial lactate ≥ 4 Vital Signs Review (All 4: T, P, R, BP)Cardiopulmonary Exam Capillary Refill Evaluation Peripheral Pulse EvaluationSkin ExaminationUrine outputShock Index Arterial Oxygen SaturationORAny One of the following four:CVP or RAP _____SVO2 or ScvO2 ______Bedside ECHO, TEE, IVC ultrasound, 2D ECHO, or Doppler ECHOPassive Leg Raise Exam OR Fluid Challenge 00SEPTIC SHOCK 6 HOUR BUNDLEWithin 6 hours of Presentation of Septic ShockDateTimeMet:IF hypotension persists after fluid resuscitation:Administer VasopressorMedication: ______________________From crystalloid fluid admin to 6 hours after Presentation of Septic ShockDateTimeMet:IF persistent hypotension-or- initial lactate ≥ 4 Vital Signs Review (All 4: T, P, R, BP)Cardiopulmonary Exam Capillary Refill Evaluation Peripheral Pulse EvaluationSkin ExaminationUrine outputShock Index Arterial Oxygen SaturationORAny One of the following four:CVP or RAP _____SVO2 or ScvO2 ______Bedside ECHO, TEE, IVC ultrasound, 2D ECHO, or Doppler ECHOPassive Leg Raise Exam OR Fluid Challenge 24003098425Septic ShockCriteria for Septic Shock MUST BE MET WITHIN 6 HOURS OF Severe Sepsis:Q1. Trigger Event for Crystalloid Fluids: ONE OF THE FOLLOWING:Pt ValueDateTimeInitial hypotension: ( X2 readings 6 hrs prior to or after S. Sepsis present & before fluids completed)INITIAL LACTATE LEVEL > = 4 MMOL/LPHYSICIAN/APN/PA DOCUMENTS:SEPTIC SHOCK OR R/O POSSIBLE/SUSPECTED SEPTIC SHOCKQ1 Met: Y / N 00Septic ShockCriteria for Septic Shock MUST BE MET WITHIN 6 HOURS OF Severe Sepsis:Q1. Trigger Event for Crystalloid Fluids: ONE OF THE FOLLOWING:Pt ValueDateTimeInitial hypotension: ( X2 readings 6 hrs prior to or after S. Sepsis present & before fluids completed)INITIAL LACTATE LEVEL > = 4 MMOL/LPHYSICIAN/APN/PA DOCUMENTS:SEPTIC SHOCK OR R/O POSSIBLE/SUSPECTED SEPTIC SHOCKQ1 Met: Y / N 2324103632835SEPTIC SHOCK 3 HOUR BUNDLESeptic Shock Fluid Administration: INITIATED within 3 hours of Presentation of initial hypotension, Lactate > 4 or Documentation of Septic ShockDateStart TimeEnd TimeDuration (minutes)Volume given within windowVolume completely infused? (Y/N)Met: Resuscitation with 30 ml/kg crystalloid fluids Pt Wt: _________kg x 30ml= __________ goal volume BMI: ________ Pt Ideal Wt: _______ kg x 30ml= _________ goal volume Goal volume less 10%: __________ mlQ2. Persistent HypotensionTwo or more consecutive readings SBP < 90, or MAP <65, or a drop in SBP by > 40 (in the hour after fluids completed) supported by provider documentationBP Readings:Documentation for other cause for hypotension: Y/N SEPTIC SHOCK PRESENTATIONEarliest of MD/PA/NP dx, Lactate > 4, or Persistent HypotensionDateTime00SEPTIC SHOCK 3 HOUR BUNDLESeptic Shock Fluid Administration: INITIATED within 3 hours of Presentation of initial hypotension, Lactate > 4 or Documentation of Septic ShockDateStart TimeEnd TimeDuration (minutes)Volume given within windowVolume completely infused? (Y/N)Met: Resuscitation with 30 ml/kg crystalloid fluids Pt Wt: _________kg x 30ml= __________ goal volume BMI: ________ Pt Ideal Wt: _______ kg x 30ml= _________ goal volume Goal volume less 10%: __________ mlQ2. Persistent HypotensionTwo or more consecutive readings SBP < 90, or MAP <65, or a drop in SBP by > 40 (in the hour after fluids completed) supported by provider documentationBP Readings:Documentation for other cause for hypotension: Y/N SEPTIC SHOCK PRESENTATIONEarliest of MD/PA/NP dx, Lactate > 4, or Persistent HypotensionDateTime2362201982470Repeat Volume Status and Tissue Perfusion Assessment: Abstract from crystalloid fluid admin date/time. Stop abstracting 6 H after septic shock presentation. (Provider documentation ONLY) – Any 5 of 8 OR documentation assessment completed. Assessment Completed Y___ No ___ Date______ Time ______ Met: ______00Repeat Volume Status and Tissue Perfusion Assessment: Abstract from crystalloid fluid admin date/time. Stop abstracting 6 H after septic shock presentation. (Provider documentation ONLY) – Any 5 of 8 OR documentation assessment completed. Assessment Completed Y___ No ___ Date______ Time ______ Met: ______609600040582850060816874131310Rate (Vol/Min)020000Rate (Vol/Min) ................
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