Emergency Department Adult Sepsis Clinical Pathway



Canberra Hospital and Health ServicesClinical Procedure Emergency Department Adult Sepsis Clinical PathwayContents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc522608432 \h 1Purpose PAGEREF _Toc522608433 \h 2Alerts PAGEREF _Toc522608434 \h 2Scope PAGEREF _Toc522608435 \h 2Section 1 – Adult Sepsis Screening and Action Plan PAGEREF _Toc522608436 \h 2Section 2 – Risk Factors and Criteria PAGEREF _Toc522608437 \h 3Section 3 – Sepsis Bundle PAGEREF _Toc522608438 \h 3Section 4 – Escalation PAGEREF _Toc522608439 \h 4Implementation PAGEREF _Toc522608440 \h 5Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc522608441 \h 5References PAGEREF _Toc522608442 \h 5Definition of Terms PAGEREF _Toc522608443 \h 6Search Terms PAGEREF _Toc522608444 \h 6PurposeThe procedure guides clinicians on the initiation and use of the Adult Sepsis Clinical Pathway using the Adult Sepsis Screening and Action Plan.Back to Table of ContentsAlerts 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.Back to Table of ContentsScopeThis 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 OfficersNurses and Midwives Student Medical Officers and Nurses under direct supervision.Back to Table of ContentsSection 1 – Adult Sepsis Screening and Action PlanEquipment Adult Sepsis Screening and Action Plan Adult Medication ChartIntravenous Fluid Additive OrdersDaily Fluid Balance ChartGeneral 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.Back to Table of Contents Section 2 – Risk Factors and CriteriaCommence screening form and tick if the patient has the following risk factors:Age > 65 YearsFever or rigorsHad a fallImmunocompromisedRecent Surgery/procedureRe-presentation within 48 hours of being discharged from hospitalIndwelling Medical Device (IVC)Acute DeteriorationLung: Cough, Shortness of breathNeurological: Altered level of consciousness or new confusionRecent post-partum and or breastfeedingSkin: wound, cellulitisUrine: Dysuria, frequency, odourAbdomen: Pain, peritonitisOn the screening form tick the relevant criteria:Respirations < 10 or > 25 per minuteOxygen Saturation < 95% on any oxygenHeart Rate < 50 or > 120 per minuteSystolic BP < 90mmHgTemperature < 35.5oC or > 38.5oCAltered Level of Consciousness or new confusion Lactate ≥ 2mmol/LBase excess < -5.0 (if known)Back to Table of Contents Section 3 – Sepsis BundleIf patient is screened as being likely to have sepsis and they:Look unwellHave no Resuscitation plan limiting treatmentHave risk factors for sepsisHave 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 significantOther 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 ( ). Consider allergies prior to choice of antibiotic. Any restricted antibiotics are to be ordered in line with the CHHS Antimicrobial Stewardship (AMS) ProcedureIf hypotensive and/or the Lactate is > 2 mmol/L administer a fluid bolus 20 mL/kg of 0.9% Sodium ChlorideReassess Lactate after each 20 mL/Kg fluid bolusReassess and repeat fluid bolus as clinically indicatedIf no improvement post fluid challenge request ICU Outreach referralCommence a strict fluid balance chart with hourly measuresConsider insertion of indwelling urinary catheter if clinically indicatedAll 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.Back to Table of Contents Section 4 – EscalationIf after delivering the Sepsis Bundle Interventions, the patient still has any of the following:Respiratory Rate > 25 breaths per minuteSystolic BP < 90 mmHgReduced level of consciousness despite resuscitationLactate not reducingThen the following actions should be taken:ED Consultant review immediatelyInfectious diseases referral should be madeConsider ICU Outreach referralBack to Table of ContentsImplementation 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.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationProceduresCHHS Healthcare Associated Infections Clinical ProcedureCHHS Patient Identification and Procedure Matching PolicyCHHS Vital Sign Early Warning Score ProcedureCHHS Consent and Treatment PolicyProcedures and Guidelines CHHS Code Blue Emergency Management PlanCHHS Pathology Requests and Specimens ProcedureCHHS Patient Identification – Pathology Specimen Labelling ProcedureCHHS Venepuncture Blood Specimen Collection ProcedureCHHS 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 GuidelineLegislationHealth Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Back to Table of ContentsReferencesClinical Excellence Commission, Sepsis Kills Patient Safety Program, , NSW Health.The UK Sepsis Trust, Sepsis 6 Screening and action tool, .Back to Table of ContentsDefinition of Terms AMS – Antimicrobial StewardshipCOAGS – Coagulation studiesCOPD – Chronic Obstructive Pulmonary DiseaseCRP – C reactive protein – inflammation markerED – Emergency DepartmentEDIS - Emergency Department Information SystemEUC – Electrolytes, Urea and CreatinineFBC – Full Blood CountICU – Intensive Care UnitKg – KilogramsLFT – Liver function testMEWS – Modified Early Warning ScoremL – MillilitresBack to Table of ContentsSearch 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 AmendedSection AmendedDivisional ApprovalFinal Approval 18 July 2018New DocumentNarelle Boyd, ED Crit CareCHHS Policy CommitteeThis document supersedes the following: Document NumberDocument Name ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download