Sunday, September 20, 2009


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 Implantable device
Urinary tract infection Wound infection infection
Acute abdominal infection Bloodstream catheter Other ____________
Meningitis infection
Skin/soft tissue infection Endocarditis
___ 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)
Hypothermia <> 90 bpm
Tachypnea > 20 bpm
Acutely altered mental
Leukocytosis (WBC
count >12,000 μL–1)
Leukopenia (WBC
count <>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 <> 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 <> 2.0 mg/dl (176.8 mmol/L) or Urine Output <> 2 hours
Bilirubin > 2 mg/dl (34.2 mmol/L)
Platelet count <>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.
Adapted from the ©2005 Surviving Sepsis Campaign and the Institute for Healthcare Improvement