Early Assessment: Severe Sepsis Triage Screening Tool
Does the patient have any three of the following?
Suspected infection
Temp > 100.4 or < 96.5 or rigors
HR > 90
RR > 20
Any alteration of mental status
O2Sat < 90%
SBP < 90
If yes, then implement the sepsis panel orders.
Triage sepsis panel orders MUST include ALL of the following:
Notify clinician to initiate verbal order for sepsis panel
CBC
Metabolic panel
Lactate (venous or arterial)
PT/PTT
blood cultures
Record vital signs Q1 hour plus temperature
Is the patient’s SBP < 90 or MAP < 65?
If yes, consider RRT and/or ICU Triage/ICU Consult for possible transfer immediately and discuss the likelihood that patient is experiencing septic shock.