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Sepsis Documentation BP: 133/75 Mean Arterial Pressure (Device): 87 Pulse: 116 Resp: 22 Temp: 99.2 °F (37.3 °C) SpO2: 100 % A – 2 SIRS criteria within six hours of each other due to suspected infection: Temp > 100.9°F (38.3°C) or < 96.8°F (36°C) Respiratory Rate > 20 Heart Rate > 90 WBC > 12 or < 4, or Bands >10% B – Acute Organ Dysfunction due to infection: Lactate > 2 mmol/L Hypotension: a single systolic BP < 90 or MAP < 65 Systolic BP decrease > 40 points vs baseline related to sepsis Acutely altered mental status Acute Respiratory Failure requiring CPAP, BiPAP, or vent Total Bilirubin > 2 mg/dl AKI: Creatinine > 2.0 or elevation >0.5 above baseline AKI: Urine output < 0.5ml/kg/hour for 2 hours Coagulopathy: INR > 1.5 or a PTT > 60 sec not related to medication Platelet count < 100,000 C – Septic Shock Criteria: Either Lactic acid >= 4 OR persistent hypotension (Systolic BP < 90 X2 or MAP < 65 X2 within 60 minutes after completing 30 mL/kg bolus): *** The patient {Sepsis Stratification:158596} Criteria A - sepsis A and B - severe sepsis A, B and C - septic shock Exceptions to bundle timelines: End of Life Care Exclusions? {May be prior to arrival or a new order timed within six hours of presentation of severe sepsis or septic shock. If prior to arrival, DOCUMENT IN NOTE} *** Did the patient or surrogate decision-maker refuse any portion of the sepsis bundle? *** Yes: Central line/ pressors, Mechanical ventilation, IV fluid administration, IV antibiotics adminstration and Blood draws Was any portion of the Sepsis Bundle initiated at Kaiser Permanente clinic, urgent care, EMS unit, or SNF prior to ED presentation? *** Did patient arrive via EPRP transfer? *** Critical care time: I spent a total of *** minutes throughout the day delivering critical care to this patient, exclusive of procedures. Is Sepsis secondary to Pneumonia? {SEPSIS PNEUMONIA:158610} {Sepsis Pocket Card Within 3 hours of either severe sepsis/ septic shock: Order Lactic Acid with Reflex to Repeat and Blood Cultures x 2 Give broad spectrum IV antibiotics (refer to pocket card for options) after drawing cultures Initiate 30 mL/kg IV crystalloid bolus. Dosing may be based using ideal body weight if BMI >30 but this variation must be documented in the note. Within 6 hours of septic shock: ALL of the above Add to your note: .sepsticshockreevaluation for required exam elements after fluid initiation with time stamp If persistently hypotensive (Systolic BP < 90 or MAP < 65 after 30 mL/kg bolus ), start pressors Before signing note: Remove any prior sepsis diagnoses from Active Problem List imported into your note. DELETE THIS TEXT BEFORE SAVING NOTE}



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