Severe Sepsis Macro

Sepsis Suspected

  • Time sepsis suspected (e.g. time antibiotics ordered): [______](military time).
  • Fluid bolus ordered (choose one):
    • [__] 30ml/kg
    • [__] IBW only if BMI>30: estimated IBW: [__]kg
    • [__] Reduced bolus due to CHF/CKD risk, amount selected: [______]ml
    • [__] Bolus not indicated because did not have 2 low BPs within 3 hours of each
  • [__] Sepsis reevaluation performed immediately after fluids infused
    • Patient [__] was/[__] was not hemodynamically stable.
    • Vasopressors [__] were not/ [__] were ordered.

Sepsis excluded

  • Severe Sepsis Excluded: [______](military time).

There was NO New Organ Dysfunction Due To Infection because there was an alternative cause:

  • Lactic acid >2 (suspected alternate cause)
    • [__] Dehydration
    • [__] CKD
    • [__] Liver Disease/Alcoholism
    • [__] Respiratory failure
    • [__] Drugs Epinephrine/B Agonists/Metformin
    • [__] Other: [____________________________________]
  • Creatinine>2.0 (suspected alternate cause)
    • [__] Dehydration
    • [__] CKD
    • [__] Other: [____________________________________]
  • Bilirubin>2.0 (suspected alternate cause)
    • [__] Liver disease
    • [__] Alcohol
    • [__] Viral Hepatitis
    • [__] Extrahepatic Obstruction
    • [__] Other: [____________________________________]
  • Platelets<100,000 (suspected alternate cause)
    • [__] Liver disease
    • [__] Medications
    • [__] Alcoholism
    • [__] Autoimmune
    • [__] Bone marrow suppression
    • [__] Cancer
    • [__] Other: [____________________________________]
  • Noninvasive/Invasive Respiratory Support needed for
    • [__] Asthma/COPD
    • [__] CHF
    • [__] PE
    • [__] Other: [____________________________________]
  • Altered mental status
    • [__] Metabolic encephalopathy
    • [__] Toxic encephalopathy
    • [__] Baseline
    • [__] Psych
    • [__] Stroke/TIA/Seizure
    • [__] Other: [____________________________________]
  • Hypotension (single low reading either pre-arrival or in ED within 6 hours of time zero)
    • [__] Dehydration
    • [__] Baseline
    • [__] Cardiogenic shock
    • [__] Hemorrhagic shock
    • [__] Other: [____________________________________]

Comfort Care/Hospice/Palliative Care/Patient Refusal

  • Patient will not proceed to the bundle due to:
    • [__] Patient refusal evidence by pulling out IV/IO/PICC
    • [__] Patient/decision maker request comfort care/palliative care only
    • [__] Patient has a referral to hospice care at the time of severe sepsis determination.