Hi Jeanie,
To answer your questions:
1. Yes, screen is done in Triage. Debated usefulness since the nurse
does not have “all the data” about the patient. Screen redone 2 more times
during ED stay.
2. All are included but it doesn’t make sense because there is no WBC
“available” in Triage.
3. No other criteria
4. Yes, it is included but not always answered correctly and so will
cause the patient NOT to screen positively when it should have/could have been
a positive screen for severe sepsis.
5. & 6. All electronic, orders are in the system.
We have just completed an ED (only) nurse driven protocol that the nurse can
initiate before the patient is seen by a doctor (approved by Legal & Med Exec
Committee) – here it is:
If the patient screens positive for Severe Sepsis &/or Septic Shock
initiate the following nurse driven protocol immediately:
1. Start 1L of NS wide open (not on an IV pump; use a pressure bag if
needed)
2. POC Lactate level
3. Blood cultures x 2 (one from central line/port if in place on arrival
and one peripheral)
4. Notify the ED physician immediately of patient’s positive screen,
obtain a broad spectrum antibiotic order to be given within one hour of triage
time (Time Zero) and for further fluid resuscitation orders.
Peggy
From: Sepsisgroups [mailto:[email protected]] On
Behalf Of Jeanie Bollinger
Sent: Friday, November 14, 2014 8:39 AM
To: [email protected]
Subject: [Sepsis Groups] Sepsis screening in the ED
I would like to ask a question concerning your sepsis screening process during
triage in the ED. This would include triage prior to arriving in an ED
treatment room and all EMS arrivals.
1. Does the triage nurse screen for sepsis?
2. If so, how many SIRS criteria are included?
3. Are any other criteria included that are not the SCCM SIRS criteria:
glucose, SPO2, BP
4. Is “suspect or documented infection” included in the screen?
5. If the screen is positive, are any labs automatically ordered or does
a MD have to see the patient first?
6. Is this screen completed electronically or on a paper form?
Thank-you so much for your input.
Jeanie Bollinger MSN,RN,ACCNS-AG, CCRN
Sepsis Clinical Nurse Specialist
Nursing Department of Excellence
Mission Health
Asheville, NC
Phone: 828-213-5878
Beeper: 828-207-2363
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