DIAGNOSIS CRITERIA RECOMMENDATIONS FOR CRITERIA

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1 DIAGNOSIS CRITERIA RECOMMENDATIONS F CRITERIA Fever Temperature > 38.3 C (101 F) If infection is suspected, evaluate SIRs Criteria for Sepsis diagnosis Sepsis (Suspected infection, 1-2 SIRs Criteria w/o organ dysfunction) Severe Sepsis (Suspected infection, 2 SIRs Criteria w/ any evidence of acute organ dysfunction) Source of actual/suspected infection: SIRs Criteria: Temperature > 38.3 C (101 F) or < 36 C (96.8 F) Heart Rate > 90 bpm (tachycardia) Resp Rate > 20 bpm (tachypnea) or pco2 < 32 mmhg WBC > 12,000 or < 4,000 or > 10% bands Source of actual/suspected infection: SIRs Criteria: Temperature > 38.3 C (101 F) or < 36 C (96.8 F) Heart Rate > 90 bpm (tachycardia) Resp Rate > 20 bpm (tachypnea) or pco2 < 32 mmhg WBC > 12,000 or < 4,000 or > 10% bands Organ Dysfunction: SBP < 90, MAP < 65, or a SBP decrease of > 40 points Creatinine > 2.0 or urine output < 0.5 ml/kg/hr for 2 hrs Bilirubin > 2 mg/dl Platelet count < 100,000 INR > 1.5 or PTT > 60 sec Lactate > 2 mmol/l Initial Lactate level Blood cultures prior to antibiotic start Appropriate antibiotic selection 4 hr repeat Lactate if initial is > 2 mmol/l Blood cultures prior to antibiotic start Appropriate IV antibiotic selection started within 3 hrs of severe sepsis Fluid Resuscitation at 30 ml/kg of crystalloid if hypotensive or suspected hypovolemia and repeat focused clinical exam 30 min after initiation (including vitals, cardiopulmonary, capillary refills, peripheral pulses, and skin assessment) Septic Shock (Suspected infection, 2 SIRs Criteria w/ any evidence of acute organ dysfunction and persistent tissue hypo perfusion after crystalloid fluid administration or initial lactate level 4 mmol/l) Source of actual/suspected infection: SIRs Criteria: Temperature > 38.3 C (101 F) or < 36 C (96.8 F) Heart Rate > 90 bpm (tachycardia) Resp Rate > 20 bpm (tachypnea) or pco2 < 32 mmhg WBC > 12,000 or < 4,000 or > 10% bands Organ Dysfunction: SBP < 90, MAP < 65, or a SBP decrease of > 40 points Creatinine > 2.0 or urine output < 0.5 ml/kg/hr for 2 hrs Bilirubin > 2 mg/dl Platelet count < 100,000 INR > 1.5 or PTT > 60 sec Lactate 4 mmol/l For ED patients needing a critical care bed initiate ED Sepsis Alert Blood cultures prior to antibiotic start Appropriate IV antibiotic selection started within 3 hrs of severe sepsis CVC in superior vena cava CVP and ScvO2 monitoring within 6 hrs Required, if not already done: Fluid Resuscitation at 30 ml/kg of crystalloid if hypotensive or suspected hypovolemia and repeat focused clinical exam 30 min after initiation (including vitals, cardiopulmonary, capillary refills, peripheral pulses, and skin assessment) Licensed Provider Focused Exam Documentation (Required if Fluid Resuscitation has been infused) Vital Signs: BP / MAP HR Resp Rate Temp F or C Cardiac: RRR Irregular S1S2 S3 S4 Murmur grade: Other: Pulmonary: Clear Dull Crackles Diminished Other: Peripheral Pulses: Absent Bounding Other: Capillary Refill: Brisk < 2 sec > 2 sec Other: Skin Exam: Warm Dry Cool Clammy Mottled Other: Date Time Signature of Licensed Provider Performing Assessment * * FM REV. 02/2019 Page 1 of 8

2 1. Do you expect that the patient s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission? Yes, admit as inpatient, proceed to # 2 No, place in observation 2. If admitted as inpatient, Physician Certification: Diagnosis: Sepsis Severe Sepsis Septic Shock Level of Care: Critical Care Intermediate Care Acute Care Unit Preference: 3. Telemetry: Medical/Surgical Acute Care complete Telemetry Orders (form # 36084) 4. Isolation Contact Airborne Droplet For: 5. Consult(s): STAT or Routine Diagnostics: 6. STAT Labs (If not done in the last 6 hrs): Serum Lactate, repeat in 4 hrs if lactate level is > 2 CBC CMP Magnesium level DIC Profile PT/INR and PTT Random Cortisol level STAT Labs (If not done in the last 7 days): Quantitative hcg for any menstruating female 12 years of age STAT Cultures (If not done in the last 48 hrs): Critical Care: Nasal Staph screen (required) Intermediate/Acute Care: Nasal staph screen (optional) Blood cultures now x 2 sites, min apart prior to antibiotics Sputum culture and gram stain (Required if suspected pneumonia or intubated) MRSA Nasal Swab (Required if suspected pneumonia or intubated) Urinalysis and Urine culture Other: Other Diagnostics: Portable CXR STAT Routine In AM Reason: ABG STAT Routine In AM CT Head w/ or w/o contrast STAT Routine Reason: CT Chest w/ or w/o contrast STAT Routine Reason: CT Abd/Pelvis w/ or w/o contrast STAT Routine Reason: EKG STAT Reason: Read by: Echocardiogram STAT Reason: Read by: AM Labs: CBC CMP Serum lactate Magnesium level Phosphorous level Hgb A1C Assessment/Intervention/Monitoring 7. Vital signs (Notify physician for SBP < 90, MAP < 65, or > 40 point decrease in last recorded SBP considered normal): Critical Care: q 1 hr Intermediate Care: q 2 hrs x 24 hrs, then q 4 hrs Acute Care: q 4 hrs 8. Strict Intake/Output: Critical Care: q 1 hr (Notify physician if UOP < 0.5 ml/kg/hr) Intermediate Care: q 4 hrs x 24 hrs then per unit routine (Notify physician if UOP < 0.5 ml/kg/hr or < 300 ml in 8 hrs) Acute Care: per unit routine (Notify physician if UOP < 300 ml in 8 hrs) FM REV. 02/2019 Page 2 of 8

3 9. Urinary Catheter: Critical Care: Urinary catheter to urometer for critical care/strict I&O Intermediate/Acute Care: Insert urinary catheter to bedside bag for: 10. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620) 11. O2 per protocol (form # 34431) 12. Intravenous Access: Critical Care: Place two (2) large bore IVs, if possible and no central venous access Intermediate Care: Place two (2) large bore IVs, if possible Acute Care: Maintain INT 13. Diet (choose one): NPO Regular Cardiac Diabetic consistent carb Renal Other: 14. Oral Nutritional Supplement Standing Orders (form # 31417), initiate if patient meets criteria 15. Consult Speech Therapy for swallow eval 16. Activity: Progressive mobility as tolerated, may use BSC or BRP Up ad lib 17. Initiate PT/OT Protocol (form # 32655), if substantial decrease from baseline function unlikely to resolve within 48 hrs or placement and disposition needed. 18. Smoking Cessation Counseling 19. Pulmonary Rehab Evaluation 20. PEP Therapy (Acapella) q 4 hrs while awake 21. Initiate Sepsis Tracker Guide Flowsheet (form # 43715) Hemodynamic Monitoring for Critical Care: 22. If CVC is in place and located in SVC only: ScVO2 x 1 STAT upon arrival, then if ordered: ScVO2 q 4 hrs x times (6 times maximum) Notify physician if ScVO2 < 70% (Physician: to consider blood transfusion and/or Dobutrex) CVP measurements x 1 STAT upon arrival, then document q 1 hr until CVP 8, then q 2 hrs 23. Respiratory Therapy to insert arterial line STAT x 1 for arterial blood pressure monitoring q 1 hr SCHEDULED MEDICATIONS: 24. Glucose Control: Critical Care/Intermediate Care: Initiate Critical Care Insulin Protocol Orders (form # 21386) Acute Care: Finger stick glucose x 1 upon arrival to unit if > 180 repeat in 1 hr. (Notify physician if > 180 x 2) or Insulin SQ or Pump Orders (form # 36796) 25. Aerosol Treatment: Albuterol 2.5 mg / ipratropium 0.5 mg neb q 4 hrs while awake around the clock Albuterol 2.5 mg neb q 4 hrs while awake and prn wheezing or q 4 hrs and prn wheezing Atrovent (ipratropium) 0.5 mg neb q 4 hrs while awake or q 4 hrs Do not order with Spiriva (tiotropium) Neut (sodium bicarbonate) 4% neb 5 ml q 4 hrs while awake 26. VTE Prophylaxis: Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058) Pharmacologic Contraindication: Allergy Bleeding risk or Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg age > 75) or Lovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30 ml/min) Mechanical: Sequential Compression Device FM REV. 02/2019 Page 3 of 8

4 27. IV Fluid Resuscitation: Severe Sepsis (Recommended): Lactate Ringers or Normal Saline 30 ml/kg IV bolus over min May hang multiple bags wide open or use pressure bags, if needed. Recheck vitals 30 min after infusion completion and notify physician if SBP < 90, MAP < 65, or > 40 point decrease in last recorded SBP considered normal. Septic Shock (Required, if not already given): Lactated Ringers or Normal Saline 30 ml/kg IV bolus over min. May hang multiple bags wide open or use pressure bags, if needed. Recheck vitals 30 min after infusion completion and notify physician if SBP < 90, MAP < 65, or > 40 point decrease in last recorded SBP considered normal. Maintenance Fluids: NS infusion at ml/hr LR infusion at ml/hr Other: 28. Nicotine Withdrawal: Nicotine Patch 14 mg or 21 mg apply topical patch daily 29. Critical Care Stress Ulcer Prophylaxis: Pepcid (famotidine) 20 mg IV twice a day or Protonix (pantoprazole) 40 mg IV once daily (DC Pepcid) 30. Vasopressors: Levophed (Nepinephrine) Initiate infusion at 5 mcg/min or 2 mcg/min 4 mcg/min 10 mcg/min 15 mcg/min 20 mcg/min 25 mcg/min 30 mcg/min or mcg/min Titrate to maintain MAP or MAP -, or SBP or SBP - by 2 mcg/min or 5 mcg/min or mcg/min q 5 min to a max dose of 30 mcg/min or mcg/min F PERSISTENT MAP 65 mmhg, CONSIDER ADDING: Vasopressin Sepsis/Shock Do not titrate, set rate 0.03 units/min Initiate infusion at 0.03 units/min to maintain MAP or MAP - titration by 0.01 units/min q 15 min to a max dose of 0.04 units/min Epinephrine (adrenalin) Initiate infusion at 2 mcg/min or 4 mcg/min 6 mcg/min 10 mcg/min or mcg/min Titrate to maintain MAP or MAP -, SBP or SBP -, or CI 2-5 or CI - by 1 mcg/min or mcg/min q 5 min to a max dose of 10 mcg/min or mcg/min FM REV. 02/2019 Page 4 of 8

5 F PERSISTENT MAP 65 mmhg, CONSIDER ADDING (continued): Neosynephrine (PHENYLephrine) Initiate infusion at 100 mcg/min or 25 mcg/min 50 mcg/min 150 mcg/min 200 mcg/min or mcg/min Titrate to maintain MAP or MAP - or SBP or SBP - by 20 mcg/min or 5 mcg/min 10 mcg/min 40 mcg/min or 60 mcg/min or mcg/min q 5 min to a max dose of 200 mcg/min or mcg/min INOTROPE: F PO TISSUE PERFUSION DISPITE OTHER MEASURES Dobutrex (dobutamine) Initiate infusion at 5 mcg/kg/min or 2.5 mcg/kg/min 7.5 mcg/kg/min 10 mcg/kg/min or mcg/kg/min Titrate to maintain SBP or SBP -, MAP or MAP -, CI 2-5 or CI - by 2.5 mcg/kg/min or mcg/kg/min q 5 min to a max dose ED/ICU 40 mcg/kg/min, IMCU 10 mcg/kg/min Do not titrate, set rate: 2 mcg/kg/min or 2.5 mcg/kg/min 5 mcg/kg/min 7.5 mcg/kg/min 10 mcg/kg/min Max dose Cardiac/Medical Telemetry unit 5 mcg/kg/min, IMCU or HF unit 10 mcg/kg/min (not titrated) 31. Steroids (for patients with persistent shock poorly responsive to IVF and vasopressor support): Solu-Cortef (hydrocortisone) mg IV q hrs 32. Antibiotic Therapy (Select antibiotic choice for sepsis due to known or suspected source of infection): Administer first dose within 1 hr for severe sepsis/septic shock, if not already given in ED Community Acquired Pneumonia without pseudomonal risk Community Acquired Pneumonia with pseudomonal risk Check an indication: Immunocompromised Severe COPD with frequent antibiotic or systemic steroid use Structural lung disease (e.g. Bronchiectasis; Cystic Fibrosis) Aspiration Pneumonia: Risk factors: CVA, alcoholism, altered mental status / Rocephin (ceftriaxone) 1 gm IV STAT, then q 24 hrs Zithromax (azithromycin) 500 mg IV STAT, then q 24 hrs Zosyn (piperacillin/tazobactam) gm IV Cipro (ciprofloxacin) 400 mg IV Avelox (moxifloxacin) 400 mg IV or po** STAT, then q 24 hrs **Do not use oral antibiotics with severe sepsis or septic shock diagnosis. ADD Rocephin (ceftriaxone) 1 gm IV STAT, then q 24 hrs for Severe Sepsis/Septic Shock Documented Penicillin Allergy Merrem (meropenem) 1 gm IV STAT, Cipro (ciprofloxacin) 400 mg IV STAT, Rocephin (ceftriaxone) 1 gm IV Zosyn (piperacillin/tazobactam) STAT, then q 24 hrs gm IV Clindamycin 600 mg IV STAT, then q 8 hrs FM REV. 02/2019 Page 5 of 8

6 MRSA Pneumonia: Vancomycin IV STAT, Pharmacist to dose and follow x 72 hrs Risk factors: Hemodialysis, IV drug abuse, Indwelling CVC Critical Care ONLY: Zyvox (linezolid) 600 mg IV STAT, then q 12 hrs x 72 hrs Pneumonia related to hospiliazation for 48 hrs: 2016 IDSA guidelines recommend 7 day treatment with clinical improvement Hospital Acquired Pneumonia (HAP) without Zosyn (piperacillin/ tazobactam) gm IV Documented Penicillin Allergy Merrem (meropenem) 1 gm IV STAT ventilator support, septic shock or structural lung disease Vancomycin IV STAT, pharmacist to dose and follow x 72 hrs Vancomycin IV STAT, pharmacist to dose and follow x 72 hrs Hospital Acquired Pneumonia (HAP) with ventilator support, septic shock, or structural lung disease Sepsis due to UTI Sepsis due to Intraabdominal or Unknown source Zosyn (piperacillin/ tazobactam) gm IV Cipro (ciprofloxacin) 400 mg IV STAT, then q 8 hrs Vancomycin IV, pharmacist to dose and follow x 72 hrs Rocephin (ceftriaxone) 1 gm IV STAT, then q 24 hrs ADD Gentamicin 5 mg/kg IV STAT x 1 dose (Round to the nearest 20 mg) Rocephin (ceftriaxone) 1 gm IV STAT, then q 24 hrs Flagyl (metronidazole) 500 mg IV Zosyn (piperacillin/ tazobactam) gm IV Documented Penicillin Allergy Merrem (meropenem) 1 gm IV STAT, Cipro (ciprofloxacin) 400 mg IV STAT, Vancomycin IV STAT, pharmacist to dose and follow x 72 hrs Fortaz (ceftazidime) 1 gm IV STAT, then q 8 hrs ADD Gentamicin 5 mg/kg IV STAT x 1 dose (Round to the nearest 20 mg) Invanz (ertapenem) 1 gm IV STAT, then q 24 hrs / Sepsis with risk of MRSA Sepsis due to Bacterial Meningitis Vancomycin IV STAT, pharmacist to dose and follow x 72 hrs Decadron (dexamethasone) 10 mg IV STAT within 30 min of initial dose of antibiotics, then q 6 hrs Rocephin (ceftriaxone) 2 gm IV STAT, then q 12 hrs Vancomycin IV STAT, pharmacist to dose and follow x 72 hrs Ampicillin 2 gm IV STAT, then q 4 hrs (for patient > 50 yo or immunocompromised) FM REV. 02/2019 Page 6 of 8

7 Sepsis due to Skin/Soft Tissue Infections Ancef not indicated as monotherapy for Severe Sepsis/Septic Shock Unasyn (ampicillin/sulbactam) 3 gm IV STAT, then q 6 hrs ADD Vancomycin IV STAT, pharmacist to dose and follow x 72 hrs Ancef (cefazolin) 1 gm IV ADD Vancomycin IV STAT, pharmacist to dose and follow x 72 hrs **Consider using Vancomycin for cellulitis with abscess or ulceration Zosyn (piperacillin/ tazobactam) gm IV Vancomycin IV STAT, pharmacist to dose and follow x 72 hrs Fortaz (ceftazidime) 1 gm IV STAT, then q 8 hrs Clindamycin 600 mg IV Vancomycin IV STAT, Pharmacist to dose and follow PRN MEDICATIONS: Nurses may administer an ordered pain medication in a different pain category (mild, moderate, severe) than the patient stated pain level based on other assessment criteria included in Provider Order policy # Electrolyte Replacement Protocol (form # 21340) 34. Additional Fluid Bolus: Critical Care: If initial IV Fluid Resuscitation for Severe Sepsis/Septic Shock does not result in normalization of lactate, urine output > 0.5 ml/kg/hr, CVP 8, SBP 90, or MAP 65 then give: NS 1000 ml bolus x q 30 min prn, until goals are met or LR 1000 ml bolus x q 30 min prn, until goals are met Intermediate/Acute Care: If initial IV Fluid Resuscitation for Severe Sepsis was not given or does not result in normalization of lactate, urine output > 0.5 ml/kg/hr or > 300 ml in 8 hrs, SBP 90, or MAP 65 then give: NS 250 ml bolus prn x 1 dose and recheck vitals within 30 min and notify physician 35. Mild Pain per nursing assessment (policy ), Temp >100.5F, HA: Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn 36. Moderate Pain per nursing assessment (policy ): Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered. or If patient cannot take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn instead of Norco. DC if Percocet ordered. or Percocet (oxycodone/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered. and/or Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o or < 50 kg) or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < Severe Pain per nursing assessment (policy ), (Begin when Epidural or PCA has been discontinued) Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered. or Dilaudid (HYDROmorphone) mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for excessive sedation. DC if Morphine ordered. FM REV. 02/2019 Page 7 of 8

8 PRN MEDICATIONS (continued): Nurses may administer an ordered pain medication in a different pain category (mild, moderate, severe) than the patient stated pain level based on other assessment criteria included in Provider Order policy # Nausea/Vomiting: Zofran (ondansetron) 4 mg IV or po q 6 hrs prn If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o) 39. Sleep: Melatonin 5 mg po q HS prn or Ambien (zolpidem) 5 mg (female or males 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn 40. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn 41. Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement 42. Constipation: Milk of Magnesia (MOM) 30 ml po daily prn If no BM after 48 hrs: Dulcolax (biscodyl) 10 mg per rectum daily prn and/or Senokot-S (docusate/senna) 2 tablets po at bedtime nightly 43. Cough: Robitussin (guaifenesin) 15 ml po q 4 hrs prn 44. Sore Throat: Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn ADDITIONAL DERS: Date Time Physician Signature PID Number FM REV. 02/2019 Page 8 of 8