ED Critical Care
Sepsis Data Sheet
What center are you at?
Elmhurst
Mount Sinai
Queens Hospital Center
Jersey City
Does patient Meet Criteria for SIRS and do you think it is caused by an infection?
SIRS=2 or more of (temp > 100.4 or <96.8), HR > 90 bpm, RR > 20 bpm, (WBC < 4000, >12000, or > 10 % bands)
Yes
No
Record the patient's Medical Record Number:
Record Time of Triage:
Use 24 hour time without a colon (e.g. 2321)
Was serum lactate obtained?
Yes
No
If yes, what was the lactate result?
If yes, what time was the lactate obtained?
Use 24 hour time without a colon (e.g. 2321)
Was the patient's MAP < 65 after 20 cc/kg crystalloid?
Yes
No
What time was the patients MAP < 65 after 2 liters of fluid
Use 24 hour time without a colon (e.g. 2138)
If pt never dropped their MAP < 65 and initial Lactate < 4 skip to the last question.
If not, continue to the following questions
What time was the first antibiotic administered?
Use 24 hour time without a colon (e.g. 2321)
What antibiotics were administered?
Document time CVP first > 8 mm Hg:
If cvp never obtained, type 9999. If CVP obtained but never got over 8, type 8888
Document time ScvO2 first > 70%:
If ScvO2 never obtained, type 9999. If ScvO2 obtained, but never >70%, type 8888
Was the patient's MAP < 65 after CVP > 8 and on NorEpi > 20 mcg/minute?
Yes
No
If you answered yes to the previous question, were steroids administered?
Yes
No
Was the patient transfused with PRBCs?
Yes
No
Did the patient received dobutamine?
Yes
No
Where did the patient get admitted to?
What time did the patient go to their bed?
Use 24 hour time without a colon (e.g. 2321)
Was the patient made DNR?
Yes
No
What is your name?
Last, First
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