Do you provide care in an Emergency Department? Despite the significant risk of morbidity and mortality from severe sepsis, adequate initial therapy is initiated for fewer than 58% of patients.18
We’re asking you to commit to treating your patients by following the BC Emergency Department Sepsis Guidelines.
- Know the warning signs for sepsis, identify patients exhibiting signs of sepsis early, and triage them appropriately.
- Measure the lactate of patients with sepsis within 3 hours of presentation to triage and test again within 2-4 hours if the initial result is greater than 2mmol/L.
- Draw a blood culture prior to administering antibiotics and complete a crystalloid fluid bolus (30cc/kg) within first three hours.
You are not alone. You’ll be joining health care providers from across BC who have already committed to implementing the BC Sepsis Guidelines in their emergency departments and measuring their results.
Help us deliver the best care for our patients.
Our vision is to reduce sepsis morbidity and mortality rates throughout BC by identifying sepsis patients early, using best clinical practices, and achieving seamless transitions of care.
BEST CARE, NO MATTER WHERE.
Emergency Department Guidelines
All patients with two out of four SIRS (heart rate greater than 90, respiratory rate greater than 20, temperature greater or equal to 38 ⁰ C or less than 36⁰ C, altered mental state) and suspected infection and one of the following risk factors should be considered at risk of sepsis:
- Looks unwell
- Age greater than 65 years
- Recent surgery
- Immunocompromised (AIDS, chemotherapy, neutropenia, asplenia, transplant, chronic steroids)
- Chronic illness (diabetes, renal failure, hepatic failure, cancer, alcoholism, IV drug use)
All patients with two out of four SIRS and suspected infection (with above risk factor):
- Venous lactate measurement within 3 hours of presentation to triage
- If initial lactate is greater than 2mmol/L, repeat venous lactate measurement in next 2-4 hours
For adults in SHOCK (SBP less than 90 mmHg and/or MAP less than 65 mmHg) with POSSIBLE infectious cause (septic shock) or a HIGH likelihood of sepsis:
- Blood culture before IV antibiotics
- Broad spectrum IV antibiotics within 1 hour
- Selection of broad-spectrum antibiotics, including MRSA, MDRO and fungal coverage, should be based on local antibiograms and clinical indication (see SSCG 2021)
- Empiric antimicrobials should be discontinued if an alternative cause of illness is demonstrated or strongly suspected
For adults NOT in SHOCK (systolic less than 90 or MAP less than 65 mmHg) with POSSIBLE sepsis, we suggest a time-limited course of rapid investigation and if concern for infection persists:
- Blood culture before IV antibiotics
- Broad spectrum IV antibiotics within 3 hours
- Administer at least 30 mL/kg of balanced crystalloid within first 3 hours of resuscitation if evidence of hypoperfusion (tachycardia, low urine output, acute kidney injury, elevated lactate, etc)
For adults with a LOW LIKELIHOOD of infection and NOT in shock, we suggest deferring antimicrobials while continuing to closely monitor the patient.
Download the Guidelines:
The provincial Sepsis Clinical Expert Group developed the BC Emergency Department Sepsis Guidelines, taking into account the most up-to-date literature (references below) and expert opinion.
Additional Recommendations and Resources for Emergency Department Sepsis
- Arnold RC, Shapiro NI, Jones AE, et al. Multi-center study of early lactate clearance as a determinant of survival in patients with presumed sepsis. Shock. 2009;32(1):35-39.
- Evans, Laura; et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021, Critical Care Medicine: November 2021 – Volume 49 – Issue 11 – p 1063-1143doi: 10.1097/CCM.0000000000005337
- Gacoulin A, Tulzo Y, Lavoue S, et al. Severe pneumonia due to Legionella pneumonphilia: Prognostic factors, impact on delayed appropriate antimicrobial therapy. Intensive Care Med. 2002; 28:686-691.
- Gaieski DF, Mikkelsen ME, Band RA, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010; 38(4):1045-1053.
- Gorski, Lisa A. MS, RN, HHCNS-BC, CRNI®, FAAN; et al. Infusion Therapy Standards of Practice, 8th Edition, Journal of Infusion Nursing: January/February 2021 – 44(1S) p S1-S224 doi: 10.1097/NAN.0000000000000396
- Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006; 34:1589 –1596.
- Loubani OM, Green RS (2015) A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J CritCare 30(3):653e9-17 doi: 10.1016/j.jcrc.2015.01.014
- Micek ST, Roubinian N, Heuring T, et al. Before-after study of a standardized hospital order set for the management of septic shock. Crit Care Med. 2006; 34:2707–2713.
- Mikkelsen ME, Gaieski DF, Goyal M, et al. Factors associated with nonadherence with early goal-directed therapy in the ED. 2010; 138(3): 551-558.
- Morrell M, Fraser VJ, Kollef MH. Delaying the empiric treatment of candida bloodstream infection until positive blood culture results are obtained: a potential risk factor for hospital mortality. Antimicrob Agents Chemother. 2005; 49:3640–3645.
- Nguyen H, Rivers E, Knoblich B, et al. Early lactate clearance is associated with improved out- come in severe sepsis and septic shock. Crit Care Med. 2004; 32(8):1637-1642.
- Rhodes A, Evans L, Alhazzani W, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2016. Crit Care Med 2017; 45(3).
- Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001: 345:1368-1377.
- Singer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016; 315(8): 801-810.
- Surviving Sepsis Campaign. Surviving Sepsis Campaign: Updated Bundles in Response to New Evidence. www.survivingsepsis.org/bundles. Accessed 9 Feb. 2017.
- Wang HE, Shapiro NI, Angus DC, et al. National estimates of severe sepsis in United States emergency departments. Crit Care Med. 2007; 35:1928 –1936.
- Weinstein MP, Reller LP, Murphy JR, et al. The clinical significance of positive blood cultures: A comprehensive analysis of 500 episodes of bacteremia and fungemia in adults. I. Laboratory and epidemiologic observations. Rev Infect Dis. 1983; 5:35–53.
- Freund Y, Lemachatti N, Krastinova E, et al. Prognostic accuracy of Sepsis-3 criteria for in-hospital mortality among patients with suspected infection presenting to the emergency department. JAMA. 2017; 317(3):301-308.
- Mikkelsen ME, Gaieski DF, Goyal M, et al. Factors associated with nonadherence with early goal-directed therapy in the ED. Chest. 2010; 138(3): 551-558.