Table 4

Version modifications of the sepsis pathway from 2013 to 2017 (see online supplementary file for pathway versions 2 and 3)

Version 1—September 2013Version 2—March 2015Version 3—November 2017
RecognitionBased on SIRS criteria or SBP<100 mm Hg AND risk factors, signs and/or symptoms of infection.
Prompt to call MET at any time if hospital MET criteria fulfilled.
Prompt to check/confirm patients resuscitation status.
Added additional signs of hypoperfusion (cool peripheries, decreased urine output) to aid sepsis recognition.Added severe sepsis criteria (SBP<100 mm Hg, altered mental state, lactate≥2 mmol/L) in addition to SIRS criteria.
Resuscitation—oxygen therapyOxygen therapy to maintain SaO2>95%.No change.Added SaO2 88%–92% recommendation for COAD and chronic type II respiratory failure.
Resuscitation—blood culturesTwo sets of blood cultures preantibiotics (including from all lumens of CVAD if in situ).No change.No change.
Resuscitation—lactate and fluid therapyRapid Hartmann’s fluid bolus (10–20 mL/kg) recommended for SBP<90 mm Hg or lactate≥4.0 mmol/L.
Repeat bolus (10–20 mL/kg) once if no improvement.
Revised rapid fluid bolus for lactate>2 mmol/L.
Changed fluid bolus to weight based.
1 L<60 kg, 1.5 L 60–80 kg, 2 L if>80 kg.
Revised volume of rapid fluid bolus to 500 mL crystalline fluid (with larger volumes in emergency department).
Resuscitation—initial antibioticsFirst dose to be administered within 30 min of sepsis recognition.
No penicillin allergy: piperacillin/tazobactam.
Non-life-threatening penicillin allergy: cefepime.
Life-threatening penicillin allergy: ciprofloxacin and vancomycin.
Add gentamicin if any of: SBP<90 mm Hg, lactate>4 mmol/L, inpatient onset sepsis, previous resistant Gram-negative infection.
Add vancomycin if any of: SBP<90 mm Hg, lactate>4 mmol/L, known MRSA carriage or obviously infected vascular device.
Added infection site-specific empiric antibiotic recommendations.
Added option for preprescribed antibiotics for high-risk patients to be administered by nurse ‘if patients commenced on sepsis pathway’.
Added recommendation for empiric meropenem for patients with clinical deterioration while on broad-spectrum antibiotics.
Revised empiric antibiotic recommendations to include targeted antibiotics for presumed site and severity of infection (ie, ceftriaxone plus azithromycin for severe CAP).
No change to empiric recommendations for unknown source of infection or neutropenic fever.
ReferralWithin the first hour notify home team (±+/-infectious diseases  if patient is already on antibiotics or has previous resistant bacteria, ±surgery if required).Added prompt for ICU referral±MET within the first hour if no improvement.No change.
Monitoring treatment responseClose monitoring for first 2 hours of sepsis recognition to ensure SBP>90 mm Hg, urine output>0.5 mL/kg/hour, SaO2>95% and improved conscious state.
If no improvement refer to ICU.
Revised close monitoring period to 6 hours: vital signs every 30 min for first 2 hours then hourly for 4 hours.
Added prompt to repeat lactate within 4 hours if initial level was>2 mmol/L.
No change.
Ongoing antibiotics (after first 24 hours)No specific recommendations.Added prompt for antibiotic review after 48 hours and de-escalation where appropriate.
Non-neutropenic patients:
Included specific antimicrobial options according to site of infection.
Neutropenic patients:
Included risk assessment using MASCC criteria and recommendations for oral switch if low risk.
Added oral switch options and recommended duration according to site of infection.
Management of new fever/sepsis episodeNo specific recommendations.Added recommendations for management of fever/sepsis recurrence for patients already on sepsis pathway (ie, repeat blood cultures and lactate, fluid bolus as required and antibiotics advice from infectious diseases).No change.
DocumentationAdded section with key diagnoses for accurate medical coding (ie, sepsis, severe sepsis, septic shock, neutropaenia, organ failure, positive blood culture).Removed audit page.
  • CVAD, central venous access device; ICU, intensive care unit; MASCC, Multinational Association for Supportive Care in Cancer; MET, medical emergency team; MRSA, methicillin resistant staphylococcus aureus; SBP, systolic blood pressure; SIRS, systemic inflammatory response syndrome.