Sepsis — Monitor Response; Vital Sign Targets and Clinical Goals — Clinical Pathway: Emergency Department, Inpatient and PICU

Sepsis Clinical Pathway — Emergency Department, Inpatient and PICU

Monitor Response and Vital Sign Targets

RN Assessment, Documentation

Sepsis Specific Parameters to Assess

  • Mental status
  • Capillary refill
  • Pulse strength
  • Extremity temperature
  • Vital signs

Frequency

  ED Inpatient ICU
Sepsis Watcher
  • At time of pathway initiation
  • Every 30 min for an hr
  • If stable, hourly until clinical goals met
  • At time of pathway initiation
  • Every 30 min for an hr
  • If stable, hourly until clinical goals met
  • At time of pathway initiation
  • Every 30 min for an hr
  • If stable, hourly until clinical goals met
Sepsis or Septic Shock
  • At time of pathway initiation
  • Every 15 min until clinical goals met or admission to PICU
  • Frequency determined in Consultation with PICU/CAT/CCOT
  • At time of pathway initiation
  • Every 15 min for the 1st hr
  • Every 30 min for the 2nd hr
  • Hourly until clinical goals met
Discuss patient specific assessment spacing with the fellow, advanced practice provider, or attending provider

Age-related Vital Sign Targets

Age Heart Rate SBP MAP DBP
31 days to < 1 year 100-160 > 65 > 45 > 30
1 year to < 2 years 90-160 > 70 > 50 > 35
2 to < 6 years < 140 > 75 > 50 > 40
6 to < 13 years < 130 > 85 > 60 > 45
≥ 13 years < 110 > 90 > 65 > 50