What is the recommended emergency department protocol for managing sepsis?

Emergency Department Sepsis Protocol

Implement immediate recognition using NEWS2 scoring, followed by rapid administration of at least 30 mL/kg IV crystalloid within 3 hours and antibiotics within 1 hour of identification, as sepsis is a medical emergency requiring urgent treatment. 1, 2

Immediate Recognition and Risk Stratification

• Use NEWS2 (National Early Warning Score 2) as the standardized screening tool for all patients aged 16 and over with suspected or confirmed infection 1
• NEWS2 score ≥7 indicates high risk of severe illness or death from sepsis and triggers immediate protocol activation 1
• NEWS2 score ≥5 (consecutive readings) warrants hospital alert and close monitoring 1
• Consider qSOFA combined with lactate measurement for additional risk stratification, particularly in nurse-led assessments, though this has modest incremental benefit over NEWS2 3

Initial Resuscitation Bundle (First 3 Hours)

The following interventions must begin immediately upon sepsis recognition:

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 2
• This is a strong recommendation based on the Surviving Sepsis Campaign guidelines 2
• Following initial bolus, guide additional fluids by frequent reassessment of hemodynamic status including heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, and urine output 2
• Use dynamic variables over static variables to predict fluid responsiveness when available 2

Antibiotic Administration

• Draw blood cultures before antibiotics, but do not delay antibiotic administration 1, 2
• Administer broad-spectrum antibiotics within 1 hour of calculating the initial NEWS2 score or recognition of sepsis 1
• Time to antibiotic administration is directly associated with mortality (odds ratio 1.04 per hour delay) 4
• The median time to antibiotics in high-performing systems is approximately 57-95 minutes, but this should be shortened further 4, 5

Laboratory Assessment

• Obtain serum lactate measurement immediately 2, 4
• Elevated lactate (≥2 mmol/L) indicates tissue hypoperfusion and should guide resuscitation intensity 2
• Target normalization of lactate during resuscitation as a marker of adequate tissue perfusion 2

Hemodynamic Targets

• Maintain mean arterial pressure (MAP) ≥65 mm Hg in patients requiring vasopressors 2
• This is a strong recommendation with moderate quality evidence 2
• Perform further hemodynamic assessment (such as cardiac function evaluation) if clinical examination does not clearly identify shock type 2

Implementation Strategies That Improve Outcomes

Nurse-Driven Protocols

• Implement nurse-initiated sepsis protocols using structured screening tools at triage 6, 7
• Nurse-driven protocols significantly improve compliance with 3-hour bundle elements, increasing from 30% to 80% in one study 6
• These protocols reduce time to lactate measurement, blood culture collection, and antibiotic administration 6, 7

Electronic Health Record Integration

• Use EHR-based triage sepsis alerts to trigger immediate team notification and resource mobilization 5
• Electronic alerts combined with standardized order sets reduce time to IV fluids by 31 minutes and time to antibiotics by 59 minutes 5

Communication and Documentation

• Explicitly document "sepsis" in the medical record when diagnosed, as this is the strongest predictor of accurate coding and appropriate care escalation (OR 19.58) 8
• Alert receiving hospital teams when transferring patients with NEWS2 ≥5 and suspected infection 1

Special Considerations for Remote/Rural Settings

• In remote locations where hospital transfer exceeds 1 hour, administer antibiotics in accordance with local guidelines before transfer 1
• Put mechanisms in place for antibiotic administration in ambulances for high-risk patients (NEWS2 ≥7) if antibiotics have not been given by a GP 1
• Evaluate sepsis risk using NEWS2 when taking over care from community or custodial settings 1

Critical Pitfalls to Avoid

• Do not delay antibiotics for diagnostic procedures - the 3-hour bundle completion time is associated with mortality (OR 1.04 per hour), but rapid antibiotic administration shows the strongest mortality benefit 4
• Do not rely solely on qSOFA - while it can be combined with lactate for modest improvement, NEWS2 is the preferred standardized tool 1, 3
• Avoid under-recognition in pneumonia patients - pneumonia as the infection source is associated with lower rates of sepsis documentation and coding, leading to delayed appropriate care 8
• Do not assume rapid fluid bolus completion improves mortality - while the 30 mL/kg bolus is recommended, the time to complete fluid bolus was not associated with mortality in one large study (OR 1.01 per hour, p=0.21), unlike antibiotic timing 4

Antibiotic Review and De-escalation

• Review antibiotic choice within 1 hour of receiving microbiological results 1
• Change to narrower spectrum antibiotics when appropriate based on culture results and clinical response 1
• Follow local antibiotic guidelines or seek senior advice when needed 1

Goals of Care Discussion

• Discuss goals of care and prognosis with patients and families early, ideally within 72 hours of ICU admission 2
• Incorporate palliative care principles where appropriate, as this is a strong recommendation with moderate quality evidence 2