Patients who don't trigger the escalation criteria

's situation meant her condition changed to one of high (red) risk. However, if your patient doesn't reach high (red) risk criteria then what do you need to do to ensure you give the treatment and care that they require?

Next 12 hours

In any patient deteriorating with either moderate (amber) or high (red) risk of death from sepsis, it is vital to assess the effectiveness of any intervention. Ensure that close monitoring continues as, although initial response may be observed, it is important to review whether that improvement has continued.

You would need to continue to investigate the cause of the problem, establishing an appropriate diagnosis, continuing the infection screening: requesting investigations, (e.g. radiology chest x-ray, etc.), sending samples, (e.g. urine, wound swabs) and chasing results in order to analyse these.

Fluid status: Where a patient has responded to a fluid challenge, it is important to continue assessing this and ensure that ideally oral fluids can be used to maintain hydration levels.

Following 12-24 hours

Results from the swabs and cultures taken may be starting to return depending on the tests undertaken. So, antibiotics can be reviewed in light of the sensitive organisms, ensuring these are targeted.

Microbiology concerns are ongoing. Whilst the tazocin was given early in this case study, there is a need to review all antibiotic use. Antibiotic usage is essential in minimising the problems of infection, however inappropriate usage needs to be minimised.

Hydration assessment needs to continue.

Following 24-72 hours

Sepsis "must be treated promptly with effective antibiotics. This is another important reason why we must tackle and reduce antibiotic resistance so that the first choice antibiotics can work in those who need them".

Please follow the link here for Higher Education England (HEE) e-learning on Reducing Antimicrobial Resistance.
http://www.e-lfh.org.uk/programmes/antimicrobial-resistance

Referring further

Further management of will depend on additional clinical assessment, the findings from investigations undertaken, her response to the treatments already given and the clinical judgement of the medically qualified practitioner undertaking the review.

*Select image to view enlarged
[Figure from Start Smart - Then Focus: Antimicrobial Stewardship Toolkit for English Hospitals]

MEDICINE PRESCRIPTION AND ADMINISTRATION RECORD
WARD Emergency Dept. WARD __________ WARD __________			CONSULTANT ____________________		DATE OF ADMISSION		NAME: AGE: HOSPITAL NUMBER: NHS NUMBER:
Card No 1 of 1		Chart rewritten By _____________ Date ________________________ Pharmacy check By _____________ Date ________________________			Weight _______(kg) Date ____________ Weight _______(kg) Date		NAME: AGE: HOSPITAL NUMBER: NHS NUMBER:
DRUG ALLERGY or ADVERSE EFFECT Medicine/Other Signature				If none know tick box [✔] Effect Date This section must be completed and signed by a prescriber or Pharmacist
ONCE ONLY MEDICINES
Date	Medicine	Dose	Route	Administration Instructions	Time Required	Prescriber's Sig, Print Name & Bleep	Time Given	Given By	Checked By	Pharm
	Tazocin	4.5g	I.V.	Give Immediately	18.00	A.BRN 1234	18.15	JE	AM
	Salbutamol	2.5mg	neb		18.00	A.BRN 1234	18.15	JE	AM
	Atrovent	500mg	neb		18.00	A.BRN 1234	18.15	JE	AM

Patient Details Patient Name: Age: Hospital Number:				FLUID CHART DATE: WARD: Emergency Dept.
INPUT (mLs)						OUTPUT (mLs)
Time	Intravenous fluid	Other (write)	DRUG (write) Noradrenaline	Hourly total	Running total	Urine	Hourly total	Running total	Balance (+ve or -ve)
01:00
...
18:00	500					++ incontinent
19:00	500	30 (tazocin)		1030	1030				+ve 1030
20:00	500, 500			1000	2030				+ve 2030
21:00
22:00
23:00
24:00

Patient Details Patient Name: Age: Hospital Number:				FLUID CHART Part One \| Part Two DATE: WARD: Emergency Dept. PREVIOUS DAY'S BALANCE: +ve 2533
INPUT (mLs)						OUTPUT (mLs)
Time	Intravenous fluid	Other (write)	DRUG (write) Noradrenaline	Hourly total	Running total	Urine	Hourly total	Running total	Balance (+ve or -ve)
01:00	250		10	260	260	30	30	30	+ve 230
02:00	250		10	260	520	35	35	65	+ve 455
03:00	250		10	260	780	40	40	105	+ve 675
04:00	250		10	260	1040	15	15	120	+ve 920
05:00	250	500 Hartman's	10	760	1800	25	25	145	+ve 1655
06:00	250		10	260	2060	30	30	175	+ve 1885
07:00	250		10	260	2320	30	30	205	+ve 2115
08:00	250		10	260	2580	20	20	225	+ve 2355
09:00	250		10	260	2840	10	10	235	+ve 2605
...

Haematology and Coagulopathy \| Clinical Chemistry & Liver Function Tests
Test	Normal Values	18:30
HB	11.5 - 16.5 g/dL	10.0
Platelets	150 - 450 x 10^-9/L	120
WBC	4.0 - 11.0 x 10^-9/L	14
MCV	84 - 102 fL	85
Neutrophils	2.0 - 7.5 x 10^-9/L	9.0
ESR	1 - 20
APTT Ratio	0.85 - 1.14	1.4
INR	0.8 - 1.2	1.6
Prothrombin Time	9.0 - 12.0 sec's	14
APTT	25.0 - 31.0 sec's	40
Thrombin Time	13.0 - 19.0 sec's	21
D-Dimer	0 - 250 µg/L	200
Fibrinogen	1.8 - 4.0 g/L

Haematology and Coagulopathy \| Clinical Chemistry & Liver Function Tests
Test	Normal Values	18:30
Sodium	134 - 145 mmol/L	140
Potassium	3.5 - 5.3 mmol/L	4.5
Urea	2.9 - 7.5 mmol/L	10.0
Creatinine	70 - 120 µmol/L	165
GFR	(ml/min)
Glucose	4.0 - 10.0 mmol/L	9.9
Amylase	0 - 110 U/L
CK	0 - 170 U/L
ALT	0 - 45 U/L	40
γGT	0 - 40 U/L	50
Bilirubin	0 - 21 µmol/L	40
Alk Phosphate	40 - 130 U/L	180
Albumin	30 - 50 g/L	24
CRP	0 - 10 mg/dL	110
Troponin	up to 0.1 µg/L
Bicarbonate	24 - 32 mmol/L
Calcium	2.2 - 2.6 mmol/L
Phosphate	0.8 - 1.45 mmol/L
Magnesium	0.7 - 1.0 mmol/L

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