Early Detection and Treatment of Sepsis

Publication ID: 5495452335
Published on: August 2023
Major Revision: April 17, 2024


Any infection can lead to sepsis, and worldwide, one-third of people who develop sepsis die. Mortality from sepsis increases by as much as 8% for every hour that treatment is delayed. As many as 80% of sepsis deaths could be prevented with standardization and mobilization of tools and protocols already available in many institutions. Sepsis was rated the most expensive condition to treat in hospitals, with an estimated $55 million spent on sepsis in the US each day, and $62 billion spent annually worldwide. Many healthcare organizations have shown it is possible to successfully implement and sustain improvements that reduce sepsis morbidity and mortality. This blueprint outlines the actionable steps organizations can take to successfully reduce/improve sepsis rates and summarizes the available evidence-based practice protocols.
Frontline staff

This blueprint outlines the steps that frontline staff can follow to prevent sepsis: 

  1. Sepsis Intervention
    1. Diagnose and treat sepsis as early as possible. Every hour treatment is delayed, the risk of mortality increases. Misdiagnosis leading to a late true diagnosis is a major cause of death.
    2. Monitor patients using the TIME guideline from Sepsis Alliance: Assess for Temperature, higher or lower, signs of Infection, altered Mental status, and patient indication of feeling Extremely ill, such as being short of breath.
    3. In the first hour following diagnosis:
      1. Measure lactate level.
      2. Obtain blood cultures and give IV broad-spectrum antibiotics.
      3. Quickly administer IV fluids: 30 ml/kg crystalloid for hypotension or elevated lactate.
      4. Administer vasopressors to keep a mean arterial BP greater than 65 mmHg.
      5. Administer oxygen.
      6. Transfer patient to ICU.
    4. Re-evaluate patient condition continually to determine appropriate next steps.
    5. Remain vigilant for alerts if patient vitals deteriorate to indicate possible septic shock.
  1. Discharge
    1. Explain to the patient and family members the long-term implications of sepsis beyond hospitalization, including providing information about post-sepsis syndrome.
    2. Ensure patient and family members understand their role in follow-up care, appropriate use of medications, and when and how to seek help if needed.
  2. Awareness
    1. Perform initial sepsis screening for all patients using validated tools.
    2. Rule in sepsis before ruling it out.
    3. Communicate sepsis suspicion across team members, including patient-specific risk factors.
    4. Use appropriate assessment criteria, including, but not limited to, SIRS criteria and markers of organ dysfunction.

Clinical Workflow

    1. Perform initial sepsis screening for all patients and rule in sepsis before ruling it out.
    2. Use validated screening tools.
      1. qSOFA Score: altered mental status (Glasgow coma scale < 15), respiratory rate ≥ 22/min, or systolic blood pressure ≤ 100 mmHg.
      2. If two of the above, increase monitoring and assess for ICU admission.
      3. TIME from the Sepsis Alliance: Assess for Temperature, signs of Infection, altered Mental status, and patient indication of feeling Extremely ill such as being short of breath
    3. Evaluate risk factors. Very old or very young patients, those with an impaired immune system, those with chronic conditions, and pregnant females are among the high-risk populations. Sepsis is a leading cause of death of children globally.
    4. Check for infection. Pneumonia, followed by urinary tract and abdominal infections, are the top three most common infections predicting sepsis.
    5. If initial broad screening indicates a possibility for sepsis, continue with assessment.
      1. SIRS criteria:
        1. Temperature > 38.3° C or < 36° C
        2. HR > 90/min or greater than 2 SD above normal for age
        3. RR > 20 breaths/min
        4. WBC ( < 4,000/cu mm or > 12,000/cu mm or > 10% bands)
        5. Glucose > 140 mg/dL or 7.7 mmol/L in the absence of diabetes
      2. Markers of organ dysfunction:
        1. Tissue perfusion: lactate > 2 mmol/L
        2. Cardiovascular: SBP < 90 mmHg or MAP < 70 mmHg or decrease in SBP > 40 mmHg
        3. Hepatic: Tbili > 2 mg/dL, INR > 1.5
        4. Renal: Cr increase > 0.5 mg/dL or 44.2 umol/dL from baseline or urine output < 0.5 mL/kg/hr for at least 2 hours despite adequate fluid resuscitation
        5. Pulmonary: PaO2 < 60 mmHg or SpO2 < 90% or PF ratio < 200
        6. Coagulation: Platelets < 100,000 uL-1 or aPTT > 60 sec
      3. Other
        1. Plasma C reactive protein > 2 SD above normal
        2. Plasma procalcitonin > 2 SD above normal
        3. Decrease in urine output and skin changes (mottling) or prolonged capillary refill time
        4. If organ dysfunction is present or if patient exhibits two or more SIRS criteria and is suspected of having an infection, document appropriately and initiate sepsis bundle. 


  1. Administer fluids and antibiotics as early as possible.
    1. Measure lactate level.
    2. Obtain blood cultures.
    3. Administer broad-spectrum antibiotics.
    4. Administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L within the first hour and complete within three hours of presentation.
    5. Apply vasopressors to maintain mean arterial pressure > 65 mmHg.
    6. Transfer to ICU.
  2. Evaluate the condition of the patient to determine appropriate prioritization of next steps.
    1. Conduct the following sepsis protocols within one hour of diagnosis:
    2. Administer oxygen.
      1. If patient is critically ill, oxygen should be delivered via reservoir mask at 15L/min.
      2. Once stabilized, aim for oxygen flow to achieve 94–98%.
      3. Obtain blood cultures to guide antimicrobial therapy.
      4. Give antibiotics via IV.
        1. If unsure of source of infection, administer broad-spectrum antibiotics.
        2. Reduce antibiotics as soon as possible to avoid resistance.
      5. Measure urine output.
      6. Start a fluid balance chart once the catheter is placed.
      7. Administer vasopressors for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) ≥ 65 mmHg.
      8. For septic shock, initiate septic shock bundle: In the event of persistent hypotension despite volume resuscitation (septic shock) or initial lactate ≥ 4 mmol/L (36 mg/dL), reassess volume status and tissue perfusion and document findings.
      9.  Either:
        1. Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner, including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.
        2. Or one of the following:
          1. Measure CVP.
          2. Measure ScvO2.
          3. Conduct bedside cardiovascular ultrasound.
          4. Conduct dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge.


  1. Explain to the patient and family how to recognize infection and sepsis and when to seek medical care. Recurrence of sepsis syndrome is common: 40% of patients will be rehospitalized within 90 days.
    1. Make sure patients and family members have a thorough and comprehensive understanding that sepsis is the body’s reaction to an infection, and as such, the full care team will be vigilant about possible infections.
  2. Ensure understanding of physical and cognitive self-care.
    1. Tailor care efforts to patient preferences and resources available.
    2. Explain medications and how to use them appropriately.
  3. Make an attempt to understand the patient’s daily life to mitigate barriers to medication non-adherence.
    1. Help the patient take notes on their pill card, portal, etc., to keep track of their medications.
  4. Explain follow-up appointments needed and how to schedule them.
    1. Make sure patients and families understand the need for each appointment and what questions may be appropriate to ask.
  5. Communicate with the patient about what they might experience physically and psychologically upon returning home.
    1. Convey that discharge can be emotionally rigorous and that it is okay to seek help if and when needed.
  6. Explain any long-term effects of sepsis and how to best mitigate it.
    1. Be realistic yet encouraging when describing the typical obstacles and milestones in sepsis recovery.
  7. Explain post-sepsis syndrome and ensure that patient and family members understand how to monitor for post-sepsis syndrome.


  1. Post-sepsis syndrome affects 50% of sepsis survivors. It may result in some kind of disability, such as cognitive and physical dysfunction, skin grafts, amputations, or hearing loss. Approximately 20% of survivors will have recurring sepsis and will be readmitted into the hospital. Most patients recover from sepsis when it is diagnosed and treated early.
    1. If post-sepsis syndrome is suspected, bring patient back to an emergency room stat.



Unit Managers

This guide outlines the steps that managers must follow to reduce sepsis injury and mortality.

Unit managers need to follow the steps below to prevent sepsis in their units. Early diagnosis of sepsis is paramount; every hour delay in treatment increases the risk of mortality.  Make sure the staff know this! If sepsis is suspected, call for assistance! 

Unit Management Guide

  1. Ensure diagnosis and treatment protocols are known by the staff.
    1. Ensure that sepsis prevention and early recognition protocols are embedded into clinical workflows, whether electronic or paper.
    2. Ensure staff know the presentation of sepsis:
      1. Temperature — high or low
      2. Infection
      3. Mental decline — confused, sleepy
      4. Extremely ill — pain, discomfort, shortness of breath
    3. Implement a process for continuous monitoring protocols that are readily accessible by those on the frontline.
    4. Enable immediate transfer to ICU if volume resuscitation and vasopressors are indicated.
    5. Eliminate barriers to making rapid changes to documentation templates and order sets.
    6. Establish a priority system, whether through the EHR alerts or clinical workflow decision making, to flag sepsis based on initial vital signs.
    7. Establish the expectation for sepsis screening upon admission and any change in condition.
    8. Establish a mechanism to call ahead into the emergency department if the patient has signs or symptoms of sepsis.
  2. Compare your outcomes against other related metrics your organization is tracking.
  3. Routinely review all metrics and trends with both the advisory and project teams and discuss what is going well and what is not.
  4. Identify barriers to completion of action plans and adjust the plans if necessary.
  5. Be nimble and move quickly to keep team momentum going so that people can see the results of their labor.
  6. But don’t move so quickly that you don’t consider the larger, organizational ramifications of a change in your plan.In
  7. Involve everyone in the improvement work and recognize well-executed efforts:
    1. Ensure frontline involvement in sepsis prevention improvement activities. Maintain their engagement and remove barriers to progress.
    2. Standardize continued sepsis education for all medical providers and for nonmedical professionals in a clinical position who interact with patients within the healthcare continuum.
    3. Ensure collaboration between critical access hospitals and EMS, and standardize the decision making in the EMS setting around which facilities should receive the patient based on their signs and symptoms.
    4. Incorporate atypical disciplines into sepsis education, simulations, and activities (e.g., registration staff, IT, etc.). Emphasize the staff perceptions of hierarchy as a barrier to sepsis improvement and ensure all are aware of their responsibility to raise concerns about sepsis.
    5. Hold staff accountable for providing the standard of care and reward success.
  8. Create an automated surveillance system to monitor process and assess gaps.
    1. Use an effective electronic surveillance system to improve early recognition of septic patients based on monitoring the data found in the clinical workflow.
    2. Use automated electronic screening and documentation of the process of care, based on existing data. Create a process for case reviews for outliers.
    3. Use your EHR as a data collection tool and source for predicting risk of sepsis for patients.
    4. Create a process for continuous monitoring of electronic systems and protocols, including compliance, efficacy, and outcome measures.
  9. Measure effectively and share data to inform practice.
    1. Measure and report sepsis prevention compliance monthly.
    2. Note trends in areas with low screening compliance and high incidence rate of poor outcomes due to sepsis.
    3. Routinely reassess outcomes.
    4. Debrief on a regular basis to solicit team feedback about barriers to sustained compliance.
    5. Adjust the plan quickly and nimbly as needed.
    6. Ensure that leaders have a simple process to oversee sepsis improvement work while also considering how it aligns with other initiatives across the organization.
  10. Consider the following sepsis metrics to assess on a continuous basis:
    1. EMR alerts
    2. Hand hygiene
    3. Time from recognition to administration of broad-spectrum antibiotics
    4. Obtaining blood cultures prior to antibiotics
    5. Length of stay
    6. Outcome
    7. Readmission rates
    8. Time spent in emergency room
  11. Measure both process and outcome metrics.
    1. Outcome metrics include the rates outlined at the bottom of this section.
    2. Process metrics will depend upon the workflow you are trying to improve and are generally expressed in terms of compliance with workflow changes.

Follow this checklist if the leadership team has determined that a performance improvement project is necessary to address sepsis-adverse events in your organization: 

  1. Gather the right project team.
    1. Be sure to involve the right people on the team. You’ll want two teams: an oversight team that is broad in scope, has 10–15 members, and includes the executive sponsor to validate outcomes, remove barriers, and facilitate spread. The actual project team consists of 5–7 representatives who are most impacted by the process. Whether a discipline should be on the advisory team or the project team depends upon the needs of the organization. Patients and family members should be involved in all improvement projects, as there are many ways they can contribute to safer care.
  2. Understand what is currently happening and why.
    1. Reviewing objective data and trends is a good place to start to understand the current state, and teams should spend a good amount of time analyzing data and validating the sources, but the most important action here is to go to the point of care and observe. Even if team members work in the area daily, examining existing processes from every angle is generally an eye-opening experience. The team should ask questions of the frontline during the observations that allow them to understand each step in the process and identify the people, supplies, or other resources needed to improve patient outcomes.

Recommended Sepsis Improvement Team:

  1. Nurses
  2. Intensivist (e.g., pulmonologist, infection prevention, etc.)
  3. Emergency physician
  4. Hospitalist
  5. Pharmacists
  6. Respiratory therapists
  7. Infection preventionist
  8. Laboratory representative
  9. Clinical educators
  10. Quality management representative/Quality Improvement Officer
  11. Clinical nurse specialist
  12. Nurse practitioners
  13. Patient safety officer
  14. EMS service representative
  15. Quality improvement officer
  16. EMS state director
  17. Long-term care clinician
  18. Patients and family members
  19. Patient advocates
  20. Admitting and registration staff
  21. Case management representative
  22. Public health specialists (e.g., HAI coordinator)
  23. Health promotion specialists
Hospital Executives

This protocol outlines the steps that executives can follow to prevent sepsis and septic shock mortality. 

Sepsis is defined as life-threatening organ dysfunction caused by the body’s abnormal and dysregulated response to an infection. Any infection can lead to sepsis. Septic shock is defined as a profound circulatory metabolic disfunction and is associated with a greater risk of mortality than sepsis alone.

Sepsis is the leading cause of death in US hospitals, but 87% of sepsis cases originate in the community and NOT in hospital. Therefore, rapid accurate diagnosis is key in the emergency room. Misdiagnosis is common and increases risks of mortality and morbidity.

The human, medical and health-economic dimension of the problem:

  • Sepsis affects an estimated 49 million people worldwide each year, including more than 20 million children under age 5, and nearly 5 million older children and adolescents (ages 5-19). Around the world each year, sepsis takes 11 million lives, contributing to 20% of all deaths globally and taking more lives than cancer. Worldwide, one-third of people who develop sepsis die. Sepsis-related deaths might be even higher, up to 13.7 million, based on the Global Burden of Disease Study, estimating that 7.7 million deaths associated with 33 bacterial pathogens would rank as the second leading cause of deaths globally in 2019.
  • Any infection can lead to sepsis. That is why also most of the estimated 14.9 million excess deaths during the COVID-19 pandemic are to be attributed to viral sepsis as the final common pathway to death from most infectious diseases and any in the past pandemic and in the future
  • Sepsis disproportionally affects low- and middle-income countries (LMICs) with 85% of cases occurring in LMICs.
  • However, in the US alone, more than 1.7 million people are diagnosed with sepsis each year – one every 20 seconds – and kills 350 000 people, which is more than AIDS, AMR, Breast Cancer and Opioid overdose combined and is also the major cause of the major cause of maternal deaths.
  • More than 70% of sepsis survivors newly develop cognitive, psychological and physical impairments.
  • Sepsis patients are 2-3 times more likely to be readmitted to the hospital and one third of the patients die in the first year after hospital discharge.
  • Readmission for previously-septic patients is more expensive than readmission for other conditions.
  • Sepsis was rated the most expensive condition for health care cost in the USA.

The key role of the executive level to reduce preventable deaths from sepsis: 

Rapid diagnosis and starting treatment within one hour are key to survival. Sepsis is a medical emergency that must be treated within the first hour of presentation, as the mortality rate increases hourly. Mortality from sepsis increases by as much as 8% for every hour that treatment is delayed. The majority of sepsis deaths are preventable by: (1) infection prevention – through clean care and vaccination, (2) early recognition of sepsis and (3) management as an emergency. This is especially true and is highly cost effective. This has been demonstrated in high income countries (HICS) like Australia, Sweden and the US on the facility, federal and national level.

Awareness raising and prioritization of the sepsis by the leadership on the facility, community, health care system and policy level is key, as over 80% of all sepsis cases develop in the community. Often according tools and protocols are already available in many institutions. However, the lack of interdisciplinary and cross-professional collaboration, which is required for effective infection prevention, timely recognition and management of sepsis is often missing, which underpins the key role of the hospital executive level and the inclusion of patients and family members in community education efforts. Likewise, also the close collaboration between may be very helpful to foster quality improvement efforts also on the hospital and policy level. 

Sepsis was rated the most expensive condition to treat in hospitals, with an estimated $55+ million spent on sepsis in the US each day, and $62 billion spent annually worldwide. Sepsis patients are not only 2–3 times more likely to be readmitted to the hospital than patients with heart failure or pneumonia.

Patient & Families

This guide outlines the steps that patients and family members can follow if they suspect sepsis:

  1. Sepsis is an emergency! If you notice any of the following signs, alert your care team immediately. Each hour delay in treatment increases risk of mortality.
    1. Fever and chills
    2. Mental decline
    3. Changes in breathing patterns
    4. Feelings of restlessness
    5. Physical signs of illness
    6. Unusual bleeding
    7. Changes in urine output
  2. Wash your hands frequently and cover wounds as well.
  3. Ask your care team to explain signs of sepsis and to elaborate on symptoms of septic shock.
  4. Ask your care team to explain how you can detect early signs of sepsis and deterioration.
  5. Ask your care team to explain where and how you can seek help if you recognize signs of sepsis.
  6. If you notice a change in your or your loved one’s mental health status, inform your care team immediately.
  7. Ask your care team to explain what to expect from a sepsis diagnosis.
  8. Ask your care team to explain sepsis treatment options.
  9. If you or your loved one is discharged after recovering from sepsis, ask your care team to explain what to expect in terms of both physical and cognitive functioning.
  10. Ask your care team to explain post-sepsis syndrome and what you need to do if you suspect deterioration after discharge.
  11. Ask your care team about all post-discharge appointments, therapies, medications, and potential complications.
  12. Ask your care team for resources, including direct contact phone numbers to the hospital, for post-discharge questions.
  13. Be aware of the strong possibility of rehospitalization for sepsis.
  14. If you or a loved one feels that they are being misdiagnosed, then request a second opinion from another physician.

Dantes BR, et al. Combatting Sepsis: A Public Health Perspective. (2018)

Fleischmann-Struzek, C., et al. Incidence and mortality of hospital- and ICU-treated sepsis: results from an updated and expanded systematic review and meta-analysis. (2020)

Gadre, S. K., et al.  & Duggal, A. Epidemiology and Predictors of 30-Day Readmission in Patients With Sepsis. Chest, 155(3), 483–490. (2019)

Kempker, J. et al. A global accounting of sepsis. (2020)

Markwart, R., et al. Epidemiology and burden of sepsis acquired in hospitals and intensive care units: a systematic review and meta-analysis. (2020)

Mostel, Z. et al.. Post-sepsis syndrome – an evolving entity that afflicts survivors of sepsis. (2019)

NIH. (2019). Sepsis Fact Sheet. Sepsis Fact Sheet.

NHS Trust. (n.d.). Post Sepsis Syndrome.

qSOFA (Quick SOFA) Score for Sepsis.