SBAR Transfer Faxed Report to Intermediate Care Unit

Script for Calling Primary Physician for Severe Sepsis

S / SITUATION:
“Patient ______has screened positive for sepsis at ______(Time of presentation.) The last time that Sepsis bundle was activated was ______hours ago.
B
What acute change has occurred / BACKGROUND:
“Patient has ______(confirmed infection) OR “Patient has a suspected infection of ______ (source of infection).”
“And he/she has ______ (2 or more of the following criteria)”
Temp >38.3C(101.5F)
Temp <36C (96.8F)
HR>90
RR >20
WBC >12,000
WBC <4,000
A / ASSESSMENT:
“The charge nurse and I assessed the patient together and found ______(list applicable data below),
which may indicate potential organ dysfunction due to severe sepsis.”
Acute change in mental status (neuro)
SBP< 90mmHg (cardiovascular)
Increased FiO2 demand / Need for mechanical ventilator or BiPAP (respiratory)
Creatinine >2 or Urine Output < 0.5ml /kg/hr over 2 hours (renal)
PLT <100,000 or INR >1.5(not on Warfarin) or aPTT >60 sec(hematologic)
Bilirubin >2.0 (hepatic)
Lactate >18mg/dl
*Organ dysfunction r/t chronic disease or medications does not apply.
R / RECOMMENDATION:
“I initiated the Nurse Driven Severe Sepsis Protocol by completing the blood culture x2 and lactate.”
Would you activate “Sepsis Order Set” in the CareConnect? (Type in “Sepsis” in the “Go To Order Set” tab under “Manage Orders. Then choose “General Adult Sepsis.” (Call the physician again if the order set is not activated in 5 minutes)
(If patient has HF) “Would you like to administer Lasix as well?”

Script for Calling Primary Physician for Septic Shock

S / SITUATION:
“The Nurse Driven Severe Sepsis Protocol was initiated for Patient ______minutes ago (Time of blood cultures and lactate draws) due to potential organ dysfunction due to sepsis, which were (list applicable data below).”
Acute change in mental status (neuro)
SBP< 90mmHg (cardiovascular)
Increased FiO2 demand / Need for mechanical ventilator or BiPAP (respiratory)
Creatinine >2 or Urine Output < 0.5ml /kg/hr over 2 hours (renal)
PLT <100,000 or INR >1.5(not on Warfarin) or aPTT >60 sec(hematologic)
Bilirubin >2.0 (hepatic)
Lactate >18 mg/dl
B / BACKGROUND:
“______(IV antibiotic name) was initiated within 1 hours of time of presentation”
“And a total of ______ml of NS (or LR) bolus was completed based on the patient’s weight, which was ______(kg).”
(If available) “Lactate is ______.” OR “Lactate is ______(>18 mg/dl) and repeat lactate was sent.
A / ASSESSMENT:
“Repeat lactate result is ______(>36 mg/dl).”
OR/AND
“The patient’s SBP is ______mmHg (<100 mmHg) even after the IV bolus was completed.”
R / RECOMMENDATION:
(MD is to assess the patient at bedside to determine the need of repeat IV bolus or vasopressors.)