Focus Area Name:	Focus Area Version:	Applicable from (Discharge Month):
Paediatric Sepsis	2	October 2016

...

Expand

title	Sepsis Date/Time - Expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	Not applicable
Query sepsis Suspected sepsis Sepsis considered Question sepsis Potential sepsis Likely sepsis Working diagnosis sepsis Sepsis query cause Not sepsis Sepsis unlikely Sepsis excluded

Answer Option

Answer Assitance

Unknown

If the date/time of suspected sepsis or 'query sepsis' is unable to be determined from clinical record, select "Unknown". 
  The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown". 
  Examples: 
The clinical record indicates the diagnosis date was 32-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the diagnosis date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown".
The clinical record indicates the diagnosis time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the diagnosis time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown".
Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the diagnosis date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the diagnosis date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "Unknown".

DATE

The earliest documented day, month, and year that the patient was suspected of having sepsis or was considered 'query sepsis'.

DD	Day (01-31)
MM	Month (01 - 12)
YYYY	Year (2000 - 9999)

TIME

The earliest documented time (24- hour clock) that the patient was suspected of having sepsis or was considered 'query sepsis'.
Examples:
Midnight - 00:00           Noon - 12:00
5:31 am - 05:31           5:31 pm - 17:31
11:59 am - 11:59         11:59 pm - 23:59

HH	Hour (00-23)
MM	Minutes (00-59)

What was the severity of the suspected sepsis?

...

Expand

title	High flow oxygen date/time - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
Ambulance service notes

Answer Options

Answer Option

Answer Assistance

Unknown

If the date/time of delivery of oxygen is unable to be determined from medical record documentation, enter UTD.
The medical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown".
Examples:

Documentation within the medical record indicates the delivery of oxygen date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown".
Documentation within the medical record indicates the delivery of oxygen time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown".
Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the delivery of oxygen date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "Unknown".

Date

The earliest documented day, month, and year that high flow oxygen was delivered.

DD	Day (01-31)
MM	Month (01-12)
YYYY	Year (2000 - 9999)

Time

The earliest documented time (24 hour clock) that high flow oxygen was delivered
Examples:

Midnight - 00:00	Noon - 12:00
5:31 am - 05:31	5:31 pm - 17:31
11:59 am - 11:59	11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

Does the clinical record show that the Clinician attempted to gain IV access?

...

Expand

title	IV attempted date/time - Expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
IV fluids given IV fluids commenced IV fluids started IV access at IV access attempted Multiple attempts at access Multiple attempts at IVs	Oral fluids given

Answer Options

Answer Option

Answer Assistance

Unknown

If the date/time of attempted IV access is unable to be determined from clinical record documentation, select "Unknown".
The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown."
Examples:

Documentation within the clinical record indicates the delivery of oxygen date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown".
Documentation within the clinical record indicates the delivery of oxygen time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown".
Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the delivery of oxygen date was 12-03-2007. Other documentation in the clinical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "Unknown".

Date

The earliest documented day, month, and year that IV access was attempted

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that IV access was obtained.
Examples:
Midnight - 00:00           Noon - 12:00
5:31 am - 05:31           5:31 pm - 17:31
11:59 am - 11:59         11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

How many attempts at gaining IV access did the Clinician take?

...

Expand

title	IV access date/time - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
IV fluids given IV fluids commenced IV fluids started IV access at IV access attempted Multiple attempts at access Multiple attempts at IVs	Oral fluids given

Answer Options

Answer Option

Answer Assistance

Unknown

If the date/time of attempted IV access is unable to be determined from clinical record documentation, select "Unknown".
The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown".
Examples:

Documentation within the clinical record indicates the delivery of oxygen date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown"
Documentation within the clinical record indicates the delivery of oxygen time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown."

Date

The earliest documented day, month, and year that IV/IO access was successfully gained

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that IV/IO access was successfully gained
Examples:
Midnight - 00:00           Noon - 12:00
5:31 am - 05:31           5:31 pm - 17:31
11:59 am - 11:59         11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

Does the clinical record show that the Clinician attempted to gain IO access?

...

Expand

IO attempt date/time - expand for details
Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
IO fluids given IO fluids commenced IO fluids started IO access at IV access attempted Multiple attempts at IO access	Oral fluids given

Answer Options

Answer Option

Answer Assistance

Unknown

If the date/time of attempted IO access is unable to be determined from clinical record documentation, select "Unknown".
The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown."
Examples:

Documentation within the clinical record indicates the delivery of oxygen date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown".
Documentation within the clinical record indicates the delivery of oxygen time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown".
Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the delivery of oxygen date was 12-03-2007. Other documentation in the clinical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "Unknown".

Date

The earliest documented day, month, and year that IV/IO access was attempted
Examples:
Midnight - 00:00           Noon - 12:00
5:31 am - 05:31           5:31 pm - 17:31
11:59 am - 11:59         11:59 pm - 23:59

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that IO access was obtained.

HH	Hour (00 – 23)
MM	Minutes (00-59)

How many attempts at gaining IO access did the Clinician take?

...

Expand

title	IO access date/time - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
IO fluids given IO fluids commenced IO fluids started IO access at IO access attempted Multiple attempts at IO access	Oral fluids given

Answer Options

Answer Option

Answer Assistance

Unknown

If the date/time of attempted IO access is unable to be determined from clinical record documentation, select "Unknown".
The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown".
Examples:

Documentation within the clinical record indicates the delivery of oxygen date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown".
Documentation within the clinical record indicates the delivery of oxygen time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown".
Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the delivery of oxygen date was 12-03-2007. Other documentation in the clinical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "Unknown".

Date

The earliest documented day, month, and year that IV/IO access was successfully gained.

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that IV/IO access was successfully gained.
Examples:
Midnight - 00:00           Noon - 12:00
5:31 am - 05:31           5:31 pm - 17:31
11:59 am - 11:59         11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

Does the clinical record show whether blood cultures were taken?

...

Expand

title	Blood cultures date/time - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Laboratory test results
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary

Terminology related to this question:

Applicable	Not Applicable
Cultures taken Bloods taken including cultures Blood cultures taken Blood taken for OC&S Bloods – C&S	No bloods taken

Answer Options

Answer Option

Answer Assistance

Unknown

If the date/time of blood cultures is unable to be determined from clinical record documentation, select "Unknown".
The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown".
Examples:

Documentation within the clinical record indicates the blood cultures date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown".
Documentation within the clinical record indicates the blood cultures time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown".
Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the blood cultures date was 12-03-2007. Other documentation in the clinical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "Unknown".

Date

The earliest documented day, month, and year that blood cultures were taken

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that blood cultures were taken
Examples:
Midnight - 00:00           Noon - 12:00
5:31 am - 05:31           5:31 pm - 17:31
11:59 am - 11:59         11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

Does the clinical record show that a blood glucose measurement was taken?

...

Expand

title	Blood glucose date/time - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Laboratory test results
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary

Terminology related to this question:

Applicable	Not Applicable
Blood taken – glucose Bloods – glucose Glucose level taken Glucose = x	No bloods taken

Answer Options

Answer Option

Answer Assistance

Unknown

If the date/time of the blood glucose test is unable to be determined from clinical record documentation, select "Unknown".
The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown".
Examples:

Documentation within the clinical record indicates the blood cultures date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown".
Documentation within the clinical record indicates the blood cultures time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select ""Unknown".
Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the blood cultures date was 12-03-2007. Other documentation in the clinical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "Unknown".

Date

The earliest documented day, month, and year that a blood glucose measurement was taken.

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that a blood glucose measurement was taken
Examples:
Midnight - 00:00           Noon - 12:00
5:31 am - 05:31           5:31 pm - 17:31
11:59 am - 11:59         11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

If blood glucose levels were low, was the patient treated for hypoglycaemia?

Expand

title	Blood glucose low, hypoglycaemia treatment - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
Blood taken – glucose low Bloods – glucose low Glucose level taken and found to be low Glucose = x, low Treated for hypo Hypo – treated Hypoglycaemic Hypoglycaemia	Bloods not taken

Answer Options

Answer Options	Answer Assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that the patient was treated for hypoglycaemia due to low blood glucose levels.
No	There is no documentation within the clinical record that the patient was treated for hypoglycaemia despite having low blood sugar levels.
NCI	If the patient was not hypoglycaemic, then this question should be answered 'NCI' The clinical record states that the patient was not clinically indicated to be treated for hypoglycaemia e.g. the patient was not hypoglycaemic.

Does the clinical record show that a blood gas measurement was taken?

Expand

title	Blood gas measurement taken - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Laboratory test results
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary

Terminology related to this question:

Applicable	Not Applicable
Gases taken Bloods taken for gases Blood gases taken Gases to lab Arterial gases taken Capillary gases taken Venous gases taken	Bloods not done Blood not taken Gases not done

Additional information
Blood gas measurement is integral to the management of sepsis. Blood gases guide treatment and have an impact on the prognosis of a child with sepsis.
Answer

...

Option

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question.
Yes	There is documentation within the clinical record that a blood gas measure was taken.
No	There is no documentation within the clinical record that a blood gas measurement was taken or it is unable to be determined from the clinical record.
Unable to obtain	There is documentation within the clinical record that the Clinician was unable to obtain a blood sample.

Blood gas measurement date/time

Expand

title	Blood gas date/time - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Laboratory test results
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary

Terminology related to this question:

Applicable	Not Applicable
Arterial gases taken Capillary gases taken Venous gases taken Gases taken Bloods taken for gases Blood gases taken Gases to lab	Bloods not done Blood not taken Gases not done

Answer

...

Option

Answer Option

Answer Assistance

Unknown

If the date/time of the blood glucose test is unable to be determined from clinical record documentation, select "Unknown"
The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown"
Examples:

Documentation within the clinical record indicates the blood cultures date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown"
Documentation within the clinical record indicates the blood cultures time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown"

Date

The earliest documented day, month, and year that a blood glucose measurement was taken

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that a blood glucose measurement was taken.
Examples:
Midnight - 00:00           Noon - 12:00
5:31 am - 05:31           5:31 pm - 17:31
11:59 am - 11:59         11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

What type of blood gas was measured?

Expand

title	Blood gas type - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
Arterial gases taken Capillary gases taken Venous gases taken	No bloods done Gases not done No gases done

Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question.
UTD	It is unable to be determined from the clinical record what type of blood gas was measured.
Arterial	Documentation states it is arterial blood gas which was measured.
Central venous	Documentation states it is central venous blood gas which was measured.
Peripheral venous	Documentation states it is peripheral venous blood gas which was measured.
Capillary	Documentation states it is capillary blood gas which was measured.

Does the clinical record show that a test was ordered to measure the full blood count?

Expand

title	Q25. Does the clinical record show that a test was ordered to measure the full blood count?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Laboratory test results
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary

Terminology related to this question:

Applicable	Not Applicable
FBC taken Full blood count done FBC done	No bloods done

Additional Information
Full blood count is an important measurement in the care of a child with sepsis. It guides management and has an impact on the prognosis of a child with sepsis.
Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question.
Yes	There is documentation within the clinical record that a blood test was ordered to measure the full blood count
No	There is no documentation within the clinical record that a blood test was ordered to measure the full blood count or it is unable to be determined from the clinical record.
Unable to obtain	There is documentation within the clinical record that the Clinician was unable to obtain a blood sample.

Does the clinical record show that a test was ordered to measure the lactate level?

Expand

title	Lactate test ordered - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Laboratory test results
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary

Terminology related to this question:

Applicable	Not Applicable
Lactate done Lactate taken Lactate = x Lactate levels = x	Lactate not done Bloods not done

Additional Information
Lactate levels are an important measurement in the care of a child with sepsis. It guides management and has a direct impact on the prognosis of a child with sepsis.
Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question.
Yes	There is documentation within the clinical record that a blood test was ordered to measure the lactate level.
No	There is no documentation within the clinical record that a blood test was ordered to measure the lactate level or it is unable to be determined from the clinical record.
Unable to obtain	There is documentation within the clinical record that the Clinician was unable to obtain a blood sample.

Does the clinical record show that a test was ordered to measure the CRP level?

Expand

title	CRP test ordered - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Laboratory test results
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary

Terminology related to this question:

Applicable	Not Applicable
CRP = X CRP done CRP level CRP rising CRP level decreasing	CRP not done Bloods not done

Additional Information:
CRP is an important measurement in the care of a child with sepsis. It guides management and has an impact on the prognosis of a child with sepsis.
Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question.
Yes	There is documentation within the clinical record that a blood test was ordered to measure the CRP level
No	There is no documentation within the clinical record that a blood test was ordered to measure the CRP level or it is unable to be determined from the clinical record.
Unable to obtain	There is documentation within the clinical record that the Clinician was unable to obtain a blood sample.

Does the clinical record show that the patient was already on an antibiotic upon presentation of sepsis?

Expand

title	Already on antibiotics - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
Antibiotics already administered On clarithromycin for x days IVs already commenced from St Elsewhere	No antibiotics

Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question.
Yes	There is documentation within the clinical record that the patient was already on a course of antibiotics at the time of suspected sepsis.
No	There is no documentation within the clinical record that the patient was already on a course of antibiotics at time of suspected sepsis

Were the antibiotics reviewed and changed accordingly?

Expand

title	Antibiotics reviewed and changed - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
Meds and antibiotics reviewed. Antibiotics to continue. Stay on IVs. Switch from IV to oral antibiotics Stop antibiotics Stop IVs

Additional Information:
If the patient was already on a course of antibiotics at the time of suspected sepsis then the antibiotics should be reviewed to check that they are appropriate to the sepsis infection and changed accordingly if needed.
Answer Options

Answer Options	Answer Assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that the antibiotics were reviewed and changed appropriately
No	There is no documentation within the clinical record that antibiotics were reviewed and changed.
NCI	If the antibiotics were reviewed and deemed appropriate with no changes required, then answer 'NCI'. The patient was not clinically indicated to have antibiotics reviewed and changed or the antibiotics were reviewed and deemed appropriate to the suspected sepsis infection with no changes required.

Does the clinical record show that antibiotics were prescribed?

Expand

title	Antibiotics prescribed - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
Antibiotics given IV antibiotics IV cefotaxime given IV administered Suggest start IV cefotaxime at xx dose

Additional Information
Antibiotics are a key treatment in the management of a child with sepsis.

...

Answer

...

Option

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that antibiotics were prescribed.
No	There is no documentation within the clinical record that antibiotics were prescribed or it is unable to be determined from the clinical record.
NCI	There is documentation within the clinical record that a prescription of antibiotics was not clinically indicated.

Which antibiotic was prescribed?

Expand

title	Antibioitic name - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable

Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question
amoxicillin	The clinical record states that this antibiotics was prescribed
azithromycin	The clinical record states that this antibiotics was

...

prescribed. The clinical record states that this antibiotics was prescribed
cefotaxime	The clinical record states that this antibiotics was

...

prescribed. The clinical record states that this antibiotics was prescribed
ceftriaxone	The clinical record states that this antibiotics was prescribed
cefuroxime	The clinical record states that this antibiotics was prescribed
co-amoxiclav	The clinical record states that this antibiotics was prescribed
meropenem	The clinical record states that this antibiotics was prescribed
other	The clinical record states another antibiotic name which is not listed above, or the name of the antibiotic is not stated in the clinical record

Please enter the details of the 'Other' antibiotic prescribed

Expand

title	Other antibiotic - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable

Answer Options
This question is a free text field in which you can record the details of any other antibiotic prescribed, as details within the clinical record and not covered in the answer options for the previous question.

Antibiotics prescription date/time

Expand

title	Antibiotics prescription date/time - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
Antibiotics given IV antibiotics IV cefotaxime given IV administered Suggest start IV cefotaxime at xx dose

Answer Options

Answer Option

Answer Assistance

Unknown

If the date/time of antibiotic administration is unable to be determined from clinical record documentation, select "Unknown".
If the patient was already on a course of antibiotics at the time of suspected sepsis and these were subsequently reviewed and changed, then the date and time entered should be that of the reviewed antibiotics.
The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown".
Examples:

Documentation within the clinical record indicates the antibiotic administration date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown".
Documentation within the clinical record indicates the antibiotic administration time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown".
Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the antibiotic administration date was 12-03-2007. Other documentation in the clinical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "Unknown".

Date

The earliest documented day, month, and year that antibiotics were prescribed.

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that antibiotics were prescribed.
Examples:
Midnight - 00:00           Noon - 12:00
5:31 am - 05:31           5:31 pm - 17:31
11:59 am - 11:59         11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

...

Does the clinical record show that antibiotics were given?

Expand

title	Antibiotics given - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
Antibiotics given IV antibiotics IV cefotaxime given IV administered Suggest start IV cefotaxime at xx dose

Additional Information
Following suspected sepsis antibiotics should be initiated rapidly to treat the underlying infection. Antibiotic choice should be guided by local protocols.
Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that antibiotics were given.
No	There is no documentation within the clinical record that antibiotics were given or it is unable to be determined from the clinical record.
NCI	There may be patients for whom this measure will be not clinically indicated (NCI). These patients may have documentation in their notes indicating that the consultant or team member has made a decision that this particular measure was not appropriate for this patient. An example of a patient who was NCI for this measure would be where antibiotics were already being administered at the time of diagnosis/query sepsis. This should be clearly documented in the clinical record.

Antibiotics given date/time

Expand

title	Antibiotics given date/time - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
Antibiotics given IV antibiotics IV cefotaxime given IV ceftriaxone administered IV abs administered Suggest start IV cefotaxime at xx dose

Answer Options

Answer Option

Answer Assistance

Unknown

If the date/time of antibiotic administration is unable to be determined from clinical record documentation, select "Unknown".
If the patient was already on a course of antibiotics at the time of suspected sepsis and these were subsequently reviewed and changed, then the date and time entered should be that of the reviewed antibiotics.
The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown".
Examples:

Documentation within the clinical record indicates the antibiotic administration date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown".
Documentation within the clinical record indicates the antibiotic administration time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown".
Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the antibiotic administration date was 12-03-2007. Other documentation in the clinical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "Unknown".

Date

The earliest documented day, month, and year that empiric antibiotics were given

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that empiric antibiotics were given.
Examples:
Midnight - 00:00           Noon - 12:00
5:31 am - 05:31           5:31 pm - 17:31
11:59 am - 11:59         11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

Were the antibiotics prescribed in line with local protocol?

Expand

title	Antibiotic per protocol - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
Antibiotics given IV antibiotics IV cefotaxime given IV administered Suggest start IV cefotaxime at xx dose

Additional Information:
Following suspected sepsis antibiotics should be initiated rapidly to treat the underlying infection. Antibiotic choice should be guided by local protocols.
Answer Options

Answer Option	Answer

...

Assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that antibiotics were prescribed in line with local protocol.
No	There is documentation within the clinical record that antibiotics were not prescribed in line with local protocol or it is unable to be determined from the clinical record.

Does the clinical record show that intravenous fluid resuscitation was initiated?

Expand

title	IV fluids initiated - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
Laboratory test results
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service notes
Fluid balance sheets

Terminology related to this question:

Applicable	Not Applicable
Crystalloid fluid – normal saline 0.9% saline, Ringer's solution, Ringer's lactate, glucose 0.5%, Hartmann's solution, 0.45% saline with glucose. Colloid fluid – synonyms, albumin, dextran 40, dextran 70, gelatin, HES (hydroxyethyl starches), tetrastarch, gelofusine, plasmagel, plasmion, polygeline, haemacel, gelifundol, hespan, hextend, hetastarch, pentastarch,	Oral fluid given

Additional Information
The fluid required to be given intravenously within 1 hour of the recognition of sepsis should be appropriate to the patient's volume status, cardiac and renal status. The fluids which are administered intravenously are classified as crystalloid or colloid.
Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that the appropriate volumes of fluid resuscitation were initiated.
No	There is no documentation within the clinical record that fluid resuscitation was initiated or it is unable to be determined from the clinical record.
NCI	There may be patients for whom this measure will be not clinically indicated (NCI). These patients may have documentation in their notes indicating that the consultant or team member has made a decision that this particular measure was not appropriate for this patient. An example of a patient who could be considered NCI for this measure might be where fluid overload is problematic, for example in left ventricular failure. This should be clearly documented in the clinical record. There is documentation within the clinical record that fluid resuscitation was not clinically indicated.

Intravenous fluid resuscitation initiated date/time

Expand

title	Fluid Resus date/time - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service notes
Fluid balance sheets

Terminology related to this question:

Applicable	Not Applicable
IV fluids given IV fluids commenced IV fluids started IV access at

Answer Options
If the date/time fluid resuscitation was given is unable to be determined from clinical record documentation, select "Unknown".The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown". Examples:

Documentation within the clinical record indicates the date fluid resuscitation was given was 12-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown".
Documentation within the clinical record indicates the time fluid resuscitation was given was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown".

Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the date fluid resuscitation was given was 12-03-2007. Other documentation in the clinical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "Unknown".

Answer Option

Answer Assistance

Unknown

If the date/time fluid resuscitation was given is unable to be determined from clinical record documentation, select "Unknown".
The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown".
Examples:

Documentation within the clinical record indicates the antibiotic administration date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown".
Documentation within the clinical record indicates the antibiotic administration time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown".
Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the antibiotic administration date was 12-03-2007. Other documentation in the clinical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "Unknown".

...

Date
The earliest documented day, month, and year that fluid resuscitation was initiated.
DD Day (01-31)
MM Month (01 – 12)
YYYY Year (2000 – 9999)

...

Time

The earliest documented time (24 hour clock) that fluid resuscitation was initiated.
Examples:
Midnight - 00:00           Noon - 12:00
5:31 am - 05:31           5:31 pm - 17:31
11:59 am - 11:59         11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

How much fluid (mg/kg) did the patient receive within 1 hour of fluid resuscitation being initiated?

Expand

title	Fluid amount given - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
IV fluids given at x ml/kg Bolus IV fluids x ml/kg IV saline given x ml/kg IV normal saline x ml/kg IV 0.9% Na Cl given x ml/kg IV 0.9% sodium chloride given x ml/kg IV 0.45% Na Cl given x ml/kg IV 0.45% sodium chloride with glucose given x ml/kg IV Hartmann's given x ml/kg	Oral fluids only Oral fluids given Push oral fluids Sips only taken

Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question
UTD	Select UTD if the clinical record does not state the amount of fluid the patient received
0 - 200	Select the relevant integer as per the amount of fluid the patient received, as stated in the clinical record The answer options are in integers of 10 so please select the closest value. e.g. if 15 mg/kg was given, select the answer option 10 – 19.

Did the patient's heart rate return to normal within 1 hour of fluid resuscitation being initiated?

Expand

title	heart rate back to normal - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
Heart rate now normal PEWS score now normal Pulse now normal HR normal HR = x/min, returned to normal Pulse = x/min = normal	Heart rate not recorded Pulse not recorded

Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that the patient's heart rate returned to normal within 1 hour of fluid resuscitation being initiated.
No	There is no documentation within the clinical record that the patient's heart rate returned to normal within 1 hour of fluid resuscitation being initiated or it is unable to be determined from the clinical record.
NCI	There may be patients for whom this measure will be not clinically indicated (NCI). These patients may have documentation in their notes indicating that the consultant or team member has made a decision that this particular measure was not appropriate for this patient. An example of a patient who could be considered NCI for this measure might be where fluid overload is problematic, for example in left ventricular failure. This should be clearly documented in the clinical record. There is documentation within the clinical record that fluid resuscitation and heart rate normality being achieved was not clinically indicated.

Did the patient's systolic blood pressure return to normal within 1 hour of fluid resuscitation being initiated?

Expand

title	Blood pressure back to normal - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
BP normal Blood pressure now stable and normal BP returned to physiological norms PEWS score normal BP = xx/xx = normal	BP not recorded Blood pressure not recorded

Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that the patient's blood pressure returned to normal within 1 hour of fluid resuscitation being initiated.
NCI	There may be patients for whom this measure will be not clinically indicated (NCI). These patients may have documentation in their notes indicating that the consultant or team member has made a decision that this particular measure was not appropriate for this patient. An example of a patient who could be considered NCI for this measure might be where fluid overload is problematic, for example in left ventricular failure. This should be clearly documented in the clinical record. There is documentation within the clinical record that fluid resuscitation and blood pressure normality being achieved was not clinically indicated.

Does the clinical record show that the patient was given inotropic support?

Expand

title	Inotropic support given - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
Inotropes given Inotropes commenced Inotropic support needed start on x Vasopressors given Dopamine given Dobutamine given Epinephrine given Norepinephrine given Vasopressin given Nitroprusside given Milrinone given

Answer Options:

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that inotropic support was given.
No	There is no documentation within the clinical record that inotropic support was given or it is unable to be determined from the clinical record.
NCI	There may be patients for whom this measure will be not clinically indicated (NCI). These patients may have documentation in their notes indicating that the consultant or team member has made a decision that this particular measure was not appropriate for this patient. There is documentation within the clinical record that inotropic support was not clinically indicated in the patient.

Inotropic support date/time

Expand

title	Inotropic support date/time - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
Inotropes given Inotropes commenced Inotropic support needed start on x Vasopressors given Dopamine given Dobutamine given Epinephrine given Norepinephrine given Vasopressin given Nitroprusside given Milrinone given

Answer

...

Option

Answer Option

Answer Assistance

Unknown

If the date/time of inotropic support is unable to be determined from clinical record documentation, select "Unknown".
The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown".
Examples:

Documentation within the clinical record indicates the antibiotic administration date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown".
Documentation within the clinical record indicates the antibiotic administration time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown".
Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the antibiotic administration date was 12-03-2007. Other documentation in the clinical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "Unknown".

...

Date

record documentation, select "Unknown". The earliest day, month and year that inotropic support was given.

DD	Day (01-31)
MM	Month (01-12)
YYYY	Year (2000-9999)

...

Time

The earliest documented time (24 hour clock) that inotropic support was

...

given

...

Examples:
Midnight - 00:00           Noon - 12:00
5:31 am - 05:31           5:31 pm - 17:31
11:59 am - 11:59         11:59 pm - 23:59

HH	Hour (00-23)
MM	Minutes (00-59)

Type of inotropic support given to the patient

Expand

title	Type of inotropic support - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
Inotropes given Inotropes commenced Inotropic support needed start on x Vasopressors given Dopamine given Dobutamine given Epinephrine given Norepinephrine given Vasopressin given Nitroprusside given Milrinone given

Answer Options:

Answer Option	Answer

...

Assistance
Unanswered	No answer has been provided for this question
Adrenalin	Select this option if adrenaline was given
Noradrenalin	Select this option if noradrenaline was given
Dopamine	Select this option if dopamine was given
Other	Select this option if another inotrope was given and specify which one in the free text box.
NCI	There may be patients for whom this measure will be not clinically indicated (NCI). These patients may have documentation in their notes indicating that the consultant or team member has made a decision that this particular measure was not appropriate for this patient. There is documentation within the clinical record that inotropic support was not clinically indicated in the patient.
UTD	Select UTD if the clinical record does not state the type of inotrope the patient received.

Please enter the details of the 'Other' inotropic support given to the patient

Expand

title	'Other' inotropic support - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
Dobutamine given Epinephrine given Norepinephrine given Vasopressin given Nitroprusside given Milrinone given

Answer Options
This question is a free text field in which you can record the details of any other inotropic support given to the patient and stated within the clinical record, which is not covered in the list of complications for the previous question.

Does the clinical record show that a Senior Clinician/Specialist was consulted regarding the patient care?

Expand

title	Senior Clinician consulted - expand for details

Acceptable sources of information

...

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
ST x review Reviewed by ST x Consultant review Reviewed by paeds consultant Paediatric consultant review	F1 review F2 review

Additional Information
Senior doctors should be involved in the care of children with sepsis.
Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that a Senior Clinician was consulted regarding the patient's care.
No	There is no documentation within the clinical record that a Senior Clinician was consulted regarding the patient's care.
NCI	It was not clinically indicated to have a Senior Clinician or Specialist consulted regarding the patient's care.

Date/time of first Senior Clinician/Specialist consultation

Expand

title	First Senior Clinician consultation - expand for details

Acceptable sources of information

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service notes

Terminology related to this question

Applicable	Not Applicable
ST x review Reviewed by ST x Consultant review Reviewed by paeds consultant Paediatric consultant review	F1 review F2 review

Answer Options

Answer Option

Answer Assistance

Unknown

If the date/time of the first Senior Clinician consultation is unable to be determined from clinical record documentation, select "Unknown".
The clinical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "Unknown".
Examples:

Documentation within the clinical record indicates the antibiotic administration date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "Unknown".
Documentation within the clinical record indicates the antibiotic administration time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "Unknown".
Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the antibiotic administration date was 12-03-2007. Other documentation in the clinical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "Unknown".

Date

The earliest documented day, month, and year that a Senior Clinician was consulted regarding the patient's care.

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that a Senior Clinician was consulted regarding the patient's care.
Examples:
Midnight - 00:00           Noon - 12:00
5:31 am - 05:31           5:31 pm - 17:31
11:59 am - 11:59         11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

Rank of first contact Senior Clinician/Specialist

Expand

title	Rank of first contact Senior Clinician - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
PICU notes
GP letter
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
ST x review Reviewed by ST x Consultant review Reviewed by paeds consultant Paediatric consultant review	F1 review F2 review

Additional Information:
Senior doctors should be involved in the care of children with sepsis.
Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question
Speciality Trainee 4	There is documentation within the clinical record that the first Clinician/specialist who was contacted regarding the patients care was a Speciality Trainee 4
Speciality Trainee 5	There is documentation within the clinical record that the first Clinician/specialist who was contacted regarding the patients care was a Speciality Trainee 5
Speciality Trainee 6	There is documentation within the clinical record that the first Clinician/specialist who was contacted regarding the patients care was a Speciality Trainee 6
Speciality Trainee 7	There is documentation within the clinical record that the first Clinician/specialist who was contacted regarding the patients care was a Speciality Trainee 7
Speciality Trainee 8	There is documentation within the clinical record that the first Clinician/specialist who was contacted regarding the patients care was a Speciality Trainee 8
Staff Grade/Associate Staff	There is documentation within the clinical record that the first Clinician/specialist who was contacted regarding the patients care was Staff Grade/Associate Staff
Consultant	There is documentation within the clinical record that the first Clinician/specialist who was contacted regarding the patients care was a Consultant
Paediatric Critical Care Practitioner	There is documentation within the clinical record that the first Clinician/specialist who was contacted regarding the patients care was a Paediatric Critical Care Practitioner
Other	There is documentation within the clinical record that the first Clinician/specialist who was contacted regarding the patients care was another level Clinician which is not listed

Please enter the details of the 'Other' ranking of first Senior Clinician/Specialist consulted regarding the patient care

Expand

title	'Other' ranking of first Senior Clinician - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
PICU notes
GP letter
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
ST x review Reviewed by ST x Consultant review Reviewed by paeds consultant Paediatric consultant review	F1 review F2 review

Additional Information:
Senior doctors should be involved in the care of children with sepsis.
Answer Options:
This question is a free text field in which you can record the details of the rank of the first Senior Clinician/Specialist consulted regarding the patient care, which is stated within the clinical record and not covered in the list of rankings for the previous question

What method was used to interact with the first contact Senior Clinician/Specialist?

Expand

title	Method used for first Senior Clinician contact - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
Phoned paed consultant DEC phone to paediatrician Spoke to paeds specialist D/W paeds specialist Discussed with paediatric consultant D/W Paeds ST 4	Discussed with F1 Discussed with F2

Additional information:
It is important to note within the clinical record that a hand over of care discussion took place with a senior Clinician.
Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question
In person	There is documentation within the clinical record that the Clinician was contacted via face to face interaction regarding the patients care.
Phone	There is documentation within the clinical record that the Clinician was contacted via telephone regarding the patients care.
Other	There is documentation within the clinical record that the Clinician was contacted by another method of communication not already listed regarding the patients care.

Please enter the details of the 'Other' method used to interact with the first contact Senior Clinician/Specialist

Expand

title	'Other' first contact method - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
Phoned paed consultant DEC phone to paediatrician Spoke to paeds specialist D/W paeds specialist Discussed with paediatric consultant D/W Paeds ST 4	Discussed with F1 Discussed with F2

Additional information:
It is important to note within the clinical record that a hand over of care discussion took place with a senior Clinician.
Answer Options
This question is a free text field in which you can record the details of any other communication method used to interact with the first contact Senior Clinician/Specialist regarding the patient care, as details within the clinical record and not covered in the list of rankings for the previous question.

Was escalation to a higher ranking Senior Clinician/Specialist required?

Expand

title	Escalated to higher ranking Senior Clinician - expand for details

Acceptable sources of information

...

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service summary

Terminology related to this question:

Not Applicable	Applicable
ST x review Reviewed by ST 4-8 Consultant review Reviewed by paeds consultant Paediatric consultant review	F1 review F2 review

Additional information:
Senior doctors should be involved in the care of children with sepsis.
Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that the patients care was escalated to a higher ranking Clinician/specialist.
No	There is no documentation within the clinical record that the patients care was escalated to a higher ranking Clinician/specialist.

Rank of most Senior Clinician/Specialist involved in the patient care

Expand

title	Rank of most Senior Clinician - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
ST x review Reviewed by ST 4-8 Consultant review Reviewed by paeds consultant Paediatric consultant review	F1 review F2 review

Additional information:
Senior doctors should be involved in the care of children with sepsis.
Answer Options

Answer Option	Answer Assistance
Unanswered	No answer has been provided for this question
Speciality Trainee 4	The clinical record states the highest ranking Clinician/specialist who was contacted regarding the patients care was a Speciality Trainee 4
Speciality Trainee 5	The clinical record states the highest ranking Clinician/specialist who was contacted regarding the patients care was a Speciality Trainee 5
Speciality Trainee 6	The clinical record states the highest ranking Clinician/specialist who was contacted regarding the patients care was a Speciality Trainee 6
Speciality Trainee 7	The clinical record states the highest ranking Clinician/specialist who was contacted regarding the patients care was a Speciality Trainee 7
Speciality Trainee 8	The clinical record states the highest ranking Clinician/specialist who was contacted regarding the patients care was a Speciality Trainee 8
Staff Grade/Associate Staff	The clinical record states the highest ranking Clinician/specialist who was contacted regarding the patients care was Staff Grade/Associate Staff
Consultant	The clinical record states the highest ranking Clinician/specialist who was contacted regarding the patients care was a Consultant
Paediatric Critical Care Practitioner	The clinical record states the highest ranking Clinician/specialist who was contacted regarding the patients care was a Paediatric Critical Care Practitioner
Other	The clinical record states the highest ranking Clinician/specialist who was contacted regarding the patients care was another level Clinician which is not listed

Please enter the details of the 'Other' ranking of most Senior Clinician/Specialist consulted regarding the patient care

Expand

title	'Other' ranking of most Senior Clinician - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
GP letter
Ambulance service summary

Terminology related to this question:

Applicable	Not Applicable
ST x review Reviewed by ST 4-8 Consultant review Reviewed by paeds consultant Paediatric consultant review	F1 review F2 review

Additional information:
Senior doctors should be involved in the care of children with sepsis.
Answer Options
This question is a free text field in which you can record the details of the ranking of the most Senior Clinician/Specialist consulted regarding patient care, as details within the clinical record and not covered in the list of rankings for the previous question.

At discharge were any of the following Acute complications of sepsis present?

Expand

title	Acute complications - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
Complications of sepsis Amputation of lower limb Hearing loss as a result of sepsis End stage renal failure due to sepsis Cognitive impairment as a result of sepsis Respiratory complication due to sepsis Loss of skin tissue following sepsis Other complication due to sepsis

Answer Options

Answer Options	Answer Assistance
Unanswered	No answer has been provided for this question
Amputation	There is documentation within the clinical record that amputation of a limb was necessary as a result of sepsis
Hearing loss	There is documentation within the clinical record that hearing loss occurred due to sepsis
Renal failure	There is documentation within the clinical record that renal disease occurred due to sepsis
Lung impairment	There is documentation within the clinical record that lung or respiratory impairment occurred due to sepsis
Cognitive impairment	There is documentation within the clinical record that cognitive impairment occurred due to sepsis
Skin tissue loss	There is documentation within the clinical record that skin loss occurred due to sepsis
Post-Traumatic Stress Disorder (PTSD)	There is documentation within the clinical record that PTSD was caused as a result of sepsis
Death	There is documentation within the clinical record that death resulted due to sepsis
Other	Please specify which other complication of sepsis was recorded in the patient notes
No complications	There is documentation within the clinical record which states there were no complications of sepsis present
UTD	The clinical record does not contain any information to indicate whether or not the patient has any complications of sepsis present.

Please enter the details of the 'Other' complication of sepsis encountered by the patient

Expand

title	'Other' complication of sepsis - expand for details

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
PICU notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	Not Applicable
Any complication of sepsis recorded in the clinical record

Answer Options
This question is a free text field in which you can record the details of any other complication encountered by the patient which is not covered in the list of complications for the previous question.

...

Measures

PAESEP-1 High flow oxygen delivered within 1 hour

Expand

title	PAESEP-1 - expand for details

Measure numerator statement: Number of paediatric sepsis patients who receive high flow oxygen within one hour of suspected sepsis.
Measure denominator statement: All patients included in the Assure Paediatric Sepsis population minus exclusions.

Patients excluded from the population of PAESEP-1 *If a patient meets any of the following criteria, they will be excluded from the measure.*
The patient was not clinically indicated to receive high flow oxygen

...

Measure Pass Criteria
To pass this measure, the patient must have met all of the following criteria.

 Patient has a valid sepsis suspected date/time entered on Assure
Patient did receive high flow oxygen
Patient has a valid date/time entered for high flow oxygen delivery on 

...

Assure
Patient received high flow oxygen within 1 hour of suspected sepsis

Measure questions:
The following questions make up the PAESEP-1 measure.

Questions Used to Analyse Measure Outcome (Pass/Fail/Exclude)	Questions for Data Collection Purposes Only
Sepsis suspected date/time Does the clinical record show that high flow oxygen was given? High flow oxygen given date/time	What was the severity of the suspected sepsis? Does the clinical record show that the patient was suffering from neutropenic sepsis? Is a sepsis identifier present in the clinical record?

PAESEP-2 IV or IO access within 1 hour

Expand

title	PAESEP-2 - expand for details

Measure numerator statement: Number of paediatric sepsis patients who have attempted IV or IO access within one hour of suspected sepsis.
Measure denominator statement: All patients included in the Assure Paediatric Sepsis population minus exclusions.

Patients excluded from the population of PAESEP-2 *If a patient meets any of the following criteria, they will be excluded from the measure.*
IV or IO access was not clinically indicated in the patient

Measure Pass Criteria
To pass this measure, the patient must have met all of the following criteria

Patient has a valid sepsis suspected date/time entered on Assure
Patient had IV or IO access attempted
Patient has a valid date/time entered on Assure for attempted IV/IO access
Patient had IV or IO access attempted within 1 hour of suspected sepsis
Patient had a successful IV or IO access attempt

Measure questions:
The following questions make up the PAESEP-2 measure.

Questions Used to Analyse Measure Outcome (Pass/Fail/Exclude)	Questions for Data Collection Purposes Only
Sepsis suspected date/time Does the clinical record show that the Clinician attempted to gain IV access? IV attempted access date/time Was the Clinician successful in gaining IV access? Does the clinical record show that the Clinician attempted to gain IO access? IO attempted access date/time Was the Clinician successful in gaining IO access?	What was the severity of the suspected sepsis? Does the clinical record show that the patient was suffering from neutropenic sepsis? Is a sepsis identifier present in the clinical record? How many attempts at gaining IV access did the Clinician take? Successful IV access date/time How many attempts at gaining IO access did the Clinician take? Successful IO access date/time

PAESEP-3 Blood cultures taken within 1 hour

Expand

title	PAESEP-3 - expand for details

Measure numerator statement: Number of paediatric sepsis patients who have blood cultures taken within one hour of suspected sepsis.
Measure denominator statement: All patients included in the Assure Paediatric Sepsis population minus exclusions.

Patients excluded from the population of PAESEP-3 *If a patient meets any of the following criteria, they will be excluded from the measure.*
The clinician was unable to collect a blood sample

Measure Pass Criteria
To pass this measure, the patient must have met all of the following criteria

Patient has a valid sepsis suspected date/time entered on Assure
Patient did have blood cultures taken
Patient has a valid date/time entered for blood cultures taken on Assure
Patient had blood cultures taken within1 hour of suspected sepsis

Measure questions:
The following questions make up the PAESEP-3 measure.

Questions Used to Analyse Measure Outcome (Pass/Fail/Exclude)	Questions for Data Collection Purposes Only
Sepsis suspected date/time Does the clinical record show whether blood cultures were taken? Blood cultures taken date/time	What was the severity of the suspected sepsis? Does the clinical record show that the patient was suffering from neutropenic sepsis? Is a sepsis identifier present in the clinical record?

PAESEP-4 Blood glucose measurement taken within 1 hour

Expand

title	PAESEP-4 - expand for details

Measure numerator statement: Number of paediatric sepsis patients who have a blood glucose measurement within one hour of suspected sepsis and are treat accordingly for hypoglycaemia if appropriate.
Measure denominator statement: All patients included in the Assure Paediatric Sepsis population minus exclusions.

Patients excluded from the population of PAESEP-4 *If a patient meets any of the following criteria, they will be excluded from the measure.*
The clinician was unable to collect a blood sample

Measure Pass Criteria
To pass this measure, the patient must have met all of the following criteria

Patient has a valid sepsis suspected date/time entered on Assure
Patient had a blood glucose measurement taken
Patient has a valid date/time entered for blood glucose measurement taken on Assure
Patient had a blood glucose measurement within 1 hour of suspected sepsis
Patients' blood glucose levels were not low or was treat appropriately for hypoglycaemia

Measure questions:
The following questions make up the PAESEP-4 measure.

Questions Used to Analyse Measure Outcome (Pass/Fail/Exclude)	Questions for Data Collection Purposes Only
Sepsis suspected date/time Does the clinical record show that a blood glucose measurement was taken? Blood glucose test date/time If blood glucose levels were low, was the patient treated for hypoglycaemia?	What was the severity of the suspected sepsis? Does the clinical record show that the patient was suffering from neutropenic sepsis? Is a sepsis identifier present in the clinical record?

PAESEP-5: Blood gas measurement within 1 hour

Expand

title	PAESEP-5 - expand for details

Measure numerator statement: Number of paediatric sepsis patients who have a blood gas measurement taken within one hour of suspected sepsis.
Measure denominator statement: All patients included in the Assure Paediatric Sepsis population minus exclusions.

Patients excluded from the population of PAESEP-5 *If a patient meets any of the following criteria, they will be excluded from the measure.*
The clinician was unable to collect a blood sample

Measure Pass Criteria
To pass this measure, the patient must have met all of the following criteria

Patient has a valid sepsis suspected date/time entered on Assure
Patient had a blood gas measurement taken
Patient has a valid date/time entered for blood gas measurement taken on Assure
Patient had a blood gas measurement taken within 1 hour of suspected sepsis

Measure questions:
The following questions make up the PAESEP-5 measure.

Questions Used to Analyse Measure Outcome (Pass/Fail/Exclude)	Questions for Data Collection Purposes Only
Sepsis suspected date/time Does the clinical record show that a blood gas measurement was taken? Blood gas measurement date/time	What was the severity of the suspected sepsis? Does the clinical record show that the patient was suffering from neutropenic sepsis? Is a sepsis identifier present in the clinical record? What type of blood gas was measured?

PAESEP-6 Additional blood tests ordered

Expand

title	PAESEP-6 - expand for details

Measure numerator statement: Number of paediatric sepsis patients who have all of the required additional blood tests ordered.
Measure denominator statement: All patients included in the Assure Paediatric Sepsis population minus exclusions

...

Patients excluded from the population of PAESEP-6 *If a patient meets any of the following criteria, they will be excluded from the measure.*
The clinician was unable to collect a blood sample for all three of the blood tests

Measure Pass Criteria
To pass this measure, the patient must have met all of the following criteria

Patient has a valid sepsis suspected date/time entered on Assure
Patient had all of the appropriate blood tests ordered

Measure questions:
The following questions make up the PAESEP-6 measure

...

Questions Used to Analyse Measure Outcome (Pass/Fail/Exclude)	Questions for Data Collection Purposes Only
Sepsis suspected date/time Does the clinical record show that a test was ordered to measure the full blood count? Does the clinical record show that a test was ordered to measure the lactate level? Does the clinical record show that a test was ordered to measure the CRP level?	What was the severity of the suspected sepsis? Does the clinical record show that the patient was suffering from neutropenic sepsis? Is a sepsis identifier present in the clinical record?

PLEASE NOTE: If any of the three blood tests are not ordered, then the measure will be failed

PAESEP-7: Antibiotics given within 1 hour

Expand

title	PAESEP-7 - expand for details

Measure numerator statement: Number of paediatric sepsis patients who have antibiotics given within one hour of suspected sepsis.
Measure denominator statement: All patients included in the Assure Paediatric Sepsis population minus exclusions.

Patients excluded from the population of PAESEP-7 *If a patient meets any of the following criteria, they will be excluded from the measure.*
Patient was already on an antibiotic at the time of suspected sepsis and they did not need to be changed The patient was not clinically indicated to receive antibiotics

Measure Pass Criteria
To pass this measure, the patient must have met all of the following criteria

Patient has a valid sepsis suspected date/time entered on Assure
Patient was not already on an antibiotic at the time of suspected sepsis
Patient was given antibiotics
Patient has a valid antibiotics date/time entered on Assure
Patient had antibiotics given within the 1 hour of sepsis diagnosis 

 OR
Patient has a valid sepsis suspected date/time entered on Assure
 Patient was already on an antibiotic at the time of suspected sepsis
Antibiotics were reviewed and changed
Patient has a valid antibiotics date/time entered on Assure
Patient had reviewed antibiotics given within the 1 hour of suspected sepsis

...

Measure questions:
The following questions make up the PAESEP-7 measure.

Questions Used to Analyse Measure Outcome (Pass/Fail/Exclude)	Questions for Data Collection Purposes Only
Sepsis suspected date/time Does the clinical record show that the patient was already on an antibiotic upon presentation of sepsis? Were the antibiotics reviewed and changed accordingly? Does the clinical record show that antibiotics were given? Antibiotics given date/time	What was the severity of the suspected sepsis? Does the clinical record show that the patient was suffering from neutropenic sepsis? Is a sepsis identifier present in the clinical record?

PAESEP-8 Antibiotics prescribed in line with local protocol

Expand

title	PAESEP-8 - expand for details

Measure numerator statement: Number of paediatric sepsis patients who have antibiotics prescribed in line with local protocol.
Measure denominator statement: All patients included in the Assure Paediatric Sepsis population minus exclusions.

Patients excluded from the population of PAESEP-8 *If a patient meets any of the following criteria, they will be excluded from the measure.*
Patient was already on an antibiotic at the time of suspected sepsis and they did not need to be changed The patient was not clinically indicated to be prescribed antibiotics

Measure Pass Criteria
To pass this measure, the patient must have met all of the following criteria

Patient has a valid sepsis suspected date/time entered on Assure
Patient was not already on an antibiotic at the time of suspected sepsis
Patient was prescribed antibiotics
Patient has a valid antibiotics prescription date/time entered on Assure
Patient had antibiotics prescribed in line with local protocol 

 OR
Patient has a valid sepsis suspected date/time entered on Assure
Patient was already on an antibiotic at the time of suspected sepsis
Antibiotics were reviewed and changed
Patient has a valid antibiotics prescription date/time entered for changed antibiotic on Assure
Patient had antibiotics prescribed in line with local protocol

Measure questions:
The following questions make up the PAESEP-8 measure.

Questions Used to Analyse Measure Outcome (Pass/Fail/Exclude)	Questions for Data Collection Purposes Only
Sepsis suspected date/time Does the clinical record show that the patient was already on an antibiotic upon presentation of sepsis? Were the antibiotics reviewed and changed accordingly? Does the clinical record show that antibiotics were prescribed? Antibiotics prescription date/time Were the antibiotics prescribed in line with local protocol?	What was the severity of the suspected sepsis? Does the clinical record show that the patient was suffering from neutropenic sepsis? Is a sepsis identifier present in the clinical record?

PAESEP-9 Fluid resuscitation initiated within 1 hour

Expand

title	PAESEP-9 - expand for details

Measure numerator statement: Number of paediatric sepsis patients who have fluid resuscitation initiated within one hour of suspected sepsis.
Measure denominator statement: All patients included in the Assure Paediatric Sepsis population minus exclusions.

Patients excluded from the population of PAESEP-9 *If a patient meets any of the following criteria, they will be excluded from the measure.*
Fluid resuscitation was not clinically indicated in the patient

Measure Pass Criteria
To pass this measure, the patient must have met all of the following criteria

Patient has a valid sepsis suspected date/time entered on Assure
Patient had fluid resuscitation initiated
Patient has a valid fluid resuscitation date/time entered on Assure
Patient had fluid resuscitation within the 1 hour of suspected sepsis

Measure questions:
The following questions make up the PAESEP-9 measure.

Questions Used to Analyse Measure Outcome
(Pass/Fail/Exclude)

Questions for Data Collection Purposes Only

Sepsis suspected date/time
Does the clinical record show that intravenous fluid resuscitation was initiated?
Intravenous fluid resuscitation initiated date/time

What was the severity of the suspected sepsis?
Does the clinical record show that the patient was suffering from neutropenic sepsis?
Is a sepsis identifier present in the clinical record?
How much fluid (mg/kg) did the patient receive within 1 hour of fluid resuscitation being initiated?
Did the patient's heart rate return to normal within 1 hour of fluid resuscitation being initiated?
Did the patient's systolic blood pressure return to normal within 1 hour of fluid resuscitation being initiated?

PAESEP-10 Inotropic support given within 1 hour

Expand

title	PAESEP-10 - expand for details

Measure numerator statement: Number of paediatric sepsis patients who have inotropic support given within one hour of suspected sepsis.
Measure denominator statement: All patients included in the Assure Paediatric Sepsis population minus exclusions.

Patients excluded from the population of PAESEP-10 *If a patient meets any of the following criteria, they will be excluded from the measure.*
The patient was not clinically indicated to receive inotropic support

Measure Pass Criteria
To pass this measure, the patient must have met all of the following criteria

Patient has a valid sepsis suspected date/time entered on Assure
Patient was given inotropic support
Patient has a inotropic support date/time entered on Assure
Patient was given inotropic support within the 1 hour of suspected sepsis

Measure questions:
The following questions make up the PAESEP-10 measure.

Questions Used to Analyse Measure Outcome (Pass/Fail/Exclude)	Questions for Data Collection Purposes Only
Sepsis suspected date/time Does the clinical record show that the patient was given inotropic support? Inotropic support date/time	What was the severity of the suspected sepsis? Does the clinical record show that the patient was suffering from neutropenic sepsis? Is a sepsis identifier present in the clinical record? Type of inotropic support given to the patient Please enter the details of the 'Other' inotropic support given to the patient

PAESEP-11 Senior Clinician/Specialist involvement within 1 hour

Expand

title	PAESEP-11 - expand for details

Measure numerator statement: Number of paediatric sepsis patients who are consulted by a Senior Clinician/Specialist within one hour of suspected sepsis.
Measure denominator statement: All patients included in the Assure Paediatric Sepsis population minus exclusions.

Patients excluded from the population of PAESEP-11 *If a patient meets any of the following criteria, they will be excluded from the measure.*
Senior Clinician/Specialist consultation was not clinically indicated in the patient

Measure Pass Criteria
To pass this measure, the patient must have met all of the following criteria

Patient has a valid sepsis suspected date/time entered on Assure
Patient was consulted by a Senior Clinician/Specialist
Patient has a valid Senior Clinician/Specialist consultation date/time entered on Assure
Patient was consulted by a Senior Clinician/Specialist within the 1 hour of suspected sepsis

Measure questions:
The following questions make up the PAESEP-11 measure.

Questions Used to Analyse Measure Outcome
(Pass/Fail/Exclude)

Questions for Data Collection Purposes Only

Sepsis suspected date/time
Does the clinical record show that a Senior Clinician/Specialist was consulted regarding the patient care?  
Date/time of first Senior Clinician/Specialist consultation

What was the severity of the suspected sepsis?
Does the clinical record show that the patient was suffering from neutropenic sepsis?
Is a sepsis identifier present in the clinical record?
Rank of first contact Senior Clinician/Specialist
Please enter the details of the 'Other' ranking of first Senior Clinician/Specialist consulted regarding the patient care
What method was used to interact with the first contact Senior Clinician/Specialist?
Please enter the details of the 'Other' method used to interact with the first contact Senior Clinician/Specialist
Was escalation to a higher ranking Senior Clinician/Specialist required?
Rank of most Senior Clinician/Specialist involved in the patient care
Please enter the details of the 'Other' ranking of most Senior Clinician/Specialist consulted regarding the patient care

PAESEP-12 Complications of Sepsis

Expand

title	PAESEP-12 - expand for details

Measure numerator statement: Number of paediatric sepsis patients who experienced complications of sepsis.
Measure denominator statement: All patients included in the Assure Paediatric Sepsis population minus exclusions.

Measure Pass Criteria *To pass this measure, the patient must have met all of the following criteria*
Patient has a valid sepsis suspected date/time entered on Assure

Measure questions:
The following questions make up the PAESEP-12 measure.

Questions Used to Analyse Measure Outcome (Pass/Fail/Exclude)	Questions for Data Collection Purposes Only
Sepsis suspected date/time	What was the severity of the suspected sepsis? Does the clinical record show that the patient was suffering from neutropenic sepsis? Is a sepsis identifier present in the clinical record? At discharge were any of the following Acute complications of sepsis present? Please enter the details of the 'Other' complication of sepsis encountered by the patient

Population Codes

Patients aged ≤18 years who have a primary ICD-10 diagnosis code for sepsis.

...

Why are we measuring quality of care in paediatric sepsis?
This focus area is designed to improve patient care, reduce mortality and morbidity across patients with severe infections.
Sepsis is one of the leading causes of death in children worldwide, it is estimated that infection accounts for nearly 60% of deaths in children under the age of 5.
There is clear clinical evidence that the identification and early treatment of sepsis can greatly reduce mortality. The aim of using a care bundle is to achieve reliability in delivering all key elements of care in a timely manner
The paediatric sepsis bundle is modelled on the adult bundle, which has been shown to improve adherence to resuscitation and therapy guidelines and is associated with reduced mortality. These measures are designed to be delivered to patients up to the age of 18 years old, within one hour of sepsis presentation.

References

Daniels, R. (2011) Surviving the first hours in sepsis: getting the basics right (an intensivist's perspective). Journal of Antimicrobial Chemotherapy 66(Suppl2), ii11-23.

Daniels, R., Nutbeam,T., McNamara, G., and Galvin, C. (2011) The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emergency Medicine Journal 28(6), 507-512.
Dellinger, R.P., Levy, M.M., Rhodes, A., Annane, D., Gerlach, H. et al. (2013) Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine 41(2), 580-637. http://www.sccm.org/Documents/SSC-Guidelines.pdf
McPherson, D., Griffiths, C., Williams, M., et al. (2013) Sepsis-associated mortality in England: an analysis of multiple cause of death data from 2001 to 2010. BMJ Open 3(8), e002586.
Rivers, E., Nguyen, B., Havstad, S., et al. (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine 345(19), 1368-1377.
Vogel, T.R., Dombrovskiy, V.Y., Carson, J.L., et al. (2010) Postoperative sepsis in the United States. Annals of Surgery 252(6), 1065-1071.
The UK Sepsis Trust (2015) Paediatric Sepsis 6 Pathway. full text available at: http://sepsistrust.org/wp-content/uploads/2015/08/Paediatric-Sepsis-6-version-11_1.pdf

Websites:

Surviving Sepsis Campaign www.survivingsepsis.org
National Sepsis Audit www.lsrg.co.uk/sepsis
The UK Sepsis Trust http://sepsistrust.org/

...

Version	Old Version 2	New Version 3
Changes made by	Assure Administrator	Assure Administrator
Saved on	Oct 05, 2017	Oct 06, 2017

Content Comparison

Versions Compared

Key

What was the severity of the suspected sepsis?

Does the clinical record show that the Clinician attempted to gain IV access?

How many attempts at gaining IV access did the Clinician take?

How many attempts at gaining IO access did the Clinician take?

Does the clinical record show whether blood cultures were taken?

Does the clinical record show that a blood glucose measurement was taken?

Does the clinical record show that a blood gas measurement was taken?

Blood gas measurement date/time

What type of blood gas was measured?

Does the clinical record show that a test was ordered to measure the full blood count?

Does the clinical record show that a test was ordered to measure the lactate level?

Does the clinical record show that a test was ordered to measure the CRP level?

Does the clinical record show that the patient was already on an antibiotic upon presentation of sepsis?

Were the antibiotics reviewed and changed accordingly?

Does the clinical record show that antibiotics were prescribed?

Which antibiotic was prescribed?

Please enter the details of the 'Other' antibiotic prescribed

Antibiotics prescription date/time

Does the clinical record show that antibiotics were given?

Antibiotics given date/time

Were the antibiotics prescribed in line with local protocol?

Does the clinical record show that intravenous fluid resuscitation was initiated?

Intravenous fluid resuscitation initiated date/time

How much fluid (mg/kg) did the patient receive within 1 hour of fluid resuscitation being initiated?

Did the patient's heart rate return to normal within 1 hour of fluid resuscitation being initiated?

Did the patient's systolic blood pressure return to normal within 1 hour of fluid resuscitation being initiated?

Does the clinical record show that the patient was given inotropic support?

Inotropic support date/time

Type of inotropic support given to the patient

Please enter the details of the 'Other' inotropic support given to the patient

Does the clinical record show that a Senior Clinician/Specialist was consulted regarding the patient care?

Date/time of first Senior Clinician/Specialist consultation

Rank of first contact Senior Clinician/Specialist

Please enter the details of the 'Other' ranking of first Senior Clinician/Specialist consulted regarding the patient care

What method was used to interact with the first contact Senior Clinician/Specialist?

Please enter the details of the 'Other' method used to interact with the first contact Senior Clinician/Specialist

Was escalation to a higher ranking Senior Clinician/Specialist required?

Rank of most Senior Clinician/Specialist involved in the patient care

Please enter the details of the 'Other' ranking of most Senior Clinician/Specialist consulted regarding the patient care

At discharge were any of the following Acute complications of sepsis present?

Please enter the details of the 'Other' complication of sepsis encountered by the patient

Measures

PAESEP-1 High flow oxygen delivered within 1 hour

PAESEP-2 IV or IO access within 1 hour

PAESEP-3 Blood cultures taken within 1 hour

PAESEP-4 Blood glucose measurement taken within 1 hour

PAESEP-5: Blood gas measurement within 1 hour

PAESEP-6 Additional blood tests ordered

PAESEP-7: Antibiotics given within 1 hour

PAESEP-8 Antibiotics prescribed in line with local protocol

PAESEP-9 Fluid resuscitation initiated within 1 hour

PAESEP-10 Inotropic support given within 1 hour

PAESEP-11 Senior Clinician/Specialist involvement within 1 hour

PAESEP-12 Complications of Sepsis

Population Codes

References