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Focus Area Name: | Focus Area Version: | Applicable from (Discharge Month): |
Paediatric Sepsis | 2 | October 2016 |
Data Collection Form
Measure Questions
This section is designed to assist users in the completion of Assure questions for the Paediatric Sepsis pathway to ensure the answers provided are accurate and in accordance with the audit criteria.
Sepsis Suspected Date/Time
...
| 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
| |
|
...
| 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 | Severity 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
- Hospital discharge summary
- Ambulance service notes
Terminology related to this question: Applicable | Not Applicable |
|---|
- Infection
- Sepsis
- Septic Shock
- Neutropenic sepsis
| - Not sepsis
- Sepsis unlikely
- Sepsis excluded
|
Answer Options Answer Option | Answer Assistance |
|---|
Unanswered | This will show when no alternative answer has been selected for this question | Infection | Select this answer when there is documentation within the clinical record that the patient had suspected infection.
Infection is a microbial phenomenon characterised by an inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by these organisms. | Sepsis | Select this answer when there is documentation within the clinical record that the patient had suspected sepsis. | Septic shock | Select this answer when there is documentation within the clinical record that the patient had suspected septic shock.
Septic shock is a subset of sepsis where underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.
Patients with septic shock can be identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain MAP ≥65 mm Hg and having a serum lactate level >2 mmol/L (18 mg/dL) despite adequate volume resuscitation. | Neutropenic sepsis | Select this answer when there is documentation within the clinical record that the patient had suspected neutropenic sepsis.
Neutropenic sepsis is a potentially fatal complication of anticancer treatment (particularly chemotherapy), such therapies can suppress the ability of the bone marrow to produce neutrophils (white blood cells), thus reducing the ability to respond to infection. |
|
Is there documentation within the clinical record that the patient was suffering from neutropenic sepsis?
| Expand |
|---|
| title | Neutropenic sepsis patient - 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 |
|---|
- Neutropenia
- Neutropenic sepsis
- Pancytopenia related sepsis
- Marrow suppression causing sepsis
- Chemo related sepsis
- Sepsis, neutrophils 0.5 x 10 9 per litre or less
| - Not sepsis
- Sepsis unlikely
- Sepsis excluded
|
Additional information:
Neutropenic sepsis is defined as a potentially fatal complication of anticancer treatment. The systemic therapies used to treat cancer, such as chemotherapy, effect the bone marrows ability to produce neutrophils or white bloods cells. This reduction in neutrophils increases the patient's risk of developing infection. (NICE, 2012 https://www.nice.org.uk/guidance/cg151/chapter/Introduction) Answer Options Answer Option | Answer Assistance |
|---|
Unanswered | This will show when no alternative answer has been selected for this question | Yes | Select yes if any of the following are documented in the clinical record - Neutropenic sepsis
- Pancytopenia related sepsis
- Marrow suppression causing sepsis
- Chemo related sepsis
- Sepsis, neutrophils 0.5 x 10 9 per litre or less
| No | Select no If there is no evidence of neutropenic sepsis in the clinical record. |
|
Is a sepsis identifier present in the clinical record?
| Expand |
|---|
| title | Sepsis identifier - 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 |
|---|
- Screening tool
- Screened for sepsis
- NICE screening tool
- Local sepsis screening tool used
| |
Additional information: There should be documented evidence of a sepsis identifier in the patient record. This will indicate that this person was screened for sepsis, whether this was appropriate for this person and also whether sepsis was confirmed or not. Answer Options Answer Option | Answer Assistance |
|---|
Unanswered | This will show when no alternative answer has been selected for this question | Yes | Select yes if the clinical record contains information that a sepsis identifier is present was completed. | No | Select no if the clinical record does not contain information to show that a screening tool was completed. |
|
Does the clinical record show that high flow oxygen was given?
| Expand |
|---|
| title | High flow oxygen 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 |
|---|
- Targeted oxygen delivered
- High flow oxygen given
- 100% oxygen given
- Targeted oxygen given by venturi mask
- Oxygen titrated to sats
- Oxygen given as per protocol
| - Breathing on air
- No supplemental oxygen administered
|
Answer Options Answer Option | Answer Assistance |
|---|
Unanswered | This will show when no alternative answer has been selected for this question | Yes | There is documentation within the clinical record that high flow oxygen was delivered. | No | There is no documentation within the clinical record that high flow oxygen was delivered or it is unable to be determined from the clinical record documentation. | 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. This should be clearly documented in the clinical record.
Patients with oxygen saturation levels of 95% and above can also be marked as not clinically indicated to receive oxygen. |
|
High flow oxygen given date/time
| 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: |
|
...
| 00 | Noon - 12:00 | | 5:31 am - 05: |
|
|
...
| 31 | 5:31 pm - 17:31 | | 11:59 am - 11: |
|
|
...
...
| HH | Hour (00 – 23) | | MM | Minutes (00-59) |
|
|
Does the clinical record show that the Clinician attempted to gain IV access?
| Expand |
|---|
IV Access Attempted- 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:
Additional Information
Intravenous (IV) access is vital in the administration of antibiotics and fluids for children suffering from 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 Clinician attempted to gain IV access | No | There is no documentation within the clinical record that a Clinician attempted to gain IV access or it is unable to be determined from the clinical record documentation. | NC | 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 Clinician or team member has made a decision that this particular measure was not appropriate for this patient. This should be clearly documented in the clinical record.
There is documentation within the clinical record that the patient was not clinically indicated to have IV access. |
|
IV attempted access date/time
| 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
| |
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 | No. of IV attempts - 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 after x attempts at access
- IV fluids commenced after x attempts at access
- IV fluids started after x attempts at access
- IV access at after x attempts at access
- IV access attempted x times
- Multiple attempts at access x times
- Multiple attempts at IVs x times
| |
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 number of attempts made at IV access | 0 - 10 | Select the appropriate figure as per the number of IV access attempts stated within the clinical record |
|
Was the Clinician successful in gaining IV access?
| Expand |
|---|
| title | IV 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 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
| |
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 Clinician was successful at gaining IV access | No | There is no documentation within the clinical record that the Clinician was successful at IV access, or it is unable to be determined this information from the clinical record. |
|
Successful IV access date/time
| 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
| |
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 |
|---|
| title | IO access attempt - 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: Additional Information
Intraosseous (IO) (bone) access is vital in the administration of antibiotics and fluids for children suffering from 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 consultant attempted to gain IO access | No | There is no documentation within the clinical record that a consultant attempted to gain IO access or it is unable to be determined from the clinical record documentation. |
|
IO attempted access date/time
| 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
| |
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 | No. of IO attempts - 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 after x attempts at access
- IO fluids commenced after x attempts at access
- IO fluids started after x attempts at access
- IO access at after x attempts at access
- IO access attempted x times
- Multiple attempts at IO access x times
| |
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 number of attempts made at IO access | 0 - 5 | Select the appropriate figure as per the number of IO access attempts stated within the clinical record |
|
Was the Clinician successful in gaining IO access?
| Expand |
|---|
| title | IO success - 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 |
|---|
- IO fluids given
- IO fluids commenced
- IO fluids started
- IO access at
- IO access attempted
- Multiple attempts at IO access
| |
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 Clinician was successful at gaining IO access | No | There is no documentation within the clinical record that the Clinician was successful at gaining IO access, or it is unable to be determined from the clinical record. |
|
Successful IO access date/time
| 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
| |
|
...
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 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 |
|---|
- Cultures taken
- Bloods taken including cultures
- Blood cultures taken
- Blood taken for OC&S
- Bloods – C&S
| |
Additional Information
Collecting blood cultures before antibiotic administration allows for testing to identify the organism that caused the patient's sepsis.
Blood cultures are taken by venepuncture and sent to the laboratory in specially prepared bottles for analysis of aerobic and anaerobic organisms. Evidence of single sample is sufficient for this measure but multiple samples may be taken. Answer Options Answer Option | Answer Assistance |
|---|
Unanswered | No answer has been provided for this question. | Yes | There is documentation within the clinical record that blood cultures were taken | No | There is no documentation within the clinical record that blood cultures were 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 cultures taken date/time
| 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
| |
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 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 |
|---|
- Blood taken – glucose
- Bloods – glucose
- Glucose level taken
- Glucose = x
| |
Additional Information
Blood glucose is an important determinant of severity of sepsis. It has an impact on prognosis in 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 glucose measure was taken. | No | There is no documentation within the clinical record that a blood glucose 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 glucose test date/time
| 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
| |
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
| |
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
| |
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
| |
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.
|
...
...
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: 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: 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 |
...
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,
| |
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: |
...
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
| |
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
| |
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
| |
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
| |
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
| |
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
| |
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
| |
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.
Criteria | Rank | | CodeGroup |
Primary Diagnosis Code | 1 | IN | PAEDIATRICSEPSISNE |
AND | | | |
Age | | <= | 16 |
AND | | | |
Discharge Month | | >= | Oct-16 |
codeGroupID | label | Version | CodeType | Code | Description |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | J18 | Pneumonia, organism unspecified |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | J22 | Unspecified acute lower respiratory infection |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | J15 | Bacterial pneumonia, not elsewhere classified |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | J960 | Acute respiratory failure |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | K720 | Acute and subacute hepatic failure |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | K729 | Hepatic failure, unspecified |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | N170 | Acute renal failure with tubular necrosis |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | N171 | Acute renal failure with acute cortical necrosis |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | N172 | Acute renal failure with medullary necrosis |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | N178 | Other acute renal failure |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | N179 | Acute renal failure, unspecified |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | M726 | Necrotizing fasciitis |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | J969 | Respiratory failure, unspecified |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | O85 | Puerperal sepsis |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R572 | Septic shock |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R578 | Other shock |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R579 | Shock, unspecified |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R650 | Systemic Inflammatory Response Syndrome of infectious origin without organ failure |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | P36 | Bacterial sepsis of newborn |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | P372 | Neonatal (disseminated) listeriosis |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R06 | Abnormalities of breathing |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R092 | Respiratory arrest |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R50 | Fever of other and unknown origin |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R560 | Febrile convulsions |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R570 | Cardiogenic shock |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R571 | Hypovolaemic shock |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | T827 | Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R651 | Systemic Inflammatory Response Syndrome of infectious origin with organ failure |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R652 | Systemic Inflammatory Response Syndrome of non-infectious origin without organ failure |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R653 | Systemic Inflammatory Response Syndrome of non-infectious origin with organ failure |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | R659 | Systemic Inflammatory Response Syndrome, unspecified |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A483 | Toxic shock syndrome |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | B007 | Disseminated herpesviral disease |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A49 | Bacterial infection of unspecified site |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A42 | Actinomycosis |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | B377 | Candidal septicaemia |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | D65 | Disseminated intravascular coagulation [defibrination syndrome] |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | D695 | Secondary thrombocytopenia |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | D696 | Thrombocytopenia, unspecified |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A392 | Acute meningococcaemia |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A394 | Meningococcaemia, unspecified |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A398 | Other meningococcal infections |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A399 | Meningococcal infection, unspecified |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A40 | Streptococcal septicaemia |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A312 | Disseminated mycobacterium avium-intracellulare complex |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A327 | Listerial septicaemia |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A241 | Acute and fulminating melioidosis |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A267 | Erysipelothrix septicaemia |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A021 | Salmonella septicaemia |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A047 | Enterocolitis due to Clostridium difficile |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A207 | Septicaemic plague |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A227 | Anthrax septicaemia |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A400 | Septicaemia due to streptococcus, group A |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A401 | Septicaemia due to streptococcus, group B |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A402 | Septicaemia due to streptococcus, group D |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A403 | Septicaemia due to Streptococcus pneumoniae |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A41 | Other septicaemia |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A408 | Other streptococcal septicaemia |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A409 | Streptococcal septicaemia, unspecified |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A410 | Septicaemia due to Staphylococcus aureus |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A411 | Septicaemia due to other specified staphylococcus |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A414 | Septicaemia due to anaerobes |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A413 | Septicaemia due to Haemophilus influenzae |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A412 | Septicaemia due to unspecified staphylococcus |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A415 | Septicaemia due to other Gram-negative organisms |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A419 | Septicaemia, unspecified |
PAEDIATRICSEPSISNE | Sepsis | Version 1 | ICD | A418 | Other specified septicaemia |
...
Background Information
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/
...