Focus Area Name: | Focus Area Version: | Applicable from (Discharge Month): |
Paediatric Sepsis | 2 | October 2016 |
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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
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| title | Sepsis Date/Time - Expand for details |
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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
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| Answer Option | Answer Assitance |
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| 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) |
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| title | Severity of sepsis - expand for details |
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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 |
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- Infection
- Sepsis
- Septic Shock
- Neutropenic sepsis
| - Not sepsis
- Sepsis unlikely
- Sepsis excluded
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Answer Options Answer Option | Answer Assistance |
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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. |
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Is there documentation within the clinical record that the patient was suffering from neutropenic sepsis?
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| title | Neutropenic sepsis patient - expand for details |
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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 |
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- 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
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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 |
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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. |
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Is a sepsis identifier present in the clinical record?
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| title | Sepsis identifier - expand for details |
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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 |
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- Screening tool
- Screened for sepsis
- NICE screening tool
- Local sepsis screening tool used
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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 |
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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. |
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| title | IV access date/time - expand for details |
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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 |
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- IV fluids given
- IV fluids commenced
- IV fluids started
- IV access at
- IV access attempted
- Multiple attempts at access
- Multiple attempts at IVs
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Answer Options Answer Option | Answer Assistance |
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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) |
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Does the clinical record show that the Clinician attempted to gain IO access?
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| title | IO access attempt - expand for details |
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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 |
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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. |
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| title | Blood glucose date/time - expand for details |
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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 |
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- Blood taken – glucose
- Bloods – glucose
- Glucose level taken
- Glucose = x
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Answer Options Answer Option | Answer Assistance |
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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) |
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If blood glucose levels were low, was the patient treated for hypoglycaemia?
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| title | Blood glucose low, hypoglycaemia treatment - expand for details |
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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 |
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- 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
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Answer Options Answer Options | Answer Assistance |
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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. |
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| title | Blood gas date/time - expand for details |
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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 |
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- 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
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Answer Option Answer Option | Answer Assistance |
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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) |
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What type of blood gas was measured?
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| title | Lactate test ordered - expand for details |
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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 |
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- Lactate done
- Lactate taken
- Lactate = x
- Lactate levels = x
| - Lactate not done
- Bloods not done
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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 |
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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. |
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Does the clinical record show that a test was ordered to measure the CRP level?
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| title | Antibiotics prescription date/time - expand for details |
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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 |
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- Antibiotics given
- IV antibiotics
- IV cefotaxime given
- IV administered
- Suggest start IV cefotaxime at xx dose
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Answer Options Answer Option | Answer Assistance |
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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) |
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Does the clinical record show that antibiotics were given?
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| title | Antibiotics given date/time - expand for details |
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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 |
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- Antibiotics given
- IV antibiotics
- IV cefotaxime given
- IV ceftriaxone administered
- IV abs administered
- Suggest start IV cefotaxime at xx dose
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Answer Options Answer Option | Answer Assistance |
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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) |
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Were the antibiotics prescribed in line with local protocol?
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| title | Fluid Resus date/time - expand for details |
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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 |
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- IV fluids given
- IV fluids commenced
- IV fluids started
- IV access at
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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 |
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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) |
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How much fluid (mg/kg) did the patient receive within 1 hour of fluid resuscitation being initiated?
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| title | Inotropic support date/time - expand for details |
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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 |
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- 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
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Answer Option Answer Option | Answer Assistance |
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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) |
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Type of inotropic support given to the patient
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| title | First Senior Clinician consultation - expand for details |
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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 |
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- ST x review
- Reviewed by ST x
- Consultant review
- Reviewed by paeds consultant
- Paediatric consultant review
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Answer Options Answer Option | Answer Assistance |
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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) |
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Rank of first contact Senior Clinician/Specialist
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| title | 'Other' complication of sepsis - expand for details |
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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 |
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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
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| title | PAESEP-9 - expand for details |
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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. |
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- Fluid resuscitation was not clinically indicated in the patient
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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
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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 |
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- 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?
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| title | PAESEP-12 - expand for details |
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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 |
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- Patient has a valid sepsis suspected date/time entered on Assure
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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 |
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- 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
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Population Codes
Patients aged ≤18 years who have a primary ICD-10 diagnosis code for sepsis.
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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/
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