Sepsis Screening: What Nurses Look For

Sepsis screening is a structured check for two things at once: signs that a patient may have an infection, and signs that the body's response to it is starting to cause harm. Nurses look for changes in temperature, heart rate, breathing and white blood cell count, then for evidence of new organ dysfunction such as low blood pressure, new confusion or falling urine output. Your facility's screening tool turns those observations into a decision, and a positive screen starts a time-sensitive response.

What sepsis is, in current terms

The current international definition, known as Sepsis-3 (published in 2016), describes sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. In plain terms, the infection is the trigger, but the damage comes from the body's response, which starts to affect organs such as the kidneys, lungs, brain and circulation.

Septic shock is the most severe form: low blood pressure that needs vasopressors despite fluids, along with signs of poor tissue perfusion such as an elevated lactate.

Sepsis can start from almost any infection: pneumonia, a urinary tract infection, an infected wound or line, an abdominal infection, or a source nobody has found yet.

Who is at higher risk

Any patient can develop sepsis, but keep your radar up for:

• Older adults and very young children
• People with weakened immune systems, including those on chemotherapy or immunosuppressants
• Chronic conditions such as diabetes or kidney, liver or lung disease
• Recent surgery or invasive procedures
• Invasive devices: central lines, urinary catheters, drains, ventilators
• Recent hospital stays or antibiotic use

Older adults deserve special attention because they may not run a fever. New confusion, a fall, sudden weakness or a low temperature can be the first sign.

The signs nurses screen for

Most screening tools work in steps. The exact criteria and cut-offs come from your facility's tool, but the categories look like this.

1. Is there a suspected or known infection? A new cough with sputum, burning with urination, a red or draining wound, cloudy urine in a catheter bag, an inflamed line site, abdominal pain, or a provider who has started antibiotics for a suspected source.

2. Are there signs of a systemic response? These are often called SIRS-type criteria, from the older systemic inflammatory response syndrome concept:

• Temperature that is abnormally high or abnormally low
• Heart rate above normal
• Respiratory rate above normal
• White blood cell count that is high, low, or shows immature cells

3. Is there evidence of new organ dysfunction?

• Low blood pressure or a falling mean arterial pressure
• Elevated lactate
• New or worsening confusion, or a lower level of consciousness
• Falling urine output
• A new or increasing oxygen requirement
• Lab changes such as rising creatinine or bilirubin, low platelets or abnormal clotting values

Notice the word "new" throughout. A patient on long-term dialysis with a high creatinine is not the same as a patient whose creatinine has jumped since yesterday.

Where qSOFA fits

qSOFA (quick Sequential Organ Failure Assessment) came out of the Sepsis-3 work as a bedside prompt for patients outside the ICU with suspected infection. It looks at three things: a fast respiratory rate, altered mentation and low systolic blood pressure. Meeting two or more of the three signals a higher risk of a poor outcome and should make you think hard about sepsis.

qSOFA is useful because you can check it in seconds without labs. It is not a full screen on its own, though. The Surviving Sepsis Campaign's 2021 guidelines recommend against using qSOFA alone as a single screening tool, compared with SIRS criteria or early warning scores such as NEWS or MEWS. That is one reason many hospitals use a combined tool, often built into the EHR. For more on those scores, see early warning scores for nurses.

How facility screening tools work

Many hospitals screen every patient on admission, then on a set schedule such as each shift, and again whenever the patient's condition changes. Many EHRs fire a possible sepsis alert when charted vitals and labs meet the criteria. When that happens, you typically:

1. Assess the patient at the bedside: vital signs, mental status, skin, perfusion and the likely source.
2. Complete the screening tool honestly. Do not dismiss an alert without looking at the patient.
3. Notify the provider promptly through your facility's escalation pathway. SBAR keeps the call tight: "I have a positive sepsis screen on..."
4. Call a rapid response if the patient is unstable or you are worried. If you have never called one, your first rapid response as a new nurse walks through what to expect.

Some hospitals have nurse-driven sepsis protocols that let you draw a lactate or blood cultures before the provider arrives. Only do this if your facility's policy and protocol allow it.

Sepsis bundles and the nurse's role

Once sepsis is suspected, time matters. Hospitals organize the first steps into a sepsis bundle, based on Surviving Sepsis Campaign guidance and, in the US, the federal SEP-1 quality measure that hospitals report on. Bundle elements generally include:

• Measuring lactate, and measuring it again if the first result is elevated
• Drawing blood cultures before antibiotics, as long as that does not delay them
• Giving broad-spectrum antibiotics as ordered
• Giving IV fluids as ordered for low blood pressure or an elevated lactate
• Starting vasopressors as ordered if blood pressure stays low

Each element has a time window in your facility's protocol. Nurses often control the clock: getting cultures drawn, hanging the first antibiotic quickly, starting fluids, and reassessing blood pressure, mental status and urine output after each step. Reliable IV access matters here, and the IV therapy fundamentals learning path is a solid refresher.

Document times precisely. Sepsis care is audited closely, and accurate timestamps show what was done and when.

Tips from the bedside

• Rescreen a patient who screened negative earlier if they now look worse. Sepsis evolves over hours.
• Trust trends. A heart rate climbing over a shift plus a new oxygen need is a pattern, even if no single number crosses a line.
• Ask the patient and family what is different. "She is not herself today" is valuable information.
• Escalate again if treatment is not happening fast enough, and use your chain of command.

Emergency departments see sepsis constantly, and this post on essential skills every ER nurse must master covers related triage and assessment skills. The ER nurses group is a good place to compare sepsis workflows with nurses at other hospitals.

Next step

If fast recognition and early treatment are the parts of nursing you want more of, browse ER nurse jobs with the pay shown on every post.

General information for nurses, not medical, legal, tax or financial advice. Follow your facility's policies, your state board of nursing and the terms of your employer or contract.