FAST SEPSIS PRE-ALERT TOOL
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Do You Suspect An Infection?
YES
NO
Select Patient's Heart Rate (BPM):
< 41
41 - 50
51 - 100
101 - 110
111 - 130
≥ 131
Select Patient's Systolic Blood Pressure:
< 71
71 - 90
91 - 170
171 - 200
≥ 201
Select Patient's Respiratory Rate:
< 8
8 - 13
14 - 20
21 - 30
≥ 31
Select Patient's Temperature (°C):
< 35
35.0 - 36.0
36.1 - 37.9 (or not available)
38.0 - 39.0
≥ 39.1
Select Patient's Initial Oxygen Saturation:
< 85
85 - 92
≥ 93
Select Oxygen Therapy, If Utilized:
Not utilized, only room air
O
2
via nasal prongs
O
2
via face mask
Select CNS Function:
Alert / Usual Self
New Confusion
Responds to Voice
Responds to Pain
Unresponsive
HEWS SCORE =
NO INFECTION
SEPSIS PREALERT!
NOTIFY HOSPITAL AND PERFORM CAPNOGRAPHY
NO ACTION REQUIRED.
CONTINUE CARE AS NORMAL.
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