Summary of changes

The sepsis pathway is a clinical decision support tool for initial sepsis recognition and management.

The sepsis management plan (previously Page 4) has been removed in response to feedback from NSW Health clinicians. The ongoing sepsis management should now be documented in the respective patients’ health care record, be discussed with the Attending Medical Officer (AMO) and communicated with the clinical team. Management plans should include close observation and frequency of vital sign monitoring, any repeat investigations (e.g. lactate, cultures) and plans to review and revise antimicrobial treatment.

• Revised wording to define use of the pathway and exclusions.
• Added “Could it be sepsis?” as a key prompt; aligns with sepsis NSW messaging and the Sepsis Clinical Care Standard.
• Added definition of sepsis and time-critical medical emergency.
• Revised the signs and symptoms of infection to include “looks very unwell”, “hypothermia”, “change in behaviour or altered mental state, delirium”, “unexplained pain”, “diarrhoea and vomiting”, “non-blanching rash” and “rising white cell count (WCC) or CRP if known”.
• Added “Aboriginal and Torres Strait Islander people” as a high-risk and vulnerable population group for sepsis.
• Added patient, carer, or family concern as a risk factor.
• Added “known infection not responding to treatment” and “re-presentation, deterioration or no improvement with the same illness” as greater risk of cognitive bias / diagnostic anchoring.
• Added “Commence A-G systematic assessment and document full set of vital signs observations”.

• Added “Does the patient have signs of organ dysfunction?” and inclusion of early signs to align with international guidance.
• Added lactate to Yellow Zone and Red Zone criteria.
• Removal of Base Excess measurements.
• Changed terminology from “Severe Sepsis” to “probable” and “possible” sepsis to align with sepsis definition.

• Removed triage data collection section.
• Updated formatting to include action list of interventions rather than A-G structure.
• Added visual clock cues to support timing of critical interventions.
• Added “Call for expert assistance after 2 failed attempts at cannulation and prepare for intraosseous access”
• Added “Point of care test if available” to prompt sites to use point of care testing devices where available.
• Removed procalcitonin and coagulation profile pathology on the initial order set. These tests can be optionally taken if clinically relevant.
• Added cautionary statement “do not wait for test results” to prevent delays to commencing treatment.
• Revised advice on fluid resuscitation and added monitoring of response to treatment.
• Added link to Therapeutic: Antibiotics Guidelines as recommended treatment guidance.

• Updated advice on repeat lactate to reassess response to treatment and/or monitor for signs of deterioration.
• Added guidance on vital sign monitoring and fluid balance.

The sepsis pathway is a clinical decision support tool for initial sepsis recognition and management.

The sepsis management plan (previously Page 4) in response to feedback from NSW Health clinicians. The ongoing sepsis management plan should now be documented in the respective patients’ health care record, be discussed with the Attending Medical Officer (AMO) and communicated with the clinical team. Management plans should include close observation and frequency of vital sign monitoring, any repeat investigations (e.g. lactate, cultures) and plans to review and revise antimicrobial treatment.

• Revised wording to define use of the pathway, population group including any perinatal loss.
• Added “Could it be sepsis?” as a key prompt; aligns with sepsis NSW messaging and the Sepsis Clinical Care Standard
• Added definition of sepsis and time-critical medical emergency.
• Revised the signs and symptoms of infection to include “change in behaviour”, “feeling cold”, “oliguria”, “breast redness, swelling and pain (including epidural block site”)
• Revised risk factors to include “iron-deficiency anaemia”, “unwell children”, “household members”.
• Added “Aboriginal and Torres Strait Islander people” as a high-risk and vulnerable population group for sepsis.
• Added “concern by women, family, clinician” as a risk factor.
• Added signs of organ dysfunction based off international guidance.
• Added “Commence A-G systematic assessment and document a full set of vital sign observations”.
• Added lactate to Yellow Zone and Red Zone criteria.

• Changed terminology to “probable” and “possible” sepsis to align with sepsis definition.
• Added “Escalate as per local CERS and Tiered Perinatal Network”.
• Changed wording from “Does the senior clinician consider the woman has sepsis?” to support ANY clinician can assess and consider sepsis.
• Added reminder to assess the fetal / baby wellbeing unless any perinatal loss.

• Removed triage data collection section.
• Updated formatting to include action list of interventions rather than A-G structure.
• Added visual clock cues to support timing of critical interventions.
• Added “Escalate and consult with Obstetrician / senior clinician”.
• Added “Call for assistance after 2 failed attempts at cannulation”.
• Added “Point of care test if available” to support sites to use point of care testing devices where available.
• Added reminder to “do not wait for test results: commence fluids and antibiotics” to prevent delays to commencing treatment.
• Changed volume of fluid resuscitation to be consistent across clinical areas with consideration of early referral for vasopressors and Intensive Care or retrieval services.
• Added link Therapeutic: Antibiotic Guidelines as recommended treatment guidance.

• Removed parameters of vital signs observations to monitor and reassess.
• Added “re-examine for other sources of infection and refer for surgical control if required”.
• Updated advice on repeat lactate within two hours to assess for improvement or further deterioration.
• Added guidance on monitoring vital signs and fluid balance.

The sepsis pathway is a clinical decision support tool for initial sepsis recognition and management. A contemporary language change has been made throughout from ‘newborn’ to ‘neonate’ to reflect the patient population.

The sepsis management plan (previously Page 4) has been removed in response to feedback from NSW Health clinicians The ongoing sepsis management plan should now be documented in the respective patients’ health care record, be discussed with the Attending Medical Officer (AMO) and communicated with the clinical team. Management plans should include close observation and frequency of vital sign monitoring, any repeat investigations (e.g. lactate, cultures) and plans to review and revise antimicrobial treatment.

• Revised wording to define use of the pathway in neonates up to 28 days corrected age, across all clinical settings.
• Added “Could it be sepsis?” as a key prompt; aligns with sepsis NSW messaging and the Sepsis Clinical Care Standard.
• Added definition of sepsis and time-critical medical emergency.
• Revised the signs and symptoms: bundled in systematic approach and in order or commonality of neonatal presentation.
• Added Maternal risk factors and other risk factors for sepsis.
• Added premature babies as a high risk and vulnerable population group for sepsis.
• Added “Aboriginal and Torres Strait Islander people” as a high-risk and vulnerable population group for sepsis
• Added “Family, carer, or clinician concern the baby is sick” as other risk factor for sepsis.
• Added “Unwell family members” as other risk factor for sepsis.
• Added “Re-presentation for ongoing condition or concern” as other risk factor for sepsis.
• Added link KP Neonatal Early-Onset Sepsis Calculator and QR code for ease of access.
• Added A-G systematic assessment (reference to SNOC removed to align with introduction across all clinical settings).
• Amended reference to “features of severe illness” instead of “has severe sepsis or septic shock”.
• Added laboratory features of severe illness / organ dysfunction statement.

• Added “Consider other causes” with examples (to reflect complications associated with postnatal transition period).
• Added “Does the senior clinician consider the baby has ‘possible sepsis’?” (to ensure escalation to senior clinician and removed suggestion of confirmed diagnosis).

• Removed sepsis recognition box.
• Updated formatting to include action list of interventions rather than A-G structure.
• Added visual clock cues to support timing of critical interventions.
• Added “Consult with Paediatrician / Neonatologist / Emergency Physician / NETS”
• Added supplemental oxygen and target saturation ranges.
• Added monitoring requirements and assessment for signs of shock.
• Added reference to thermal environment to achieve normothermia.
• Amended referencing to pathology and listed in order of priority.
• Blood culture collection prioritised; volume of blood required for blood culture collection added.
• Added additional relevant screening samples (e.g. lumbar puncture, urine)
• Added reminder of “do not delay antibiotic administration for sample collection or test results”
• Antibiotic administration and fluid resuscitation section split to better align with timing of care recommendations in Sepsis Clinical Care Standard.
• Described recommended choice of antibiotics to commence (reference to local guidelines removed).
• Reference to Australasian Neonatal Medicines Formulary (ANMF) with QR code link added.
• Reference to fluid administration amended to ‘consider’ reflecting an option of treatment as dependant on neonates' clinical presentation.
• Added clear glucose management recommendations (reference to local guidelines removed).

• Updated reassess section.
• Reassess signs of shock, reference to specific vasopressor and consultation step included.
• Described ongoing monitoring plan including frequency of observation.
• Added reference to reviewing investigation results.
• Added consideration of need for viral screening.
• Added referral to higher level care.
• Highlighted NETS contact number supporting ease of clinician reference/use.

The sepsis pathway is a clinical decision support tool for initial sepsis recognition and management. This pathway is to be used for babies from 28 days corrected age. For babies under 28 days of age the CEC Neonatal sepsis pathway (LINK) should be used.

The sepsis management plan (previously Page 4) has been removed in response to feedback from NSW Health clinicians. The ongoing sepsis management plan should now be documented in the respective patients’ health care record, be discussed with the Attending Medical Officer (AMO) and communicated with the clinical team. Management plans should include close observation and frequency of vital sign monitoring, any repeat investigations (e.g. lactate, cultures) plans to review and revise antimicrobial treatment.

• Revised wording and icons to define use of the pathway and exclusions.
• Added “Could it be sepsis?” as a key prompt; aligns with sepsis NSW messaging and the Sepsis Clinical Care Standard
• Added definition of sepsis and time-critical medical emergency.
• Revised the signs and symptoms to include “severe unexplained pain”, “change in behaviour and decreased level of consciousness”.
• Revised risk factors to include “complex medical history” and “worsening with the same illness”.
• Added “Aboriginal and Torres Strait Islander people” as a high-risk and vulnerable population group for sepsis.
• Added “Parental, carer, or clinician concern”.
• Added laboratory features of severe illness / organ dysfunction statement.
• Added specific Red and Yellow Zone observation criteria.

• Added “Does the senior clinician consider the patient has sepsis?” to assist with management.
• Changed terminology to “probable” and “possible” sepsis to align with definition of sepsis and timeframes to treat.

• Removed triage data collection section.
• Updated formatting to include action list of interventions rather than A-G structure.
• Added visual clock cues to support time critical interventions.
• Added “Consult with Paediatrician / Emergency Physician / ICU / NETS”
• Added “obtain vascular access within 5 minutes (intraosseous access if no vascular access)”
• Added volume of blood required for blood culture for paediatric.
• Added reminder of “do not wait for test results: commence fluids and antibiotics”
• Added links to Therapeutic: Antibiotic Guidelines and Australian Paediatric Clinical Practice Antibiotic Guidelines as recommended treatment guidance.

• Added specific Red and Yellow Zone criteria to encourage recognition of persistent signs of deterioration following fluid resuscitation. This includes addition of “OR hypoglycaemia, acidosis, low white cell count or abnormal coagulation”
• Added “Referral to local / regional paediatric experts, Intensive Care and NETS” (with contact number for NETS)
• Added advice on preparing adrenaline and link to NETS Clinical Calculator.