A Sepsis Initiative · Brief for emergency physicians

What the framework asks of EDs for sepsis care

The new ED sepsis framework (September 2026) sets minimum requirements that every emergency department must meet for adult and paediatric sepsis, from the triage screen to follow-up of results that return after the patient leaves. Hospitals are asked to act by March 31, 2027, the date tied to the sepsis attestation in their Quality Improvement Plan (QIP) submission.

Action required by: March 31, 2027QIP sepsis attestation
Applies to: Every EDRegardless of size, resources or capacity
Patients covered: Adults 16 and olderChildren 1 month to 16 years
Implementation webinar: Friday, October 9, 202610:00 to 11:00 a.m.

The ask in one minute

Memo, Sept 29, 2026 · Framework pp. 3–14

Every ED needs one standardized sepsis workflow built on four core components. These components define what hospitals attest to in the QIP ED sepsis attestation.

Screen for sepsis at triage
Identify patients with suspected sepsis
Initiate the adult or paediatric sepsis care pathway
Initiate treatment, ongoing reassessment and consultation

Local tools can stay. Hospitals can use the framework's templates or keep and adapt their own tools, as long as the minimum requirements are met and local approvals are in place. Electronic and paper workflows both qualify.
Physician time targets. Probable sepsis or septic shock: physician initial assessment within 10 minutes of escalation and empiric antibiotics within 60 minutes of recognition. Possible sepsis: physician assessment, and antibiotics if indicated, within 3 hours.
The framework's directive leaves antibiotics to physicians. The template nurse medical directive covers oxygen, bloodwork, cultures, IV access and fluid boluses. The Task Group's consensus is that empiric antimicrobials are generally better ordered by a physician after assessment, so under the template the 60-minute target depends on a prompt physician order.
System readiness is part of the ask. Every ED, including small and remote sites, must have immediate access to first-dose antibiotics and be able to start norepinephrine or epinephrine. Each ED also needs a named process for critical results that come back after the patient has left.
Status of the document. The framework states that it does not establish a standard of care or supersede clinical judgment.

Minimum requirements every ED must meet

Framework pp. 8–13, 33, 35, 38

The framework ties the QIP attestation to the four core components. Three more requirement sets (shaded rows) are also written as requirements for every ED.

Requirement	Every ED must have a standardized process or capability to
1. Screen at triage	Identify patients with signs or symptoms of acute infection at triage and screen them with the adult or paediatric criteria (or a locally approved equivalent). Keep the criteria at hand for triage staff, document or communicate the result, and repeat the screen when the patient's condition changes or concern develops.
2. Identify suspected sepsis	Label patients as possible sepsis, probable sepsis or septic shock and communicate that risk to the care team. Define who may start and stop identification and who receives and acts on it. Carry the status across ED care areas and every transfer of accountability. The framework's guidance is that identification can start from the triage screen, or from any nurse, physician or authorized clinician who sees deterioration or develops concern for sepsis. It should be discontinued when the most responsible provider (MRP) decides sepsis is no longer suspected or the pathway is no longer required.
3. Activate a care pathway	Start the adult or paediatric pathway after identification. Define who may activate and discontinue it, assign roles for monitoring and escalation, set reassessment and escalation processes, and communicate pathway status at transitions of care.
4. Treat, reassess, consult	Tools and resources for timely assessment, investigation and treatment, and for ongoing monitoring and reassessment based on the patient's condition and response to treatment. This includes IV fluid resuscitation and timely administration of ordered empiric antimicrobials, vasopressors for persistent hypotension or septic shock, recognition of deterioration with timely escalation, goals-of-care discussions when indicated, consultation and transfer planning, and documentation that supports continuity.
Clinical resource readiness	Immediate first-dose empiric antimicrobials for adults and children, including options for severe allergy and pregnancy or postpartum sepsis. Treatment and escalation on clinical grounds when labs are unavailable or delayed. Access to ED peer physician consultation, critical care consultation and transfer support. The drugs, pumps, preparation guidance and monitoring to start norepinephrine or epinephrine. Site-specific adult and paediatric investigation panels. Point-of-care access to every sepsis tool.
Critical results review	A defined process for identifying and communicating critical sepsis results, with named responsibility for review and follow-up. A process for results still pending at discharge, LWBS, LAMA, admission or transfer (for example, positive blood cultures). Escalation routes for findings that need urgent action, and documentation standards.
Education and orientation	Clinical staff oriented to local sepsis processes, with access to education on recognition, triage screening, pathway activation, reassessment, directives and order sets, timely antimicrobials, fluids and initial shock care, vasopressors (within professional roles), and escalation or transfer.

Adults 16 and older: the bedside clock

Framework §3.2 p. 17 · §3.3 p. 18

Antibiotic targets count from recognition of sepsis. The other intervals are the pathway's own time boxes, which apply whenever the patient screens positive, at triage or later. Column colours match the framework's pathway, where possible sepsis is rose and probable sepsis or septic shock is blue.

When	Possible sepsisInfection with 2 or more SIRS criteria, without organ dysfunction or hemodynamic instability	Probable sepsis or septic shockInfection with 2 or more SIRS criteria, with organ dysfunction and/or hemodynamic instability
Antibiotics	Within 3 h of recognition	Within 60 min of recognition
Screen positive	Flag as possible sepsis and start the pathway.	Flag as probable sepsis or septic shock and start the pathway. The ED sepsis and septic shock order set applies.
Within 5 min	No separate step	Cardiac monitor. MRP or physician informed immediately. Oxygen as needed.
Within 10 min	No separate step	Physician initial assessment (PIA).
Within 60 min	IV access, possible-sepsis bloodwork and diagnostics as indicated, started by medical directive or physician assessment.	STAT sepsis bloodwork including 2 blood culture sets. Two large-bore IVs. Crystalloid 30 mL/kg. Diagnostics as indicated. Empiric antimicrobials per physician once cultures are drawn. Cultures must not delay the first dose when septic shock is suspected. If the MRP is delayed, nurses start initial orders by medical directive or physician direction.
Reassess	Every 60 min: vital signs and perfusion, LOC and mental status, bloodwork review. Escalate on deterioration, which moves the patient to the probable column.	Every 15 min during initial resuscitation, then hourly until within the patient's normal range, then every 4 h for 24 h and as needed.
Within 3 h	Physician assessment (target under 3 h), with a time-limited exam and tests to confirm infection and identify the source. Empiric antimicrobials as clinically indicated. Repeat lactate within 2–4 h if the first is above 2 mmol/L. Give 30 mL/kg IV fluid within 3 h if there is evidence of hypoperfusion.	Covered by the earlier steps
After 2 boluses	Not applicable	If hypoperfusion persists or SBP stays below 100 mmHg, start norepinephrine, vasopressin or epinephrine per local protocol to a MAP above 65 mmHg. Hydrocortisone 50 mg IV q6h if vasopressors are expected or given for more than 4 h. 1:1 nursing with continuous monitoring until stable or transferred. Serial lactate every 2–4 h to guide resuscitation.
Disposition	Continue treatment and reassessment. Admission or consultation versus discharge when clinically appropriate, with ongoing monitoring and follow-up.	ICU or a higher level of care as indicated, with continued resuscitation and reassessment.
Within 6–12 h	Source investigation and control for both groups. Identify the suspected source and consult the medical service or pharmacy to adjust antibiotics as needed.

The adult triage screen

Framework §3.1 p. 16

The clinician doing triage screens every adult who presents with signs or symptoms of acute infection. The screen is SIRS-based, and an organ dysfunction step separates possible from probable sepsis.

Step 1 · Signs of infection?

Fever or chills; headache
Cough, shortness of breath or sputum
Dysuria, frequency or flank pain
Abdominal pain, nausea, vomiting or diarrhea
Redness, swelling or drainage, or suspected skin and soft tissue infection
Altered mental status or acute confusion
Clinical concern for infection from assessment or history

No Continue care as clinically indicated

Step 2 · 2+ SIRS or clinical concern?

Temperature above 38 °C or below 36 °C
HR above 90
RR above 20
PaCO₂ below 32 mmHg
WBC above 12 or below 4 ×10⁹/L, or more than 10% bands

No, but high risk Reassess and re-screen every 60 min until disposition is known. Escalate to possible sepsis on deterioration. No, not high risk Usual care

Step 3 · Organ dysfunction or instability?

SBP below 100 or MAP below 65 mmHg
Altered mental status
RR above 24
SpO₂ below 90% despite oxygen
Capillary refill over 2 s, or cool or mottled skin
Decreased urine output
Lactate above 4 mmol/L
Clinical concern for deterioration

No Possible sepsis pathway Yes Probable sepsis or shock pathway

High risk for sepsis or deterioration (adult screen)

Age 65 or older, frailty or multiple comorbidities. Pregnant or postpartum. Recent surgery or procedure, or an indwelling device. Immunocompromised (chemotherapy, transplant, hematologic malignancy, biologic or immunosuppressive therapy, steroids, untreated HIV). People who use IV drugs or have alcohol use disorder. People experiencing homelessness. ED return within 72 h or recent hospitalization.

What nurses may start before you see the patient

Framework §2 p. 13 · §3.3 pp. 18–19

The framework supplies adult medical directive content (#001, Possible and Probable Sepsis/Septic Shock). Using a directive is optional. An ED that does not use one must set up another route to fast orders, such as expedited physician assessment or a defined process for urgent orders.

Possible sepsis q60 min reassessment

Indication

Signs of infection plus 2 or more of temperature above 38 or below 36 °C, HR above 90, RR above 20. The directive also qualifies patients with infection who look unwell or are immunocompromised or chronically ill (chemotherapy, hematologic malignancy, neutropenia, untreated HIV, asplenia, transplant, biologic or immunosuppressive therapy, chronic steroids, diabetes, renal failure, cancer, alcohol use disorder, IV drug use).

Nurse-initiated

Oxygen to SpO₂ above 92% (88–92% may be reasonable in suspected CO₂ retainers)
CBC, Na, K, Cl, CO₂, Cr, glucose, HCO₃, lactate; β-hCG if of birthing age (12–50) with internal reproductive organs
Urinalysis; IV access
500 mL Ringer's lactate (or normal saline) over 10–15 min, or 25 min in CHF
12-lead ECG where indicated, reviewed by a physician per ED standards
Wound swab and sputum culture if indicated
Chest X-ray (PA and lateral) if on active chemotherapy or with respiratory symptoms
Reassess every 60 min and escalate on deterioration

Probable sepsis or shock all of the left, plus

Indication

Infection and 2 or more SIRS criteria with SBP below 100 or MAP below 65, altered mental status, RR above 24, SpO₂ below 90% on oxygen, weak peripheral pulses, capillary refill over 2 s, cool or mottled skin, lactate above 4 mmol/L, or clinical concern for deterioration.

Nurse-initiated

Continuous cardiac monitoring
Immediate escalation for physician initial assessment within 10 min
STAT bloodwork adding 2 blood culture sets from 2 sites, VBG, Ca, Mg, PO₄, ALT, ALP, total bilirubin, PTT and INR
Two patent IVs, large bore preferred
If SBP below 100 or MAP below 65: 1,000 mL Ringer's lactate (or normal saline) over 10–15 min (25 min in CHF), repeated once if no change

Not in the template directive: empiric antibiotics

The ED Sepsis Task Group reached consensus that empiric antimicrobials are generally better supported by physician assessment and a patient-specific order, in line with local stewardship. Where the template is adopted, meeting the 60-minute antibiotic target for probable sepsis depends on a prompt physician order.

The directive is not used for patients under 16, patients who do not meet inclusion criteria, patients already receiving other physician orders, patients whose goals of care do not support escalation, or patients who do not consent.
For children, sepsis directives should not start invasive or painful procedures before physician assessment. Existing ED directives for antipyretics and oral rehydration can continue.

Adult order set for probable sepsis or septic shock

Framework §3.4 pp. 20–21 · App. 6.4 p. 46

The pre-printed template covers probable sepsis (suspected infection with organ dysfunction) and septic shock. Hospitals are expected to adapt it to local labs, formulary and stewardship requirements.

Area	Pre-checked on the template	Available to add
Monitoring	Notify MRP STAT on deterioration. Flag the chart SEPSIS. BP (MAP), HR, RR and SpO₂ every 15 min during initial resuscitation, hourly until normal for the patient, then every 4 h for 24 h and as needed. Temperature and GCS every 2 h for 8 h. Supplemental oxygen, choosing a target of SpO₂ above 92% or 88–92%.	Continuous cardiac monitoring. Continuous fetal monitoring in pregnancy. Urinary catheter with hourly output.
Labs	CBC, glucose, Cr, Na, K, Cl, CO₂, Mg, Ca, PO₄, VBG, lactate, ALT, ALP, total bilirubin, PTT, INR, urinalysis. Repeat lactate every 2 h ×3 if above 2.	Troponin, CK, CRP, D-dimer, fibrinogen, albumin, amylase, β-hCG, type and screen.
Micro	2 blood culture sets from 2 different sites, before antimicrobials if this does not delay treatment.	Extra set from an indwelling vascular device. 3 sets if endocarditis is suspected. Viral or NP swab; urine, sputum, wound, stool, CSF and device cultures; vaginal culture if pregnant or postpartum.
ECG, imaging	12-lead ECG.	Chest X-ray, portable option.
Access, fluids	Two patent IVs, large bore preferred. Call MRP if access fails. Notify MRP if MAP stays below 65 after the 2nd bolus.	Bolus of Ringer's lactate or 0.9% NaCl, 30 mL/kg recommended, repeated if MAP stays below 65. Maintenance infusion. Record any bolus already given under the directive.
Vasoactives	None pre-checked	Titrate to MAP above 65. Norepinephrine 0.05 mcg/kg/min, up to 1 mcg/kg/min, peripheral IV allowed. Epinephrine 0.01 mcg/kg/min, up to 0.1 mcg/kg/min, peripheral IV allowed. Vasopressin 0.04 units/min, not titrated, central line only. Hydrocortisone 50 mg IV q6h.
Antimicrobials	None pre-checked	"Start immediately after blood culture sets drawn." Unknown source: piperacillin-tazobactam 4.5 g IV STAT then q6h (no penicillin allergy). Vancomycin 15 mg/kg rounded to the nearest 250 mg (max 3,000 mg per dose) STAT, then per pharmacy protocol, is a separate line; the source table lists it as "±" and suggests it for septic shock or suspected MRSA. Source-specific options are in the next section.
Consults	None pre-checked	ICU, internal medicine, hospitalist, infectious diseases, surgery, interventional radiology, pharmacy, respiratory therapy, CritiCall.

Blood culture collection

Two sets from two sites before antimicrobials when this does not delay treatment. Draw them one after the other; no interval or fever spike is needed.
Never delay antimicrobials in shock or other time-critical sepsis to finish collection.
Do not draw from an existing peripheral IV or arterial line. A freshly inserted, unused cannula may be used if a second site cannot be found. Label each set with site and time.
Adults: one aerobic and one anaerobic bottle per set, 8–10 mL per bottle. Children: weight-based volumes per local lab guidance.
Central line present: one peripheral set and one catheter set at the same time, equal volumes; sample 2 or more lumens if the line is under suspicion.
Two peripheral sites not possible: use the best available combination (1 peripheral set plus the line, or 2 lumens or 2 devices), and do not delay the first antimicrobial dose in shock.
Suspected endocarditis: 3 sets from different sites, which may be spaced 30–60 min apart if the patient is stable enough to wait.

Empiric antibiotics by suspected source (adults)

Framework p. 22

Suspected source	Initial ED therapy
Unknown source, undifferentiated sepsis, febrile neutropenia or immunocompromised	Piperacillin-tazobactam 4.5 g IV STAT ± vancomycin loading dose
Community-acquired pneumonia	Ceftriaxone 2 g IV STAT + azithromycin 500 mg IV/PO STAT
Urinary	Ceftriaxone 2 g IV STAT
Community-acquired abdominal, biliary or pelvic	Ceftriaxone 2 g IV STAT + metronidazole 500 mg IV STAT
Skin and soft tissue	Cefazolin 2 g IV STAT ± vancomycin loading dose
Necrotizing soft tissue infection or toxic shock syndrome	Piperacillin-tazobactam 4.5 g IV STAT + vancomycin loading dose + clindamycin 900 mg IV STAT
Suspected meningitis or CNS infection	Ceftriaxone 2 g IV STAT + vancomycin loading dose ± ampicillin 2 g IV STAT. Add dexamethasone 0.15 mg/kg IV q6h immediately before or with the first antimicrobial dose for suspected bacterial meningitis.
Pregnancy or postpartum sepsis	Piperacillin-tazobactam 4.5 g IV STAT ± vancomycin loading dose
Severe penicillin or beta-lactam allergy	Meropenem 1 g IV STAT ± vancomycin loading dose

Vancomycin loading dose throughout: 15 mg/kg rounded to the nearest 250 mg, maximum 3,000 mg per dose.

Septic shock, severe illness or ongoing deterioration calls for prompt broad-spectrum therapy. Consider vancomycin when septic shock is present or MRSA is suspected.
A clinically stable patient with a likely source can receive source-specific therapy.
Consider dose adjustment for severe renal impairment or dialysis-dependent kidney disease.
Reassess as results and clinical response arrive, then narrow, modify or stop. Definitive therapy follows local stewardship, formulary restrictions and antibiograms.

Children 1 month to 16 years

Framework §4 pp. 23–29

Infants under 3 months are a high-risk group that needs heightened vigilance and timely escalation.
Infants under 1 month are a distinct population. The paediatric tools are written for ages 1 month to 16 years, so management of neonates follows local protocols with early paediatric specialist consultation. Consultation, transfer planning and stabilization should not delay treatment.
Febrile neutropenia needs rapid identification, prompt assessment and early empiric antimicrobials, with specialty consultation.
EDs that see children need paediatric equipment, weight-based dosing resources, age-based vital sign references and defined consultation and transfer routes. Caregivers are treated as partners in monitoring and escalation.

Triage screen thresholds

Age	Tachycardia (bpm)
Under 12 months	>180
1–4 years	>150
5–12 years	>130
13 years and older	>120

Age	Tachypnea (/min)
Under 12 months	>60
1 to under 4 years	>50
4 to under 10 years	>30
Over 10 years	>25

Age	Hypotension (SBP, mmHg)
Under 1 month	<60
1 to under 12 months	<70
1–10 years	<70 + (age in years × 2)
Over 10 years	<90

Temperature abnormality for ages 0–16: below 36.0 °C or 38.0 °C and above. Signs of infection on the paediatric screen include a temperature abnormality, cough or difficulty breathing, vomiting or diarrhea, dysuria, and redness, swelling, drainage or suspected skin and soft tissue infection.

Organ dysfunction or evolving instability

Persistent unexplained tachycardia
Altered mental status: decreased, irritable, lethargic, inappropriate crying
Increased work of breathing or hypoxia
Capillary refill under 1 s or over 2 s; weak or bounding pulses
Cold extremities; mottled skin or cyanosis
Petechiae or purpura
Hypotension (a late sign)

Yes Risk for probable sepsis or shock: alert and urgent clinical assessment

If not, high risk for sepsis?

Clinical concern or looks unwell
Under 3 months of age
Malignancy; asplenia, including sickle cell disease
Solid organ or bone marrow transplant
Central line or indwelling catheter or stent
Medically complex; immunocompromised or immunosuppressed
Recent invasive surgical procedure
Return ED visit

Yes Risk for possible sepsis: alert and prioritization

If not, fever and tachycardia?

Start the febrile protocol with oral hydration and antipyretics, and reassess for evolving sepsis every 1–2 h.

Deterioration Escalate to possible, then probable Neither Usual care

Paediatric bedside clock

When	Possible sepsisInfection with high risk and/or clinical concern, without organ dysfunction or shock	Probable sepsis or septic shockInfection with organ dysfunction, septic shock and/or evolving instability
Antibiotics	Within 3 h, if indicated	STAT once cultures are drawn, inside the first 60 min
Within 5 min	No separate step	Immediate escalation with a physician at the bedside; the MRP stays at the bedside. Flag as septic. Cardiorespiratory monitoring. Oxygen as needed to keep SpO₂ above 92%. Vascular access, considering IO after 2 failed IV attempts. Bedside glucose, with D10W 5 mL/kg IV if below 2.6 mmol/L. 1:1 nursing until stable or transferred.
Within 60 min	Vital signs, perfusion and LOC every 30 min ×2. Acetaminophen as needed per protocol. Oxygen as needed to keep SpO₂ above 92%. Continuous SpO₂ and HR monitoring where available. Physician initial assessment within 60 min, with expedited testing, a 20 mL/kg bolus if indicated, and escalation to the probable pathway if needed.	STAT sepsis bloodwork. Empiric antibiotics STAT once cultures are drawn; cultures must not delay the first dose if shock is suspected. First 20 mL/kg bolus over 15 min or less, by push-pull, pressure bag or rapid infuser. Normal saline or Ringer's lactate are both appropriate, avoiding Ringer's lactate with known renal, liver or metabolic disease. Consider source control. If shock or hypoperfusion: consult PICU or CritiCall after the first bolus, give a second 20 mL/kg bolus, and continue up to 40–60 mL/kg until perfusion, heart rate or BP improves. Give less fluid, more slowly, where aggressive resuscitation is risky (poor cardiac or renal function, suspected Kawasaki disease). Reassess after every bolus, stop for fluid overload (worsening respiratory status or crackles, new or worsening hepatomegaly), and prepare a vasoactive.
At 60 min	Not applicable	Shock not resolved: start epinephrine or norepinephrine in consultation with a paediatrician, titrated to perfusion and BP. Use cardiac and lung POCUS where expertise is available. No response to vasoactives: give IV hydrocortisone. Coordinate transfer with PICU or CritiCall.
Within 3 h	Reassess vital signs, perfusion, BP, capillary refill and mental status hourly for 2 h, then every 4 h. Review labs for organ dysfunction. Antibiotics within 3 h if indicated. Escalate to the probable pathway if vital signs fail to normalize, if parenteral antibiotics are needed for a suspected bacterial infection, or if organ dysfunction or shock appears.	Covered by the earlier steps
Disposition	Consider source control within 6–12 h. Consult paediatrics for further management and admission or transfer. If discharged, arrange follow-up and give return precautions.	Shock resolved: reassess every 30 min ×2 then hourly to baseline, consult paediatrics and admit. On vasoactives: arrange transfer with PICU or CritiCall.

Paediatric order set and doses

Area	Pre-checked on the template	Available to add
Monitoring	Notify MRP STAT on deterioration. Flag PAEDIATRIC SEPSIS. Cardiorespiratory monitoring. Vital signs every 15 min during resuscitation, every 30 min ×2, hourly until normal, then every 4 h for 24 h. Temperature every 2 h for 8 h. Oxygen only for hypoxia or SpO₂ below 94%. Bedside glucose; D10W 5 mL/kg rapid IV push if 2.6 mmol/L or lower, recheck in 5 min.	Nothing further
Labs, micro	CBC, glucose, Cr, lactate, VBG, Na, K, Cl, Mg, Ca, PO₄, ALT, total bilirubin, INR, PTT, urinalysis. Blood cultures from 2 sites if able (peripheral or central), before antimicrobials, and never delaying treatment.	CO₂, HCO₃, CRP, D-dimer, fibrinogen, type and screen, β-hCG. Viral or NP swab, urine and wound cultures. Chest X-ray, 12-lead ECG, lumbar puncture.
Access	Two peripheral IVs. Notify the provider if there is no access within 5 min or after 2 failed attempts.	IO placement.
Fluids	None pre-checked	0.9% NaCl or Ringer's lactate, 20 mL/kg (max 1 L) over 15 min or less, up to 3 boluses on the form. Reassess after every bolus and stop if fluid overload develops. Up to 40–60 mL/kg may be needed until perfusion or vital signs improve. After an inadequate response, consider vasoactive support and consult specialty services. D5NS maintenance after boluses if ordered.
Vasoactives	None pre-checked	For shock persisting after 40–60 mL/kg, or earlier with decreased cardiac function or fluid overload. Epinephrine 0.05 mcg/kg/min IV/IO, max 1 mcg/kg/min. Norepinephrine 0.05 mcg/kg/min IV/IO, max 2 mcg/kg/min.
Steroid	None pre-checked	Hydrocortisone 2 mg/kg IV/IO once (max 100 mg) for vasopressor-refractory shock or suspected adrenal insufficiency.
Antibiotics	None pre-checked	"Start immediately and consult Paediatrics, ideally after blood cultures drawn." First line for unknown source: ceftriaxone 100 mg/kg (max 2,000 mg) IV/IO STAT then q24h, plus vancomycin 15 mg/kg (max 1,000 mg) IV/IO STAT then q6h. Do not delay for difficult cultures.
Consults	None pre-checked	Paediatrician, PICU, surgery, pharmacy, respiratory therapy, CritiCall.

Paediatric antibiotics by source

Suspected source	Initial ED therapy
Febrile neutropenia (consult a specialist for oncology patients)	Piperacillin-tazobactam IV/IO q8h: under 30 kg, 100 mg/kg per dose; 30–40 kg, 3.375 g; over 40 kg, 4.5 g
Intra-abdominal	First-line therapy plus metronidazole 15 mg/kg (max 500 mg) IV/IO q8h
Necrotizing fasciitis or toxin-mediated infection (toxic shock, group A strep)	First-line therapy plus clindamycin 13 mg/kg (max 600 mg) IV/IO q8h
CNS infection, encephalitis, meningitis or HSV	First-line therapy plus acyclovir 20 mg/kg (max 1,000 mg) IV/IO q8h
Severe penicillin or beta-lactam allergy	Choose by documented allergy, suspected source and local paediatric guidance

Antibiotics should not wait for consultation, transfer or diagnostic confirmation. Infants under 3 months and children who are immunocompromised or medically complex may need specialist input or alternative regimens.

ED readiness

Framework §5.1 pp. 30–33 · App. 6.2–6.3 pp. 44–45

The clinical resource readiness requirement (shaded row in the requirements table) applies to every ED. The supporting guidance below is written mainly with smaller and remote sites in mind, since they depend most on consultation and transfer.

Drugs and labs

Immediate access to first-dose empiric antibiotics. The readiness checklist asks sites to confirm 24-hour access without waiting for an on-site pharmacist. Stock should cover undifferentiated adult sepsis, MRSA, weight-based paediatric dosing, young infants, severe allergy, pregnancy or postpartum sepsis, and toxin suppression for necrotizing infection.
Site-specific adult and paediatric investigation panels built around local lab capability. Point-of-care testing such as i-STAT may be used.
Missing or delayed labs should not delay antibiotics, fluids, vasopressors, consultation or transfer.
EDs without a 24-hour lab should define which tests are done on site, which are sent out, which must not delay treatment, and how late results are reviewed.

Vasopressor capability

Immediate access to norepinephrine and epinephrine, including after hours.
Standard adult concentrations and paediatric weight-based preparation guidance.
Premixed infusions or labelled kits with dilution and pump-programming instructions, and pumps that can titrate.
Peripheral administration guidance covering site choice, patency checks, site monitoring and extravasation.
Cardiac and frequent BP monitoring, with critical care consultation and transfer triggers.
Local policy sets prescribing authority and the peripheral administration rules.

Consult	When to call	How they help
ED peer physician	Diagnostic uncertainty. Questions on stabilization, antibiotic choice or use of the framework. Limited local resources or unclear disposition. Support while specialty consultation or transfer is arranged.	Review the presentation, prioritize immediate actions, support treatment and reassessment decisions, and help with further consultation and transfer planning.
Critical care	Septic shock. Persistent hypotension after initial fluids or a need for vasopressors. Progressive organ dysfunction or respiratory failure. Deterioration despite treatment.	Guide shock management, fluids and vasopressor titration, advanced monitoring, transfer priority and stabilization while awaiting transport.

During transfer delays (weather, transport, bed capacity), the MRP stays responsible for assessment, treatment and escalation, and should re-engage consultants as the patient's status or needs change.

Formulary guidance

The appendix headings say "must be", while its introduction describes the list as suggested considerations for review that do not replace local formulary approval.

Must be in the ED or automated dispensing cabinet

Piperacillin-tazobactam 4.5 g
Ceftriaxone 1–2 g; cefazolin 2 g
Meropenem 1 g; vancomycin 1 g vials
Metronidazole 500 mg; ampicillin 2 g
Clindamycin 600/900 mg
Ringer's lactate 1 L; 0.9% NaCl 1 L
Norepinephrine premix or kit
Epinephrine infusion and 1 mg pre-filled syringes
Hydrocortisone 100 mg

Must be readily available in the hospital

Ciprofloxacin 400 mg IV
Azithromycin 500 mg
Gentamicin (obstetric, neonatal)
Cefotaxime (neonatal)
Acyclovir
Linezolid (vancomycin alternative, toxin suppression)
Vasopressin

Results that come back after the patient leaves

Framework §5.2 pp. 33–35

Critical sepsis results can arrive after discharge, admission, transfer, LWBS or LAMA. Hospitals define which results count as critical, in line with existing lab and medical staff policies. Examples include critical lactate, hematology or chemistry values, positive blood cultures, imaging suggesting severe infection, and new or worsening organ dysfunction.

Local policy must settle

Who reviews results that return after the patient has left the ED
How responsibility passes between providers, including across shifts
Escalation when the responsible clinician is unavailable
Documentation of the review and the actions taken

Positive blood cultures and late micro

Timely clinical review
A decision on whether to recall the patient
Review of antimicrobial therapy, with consultation where appropriate
Documented follow-up and handover when it spans shifts

For quality review, paediatric sepsis is already a sentinel diagnosis in the ED Return Visit Quality Program. Adult sepsis cases can be drawn from the mandatory 72-hour return visit audits.

Goals of care, crowding and handover

Framework §2 pp. 9–13

Goals of care. Consider them before ICU admission, transfer, vasopressors or other intensive treatment, working with the patient and family or substitute decision maker. Escalation should not be assumed as the default; it should follow an individualized, person-centred plan of care. These conversations should not delay immediate assessment, symptom management or care that fits the patient's goals.
The sepsis flag follows the patient. Pathway status is communicated at reassessment, on moves between ED areas and at every transfer of accountability. Each ED defines who may start and stop identification and the pathway. The framework's guidance is that identification is discontinued when the MRP decides sepsis is no longer suspected or the pathway is no longer required.
Crowded departments. When full vital signs cannot be done right away, a focused reassessment (overall appearance, level of consciousness, radial pulse, capillary refill, symptoms and response to treatment) helps catch deterioration early. It does not replace full vital sign monitoring.
Early warning scores. Optional in the ED, for example for admitted patients waiting for a bed. The QIP attestation separately requires a screening or warning mechanism on inpatient units.

Education and orientation

Framework p. 32 · §5.3 pp. 35–38

Every clinician who assesses or manages suspected sepsis must be oriented to the local process and have access to training on the topics listed under Education and orientation in the requirements table. The framework suggests hospitals consider building this into existing channels, such as onboarding and orientation, simulation, safety huddles, case reviews, M&M rounds and continuing professional development. For sites that rely on locum physicians or travel nurses, it suggests a concise local sepsis quick-reference resource that is part of orientation.

Supports include the Emergency Services Community of Practice and the Sepsis QI Community of Practice (both on Quorum), plus the ED nursing Specialty Training Fund and Virtual Training Program.

Decisions and gaps to settle locally

Reviewer's notes

Reviewer's notes · decisions the framework leaves to each site, plus differences found by comparing the tools

Which tools to adopt (screening tool, pathway, directive, order set) or which local equivalents to keep, and the approvals each needs from medical advisory, pharmacy and therapeutics, and stewardship committees.
Directive or not. If the ED will not run a nurse medical directive, decide what replaces it for fast orders.
One definition of possible sepsis. The screening tool uses five SIRS items (including PaCO₂ and WBC) or clinical concern. The directive uses the three vital-sign items, and it also accepts infected patients who look unwell or are immunocompromised or chronically ill, including diabetes or renal failure, with no SIRS criteria. On the screening tool, some of those patients fall into the high-risk group and are re-screened hourly, while others (diabetes or renal failure alone, for example) get usual care.
The possible-sepsis bolus. The directive gives 500 mL of crystalloid to every eligible patient with no blood pressure criterion, run over 25 min in CHF. Decide whether local cautions are needed, for example for dialysis patients or severe heart failure.
Cardiac monitoring is a pathway step ("cardiac monitor ASAP") and a directive item for probable sepsis, but it is an unchecked box on the adult order set. The paediatric order set pre-checks cardiorespiratory monitoring.
Hydrocortisone criteria. The adult pathway ties 50 mg q6h to vasopressors expected or given for more than 4 h. The order set lists it without criteria.
Paediatric oxygen target. The pathway says oxygen as needed for SpO₂ above 92%. The order set says oxygen only for hypoxia or SpO₂ below 94%.
Age edges. Adult tools start at 16 and paediatric tools end at 16. The paediatric tools are scoped to 1 month and older, even though the screening tool lists a hypotension threshold under 1 month, so neonates need a local protocol.
Drug location. Vasopressin sits on the adult order set, and azithromycin and acyclovir appear in the antibiotic tables, yet formulary guidance lists them for the hospital rather than the ED. Confirm after-hours access.
Smaller protocol differences to harmonize.
- Blood cultures with a central line: the adult order set adds a set from the device on top of the 2 peripheral sets; the appendix says 1 peripheral set plus 1 catheter set.
- Repeat lactate: the pathway says repeat within 2–4 h if above 2 mmol/L, and every 2–4 h once vasopressors start; the order set says every 2 h ×3 if above 2.
- Probable sepsis reassessment: the directive says every 15–30 min; the pathway and order set say every 15 min during resuscitation.
- Paediatric hypoglycemia: the pathway treats below 2.6 mmol/L; the order set treats at 2.6 mmol/L or lower.
Ownership of late results, especially positive blood cultures after discharge, LWBS or LAMA, including who acts when the result arrives on another shift.

Dates, contacts and source files

Memo · Framework pp. 4, 13, 15, 24, 36

Memo: Clinical memorandum of September 29, 2026 to hospital CEOs, CMOs and CNEs. It builds on an April 2026 memo on sepsis expectations.
Deadline: Action required by March 31, 2027, tied to the QIP sepsis attestation.
Webinar: Community of Practice webinar, Friday, October 9, 2026, 10:00 to 11:00 a.m. Registration page
Questions: Regional ED Leads (contact details are in the September 29, 2026 memo)
Adult tools: Screening tool (PDF) · Clinical care pathway (PDF) · Medical directive, editable (DOCX) · Order set, editable (DOCX)
Paediatric tools: Screening tool (PDF) · Clinical care pathway (PDF) · Order set, editable (DOCX)
Communities: Emergency Services Community of Practice · Sepsis QI Community of Practice. The tool files are hosted on Quorum and may need a Quorum sign-in.
Other references: ED Leading Practices Toolkit (for EDs new to medical directives) · PCMCH ED Paediatric Readiness
Distribution: Educational use only. This is an unofficial summary and not an official document of any health system or organization.