Sepsis at triage: recognize and act in the 1st hour

A 74-year-old woman arrives at the emergency department brought in by her daughter. The complaint is vague: "she has been weak since yesterday and barely speaks". Two days ago, she complained of burning when urinating. At triage, the nurse records a respiratory rate of 23 per minute, oxygen saturation of 95 on room air, systolic pressure of 104, pulse of 108 and temperature of 37.9 degrees. The skin on her knees is mottled and capillary refill takes about four seconds. The patient responds, but cannot say what day of the week it is, which the daughter assures is new. The scene is fictional and was written for teaching.

This text uses the case as a clinical reasoning scenario for nurses at triage. The trap is to read "weakness" as a low-priority complaint, see a "normal" pressure and send the patient to the waiting room. Sepsis often arrives like this, with a subtle appearance and no high fever. The text does not replace your institution's protocol. If you play the case of the day on NEXO, you will recognize the challenge: noticing early that small clues point to a serious illness.

Key points

• Sepsis is life-threatening organ dysfunction caused by a dysregulated response to infection.
• Many patients who progress to septic shock arrive at triage without hypotension and with nonspecific complaints.
• qSOFA should not be used as the only screening tool for sepsis.
• Scores with more parameters, such as NEWS, detect more patients with sepsis than qSOFA.
• When suspicion is high or shock is possible, the antimicrobial should be given immediately, ideally within one hour of recognition.
• Cultures, including blood cultures, come before the antimicrobial when this does not delay the start of treatment.

Why this is a reasoning scenario

Triage is the first filter in the emergency department, and nurses decide in a few minutes who waits and who goes in. In sepsis, this decision weighs heavily, because every hour counts. In a study of more than 49,000 patients in New York hospitals, each additional hour until the three-hour bundle was completed, and each additional hour until the antibiotic, was associated with higher adjusted in-hospital mortality, with an odds ratio of 1.04 per hour (Seymour et al., 2017). The effect seems small per hour, but it adds up over a long wait.

The problem is that sepsis does not arrive with a label. The patient in the scene is not hypotensive, has no high fever and came in for "weakness". She does, however, have rapid breathing, a fast pulse, mottled skin, slow capillary refill and new confusion. Each clue alone is subtle. Together, they form a picture that calls for immediate action.

What the scene teaches

The scene trains three habits. The first is to suspect infection when the complaint is nonspecific, especially in older adults. The second is to use a sensitive screening tool, and not to rely on a single low-sensitivity score. The third is to act in parallel: alert, collect, access and prepare at the same time. The post on clinical decision-making discusses how to act with incomplete information.

What sepsis is today

The Sepsis-3 consensus defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer et al., 2016). Organ dysfunction is identified by an increase of 2 points or more on the SOFA score (Singer et al., 2016). Septic shock is the subgroup with circulatory and metabolic abnormalities severe enough to greatly increase mortality, identified by the need for a vasopressor to maintain mean arterial pressure at 65 mmHg or more and lactate above 2 mmol/L, despite adequate volume (Singer et al., 2016). This combination is associated with in-hospital mortality above 40 percent (Singer et al., 2016).

The same consensus proposed qSOFA as a rapid bedside signal: respiratory rate of 22 or more, altered mental status and systolic pressure of 100 or less (Singer et al., 2016). Patients with suspected infection and at least two of these criteria had a higher chance of poor outcome (Seymour et al., 2016). qSOFA was validated to predict outcome, not to screen who has sepsis, and that difference changes its use in practice.

How sepsis reaches triage

Sepsis rarely arrives as in the textbook. In a screening study in a large emergency department in the United States, among patients who progressed to septic shock requiring vasopressors, 60 percent arrived without hypotension at triage and 56 percent arrived with nonspecific complaints, such as weakness, a fall or altered behavior (Filbin et al., 2018). The authors concluded that triage needs a low threshold to suspect infection (Filbin et al., 2018).

Clues that often appear

• Respiratory rate above usual, sometimes as the only change.
• Fast pulse with no obvious explanation.
• New confusion, drowsiness or agitation, reported by someone who knows the patient.
• Cold, mottled skin or slow capillary refill.
• Reduced urine output in recent hours.
• Probable focus: urine, lung, abdomen, skin, catheter.
• High, normal or low temperature, since the absence of fever does not rule out sepsis.

In this case, the daughter brings two valuable pieces of information: the urinary symptoms from two days ago and the change in behavior. Asking whoever is with the patient "is she different from normal?" is part of triage. The post on signs, symptoms and history shows how to read these clues.

Screening tools: what each one sees

A 2021 international guideline recommends against using qSOFA as the sole screening tool for sepsis or septic shock, compared with SIRS, NEWS or MEWS (Evans et al., 2021). The reason is low sensitivity. In a meta-analysis with 26 studies and more than 62 thousand patients with suspected sepsis, qSOFA had the highest specificity and the lowest sensitivity for mortality, SIRS criteria had the opposite pattern, and NEWS was in an intermediate position (Wang et al., 2022).

Tool	Sensitivity for mortality	Specificity for mortality
qSOFA	0.46	0.82
SIRS	0.82	0.24
NEWS	0.73	0.52

Table source: meta-analysis by (Wang et al., 2022). The values are pooled and vary according to the setting and the threshold used.

NEWS and qSOFA in the emergency department

In a Swiss study with patients brought by ambulance with suspected infection, sensitivity for detecting sepsis was 86 percent for NEWS of 5 or more and 34 percent for qSOFA of 2 or more (Durr et al., 2022). Another Swiss study, in prehospital care and at triage, found low sensitivity of qSOFA, of SIRS criteria and of the sepsis definition itself for identifying infected patients at risk of complications (Tusgul et al., 2017). A rapid systematic review of screening tools in the emergency setting concluded that the evidence is still limited to recommend a specific tool (De Silva et al., 2023).

The patient in the scene illustrates the problem. She has a rate of 23 and new confusion, so she scores 2 criteria on qSOFA. If the confusion went unnoticed, she would have 1, and the score would be "negative". On NEWS, a rate of 23 scores 2, saturation of 95 scores 1, systolic pressure of 104 scores 1, pulse of 108 scores 1, temperature of 37.9 scores 0, and new confusion scores 3, for a total of 8 points (Holland and Kellett, 2023). According to the Royal College of Physicians response table, 7 points or more call for emergency assessment (Holland and Kellett, 2023).

The score supports, suspicion decides

No tool replaces the question "could this be infection?". The study by Filbin et al. showed that adding clinical suspicion of infection to triage vital signs increased triage specificity without a large loss of sensitivity (Filbin et al., 2018). Nursing staff who ask about the focus and record the suspicion make any score more useful.

Differential diagnosis at triage

Weakness, confusion and tachycardia in an older adult have several causes. Sepsis from a urinary source is the leading hypothesis in this case, but triage needs to keep the others in mind in order to collect the right data.

Hypothesis	Supporting clues	What nursing checks
Sepsis from a urinary source	Burning on urination, confusion, tachypnea	Appearance of the urine, urine output, lower back pain
Pneumonia	Cough, shortness of breath, low oxygen saturation	Auscultation, breathing pattern
Dehydration	Low intake, dry mucous membranes	Intake over the last few days, diuretics in use
Hypoglycemia	Confusion, sweating	Immediate capillary blood glucose
Stroke	Focal deficit, altered speech	Strength, facial symmetry, time of onset
Medication effect	Drowsiness, new medication	Medication list and recent changes

The post on differential diagnosis with clues shows how to organize this list when time is short.

Nursing actions in the first hour

The 2021 guideline treats sepsis and septic shock as medical emergencies and recommends that treatment and resuscitation begin immediately (Evans et al., 2021). For nursing, this means actions in parallel, always according to the institution's protocol and the team's prescription.

Notify and change the priority

With suspected sepsis and a NEWS of 8, the patient moves up in priority and goes to an area with monitoring. The medical team is notified immediately. If the institution has a sepsis protocol, it is opened at that moment, and the time of recognition is recorded, because the first hour is counted from it.

Access, tests and cultures

• Insert a large-bore venous line, and a second line if the protocol calls for it.
• Collect lactate, since the guideline suggests measuring lactate in adults with suspected sepsis (Evans et al., 2021).
• Collect cultures, including blood cultures, before the antimicrobial, as long as this does not cause a substantial delay, defined as less than 45 minutes (Evans et al., 2021).
• Collect urine for testing and culture in the case of a urinary source.
• Measure capillary blood glucose.

Antimicrobial at the right time

For adults with possible shock or a high probability of sepsis, the guideline recommends an immediate antimicrobial, ideally within one hour of recognition (Evans et al., 2021). For adults with possible sepsis without shock, it recommends a rapid assessment of the infectious or non-infectious cause and, if the suspicion persists, an antimicrobial within three hours of recognition (Evans et al., 2021). The patient in the scene, with signs of hypoperfusion and confusion, falls into the first group. Nursing prepares the antimicrobial as soon as it is prescribed and records the exact time of administration.

Communicate clearly

The call to the medical team needs to fit in one minute and end with a clear request. A structured format helps. For the patient in the scene, the nurse can say: "I'm the triage nurse. I have a 74-year-old woman with suspected sepsis from a urinary source and a NEWS of 8. She has new confusion, according to her daughter, a respiratory rate of 23, a pulse of 108, a systolic pressure of 104, mottled skin on the knees and a capillary refill of about four seconds. She is already in the monitored room, with venous access, and I have collected lactate and blood cultures. I need you to assess her now to prescribe the antimicrobial and the fluids."

The last sentence is the most important. Saying what you need, and by when, keeps the assessment from being put off. It is also worth saying out loud the time sepsis was recognized, because the first-hour clock runs from then and everyone in the room needs to know it.

Reassess while you wait

Between the call and the doctor's arrival, nursing does not wait idle. Repeat the respiratory rate counted over a full minute, check the oxygen saturation, watch whether the confusion improves or worsens, measure urine output if there is a catheter and note the capillary refill. If the systolic pressure drops below 100 or the patient becomes more drowsy, the new information goes to the team immediately, because it changes the urgency. Each measurement is recorded with the time, which makes it possible to see the trend and assess whether the treatment is having an effect.

Fluids and vasopressor

For patients with sepsis-induced hypoperfusion or septic shock, the guideline suggests at least 30 mL/kg of intravenous crystalloid in the first three hours of resuscitation, with a weak recommendation and low-quality evidence (Evans et al., 2021). For a 60 kg patient, that corresponds to at least 1800 mL. The prescription is medical. The nursing role is to infuse at the prescribed rate, reassess breathing, saturation and auscultation during the infusion, and report any signs of overload.

If the pressure does not respond, the guideline recommends an initial mean arterial pressure target of 65 mmHg in adults with septic shock on a vasopressor (Evans et al., 2021), norepinephrine as the first-line agent (Evans et al., 2021) and starting the vasopressor through a peripheral vein instead of waiting for central access (Evans et al., 2021). When the vasopressor runs through a peripheral vein, nursing staff check the puncture site often, because extravasation can damage tissue.

Perfusion: what to look at beyond blood pressure

Blood pressure is a late marker. The patient in the scene has a systolic pressure of 104, a value that does not draw attention, but she already shows mottled skin and slow capillary refill. The guideline suggests using capillary refill time to guide resuscitation in septic shock, as a complement to other perfusion measures (Evans et al., 2021). A commentary on the topic describes capillary refill as a possible link between macrocirculation and microcirculation, because it responds quickly to changes in flow (Hernández et al., 2020).

How to measure capillary refill

In practice, nursing staff press the fingertip pad or the skin over a bone for about ten seconds, release and count the time until color returns, with good light and a warm hand. The value should be recorded and repeated, because the trend matters as much as the number. Comparing with the measurement from an hour earlier helps show whether resuscitation is working.

Other perfusion signs

• Mental status compared with the usual baseline.
• Hourly urine output, with a catheter if the team indicates one.
• Temperature and color of the extremities.
• Mottled skin on the knees and how far it extends.
• Lactate repeated according to protocol.

Lactate should be interpreted in the clinical context, since other causes can also raise it, as the guideline itself notes (Evans et al., 2021).

Step-by-step reasoning in the case

First, the suspicion: an older woman with weakness, new confusion and recent urinary symptoms. Infection is on the list from the start.

Second, the signs: respiratory rate of 23, saturation of 95, systolic pressure of 104, pulse of 108, temperature of 37.9. NEWS totals 8 with the new confusion.

Third, perfusion: mottled skin and capillary refill of about four seconds indicate hypoperfusion, despite an acceptable blood pressure.

Fourth, the priority: the patient goes to the monitored area and the medical team is notified immediately, with the time of recognition recorded.

Fifth, actions in parallel: venous access, lactate, blood cultures, urine, blood glucose.

Sixth, treatment: antimicrobial prescribed and given as soon as possible, ideally within the first hour, and crystalloid as prescribed, with reassessment during the infusion.

Seventh, reassessment: vital signs, mental status, urine output and capillary refill repeated and recorded with the time.

Common mistakes

The first mistake is giving low priority to a vague complaint. Weakness and confusion in older adults can be the only way sepsis presents.

The second mistake is waiting for hypotension. Many patients who will go on to develop shock arrive with normal blood pressure.

The third mistake is trusting a negative qSOFA. Sensitivity is low, and the guideline recommends not using it alone.

The fourth mistake is delaying the antimicrobial while waiting for cultures that are hard to collect. Collection should not delay it by more than 45 minutes.

The fifth mistake is not recording the time of recognition and of each action. Without it, there is no way to know whether the first hour was met.

The sixth mistake is infusing volume without reassessing. Nursing staff are the first to see signs of overload.

The post about diagnostic pause shows how to stop and review a picture before reaching a conclusion, and the post about diagnostic uncertainty discusses how to decide when the data do not yet add up.

How NEXO helps train this reasoning

To use the case of the day as training, try three habits. Before the first guess, ask whether infection could explain the picture. With each clue, ask whether it changes the urgency or only the focus. After the result, note which discreet clue pointed to severity.

Three exercises with cases

Look for the focus. For each case with fever or confusion, say what the most likely infectious focus would be and what you would collect.

Calculate two scores. Add up the qSOFA and the NEWS for the same patient and compare what each would say at triage.

Build the first hour. List, in order, the nursing actions you would take in parallel.

The post about simulation of care shows how to train patient assessment, and the post about interprofessional clinical reasoning discusses how nursing and medicine build the decision together.

The limits on using the game are described on the NEXO economy page. If you research the teaching of clinical reasoning, the page for researchers explains how to get in touch. Professionals who write or review cases find information under curation and under creators, and institutions can learn about the proposal on the partnerships page.

Frequently asked questions

What is sepsis according to Sepsis-3?

Life-threatening organ dysfunction caused by a dysregulated host response to infection, identified by an increase of 2 points or more on the SOFA (Singer et al., 2016).

Can I use qSOFA to screen for sepsis?

Not as a single tool. The 2021 guideline recommends against this use, compared with SIRS, NEWS or MEWS (Evans et al., 2021).

How soon should the antimicrobial be given?

With possible shock or high probability of sepsis, immediately, ideally within one hour of recognition. With possible sepsis without shock, after rapid assessment, within three hours if the suspicion persists (Evans et al., 2021).

Should I collect blood cultures before the antimicrobial?

Yes, if this does not substantially delay the start of the antimicrobial, which the guideline defines as less than 45 minutes (Evans et al., 2021).

What volume does the guideline suggest?

At least 30 mL/kg of intravenous crystalloid in the first three hours for sepsis-induced hypoperfusion or septic shock, as prescribed (Evans et al., 2021).

Final checklist

• I asked about an infectious focus even with a vague complaint.
• I asked whoever accompanies the patient whether the mental state had changed.
• I measured respiratory rate, capillary refill and blood glucose.
• I used a sensitive tool, and not qSOFA alone.
• I raised the priority and notified the medical team immediately.
• I recorded the time of recognition.
• I collected lactate and cultures without delaying the antimicrobial.
• I administered the prescribed antimicrobial as soon as possible and noted the time.
• I reassessed breathing and perfusion during the volume infusion.

Want to practice reasoning with progressive clues? Play the case of the day.

References

1. De Silva M, Chadwick W, Naidoo N. Screening tools for sepsis identification in paramedicine and other emergency contexts: a rapid systematic review. Scand J Trauma Resusc Emerg Med. 2023. PMID 37946312.
2. Durr D, Niemi T, Despraz J, et al. National Early Warning Score (NEWS) Outperforms Quick Sepsis-Related Organ Failure (qSOFA) Score for Early Detection of Sepsis in the Emergency Department. Antibiotics (Basel). 2022. PMID 36358173.
3. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021. PMID 34599691.
4. Filbin MR, Thorsen JE, Lynch J, et al. Challenges and Opportunities for Emergency Department Sepsis Screening at Triage. Sci Rep. 2018. PMID 30038408.
5. Hernández G, Castro R, Bakker J. Capillary refill time: the missing link between macrocirculation and microcirculation in septic shock? J Thorac Dis. 2020. PMID 32274184.
6. Holland M, Kellett J. The United Kingdom's National Early Warning Score: should everyone use it? A narrative review. Intern Emerg Med. 2023. PMID 36602553.
7. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016. PMID 26903335.
8. Seymour CW, Gesten F, Prescott HC, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med. 2017. PMID 28528569.
9. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016. PMID 26903338.
10. Tusgul S, Carron PN, Yersin B, et al. Low sensitivity of qSOFA, SIRS criteria and sepsis definition to identify infected patients at risk of complication in the prehospital setting and at the emergency department triage. Scand J Trauma Resusc Emerg Med. 2017. PMID 29100549.
11. Wang C, Xu R, Zeng Y, et al. A comparison of qSOFA, SIRS and NEWS in predicting the accuracy of mortality in patients with suspected sepsis: A meta-analysis. PLoS One. 2022. PMID 35427367.