Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.3
At a glance
- Screen every suspected infection with the sepsis screen.
- If the screen is positive, start the sepsis pathway at once.
- Give antibiotics within the time set in this procedure.
- Record the recognition time and the antibiotic time.
- Stop and get help straight away if: a patient has a positive sepsis screen and no antibiotic has been given or ordered.
1. Purpose
To recognise sepsis early and give antibiotics in time, using current international guidance (S1.3).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Sepsis screen | The named screening tool used for suspected infection |
| Antibiotic time | The time the first dose is given |
4. Background
Sepsis is time critical. Each hour of delay to antibiotics adds risk, so the time from recognition to treatment must be measured.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Registered nurse | Screens; starts the pathway; records times | Trained in the screen |
| Prescriber | Orders the antibiotic within the set time | Doctor with prescribing rights |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Sepsis screen tool | Current, on the chart | Checked each year |
| Local antibiotic guideline | Current | Reviewed each year |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Screen.
- Screen every patient with suspected infection on arrival and at each change of condition.
Key point: Screen early, not after the diagnosis.
Step 2. Start the pathway when positive.
- Tell the prescriber at once.
- Get blood cultures before the antibiotic if this does not delay it.
Key point: The antibiotic is the priority.
Step 3. Give the antibiotic.
- Give the first dose within the time set in this procedure.
- Record the time given.
Key point: The time is what the surveyor checks.
Step 4. Monitor and review.
- Review the patient at the time set for the pathway.
- Escalate if the score worsens.
Key point: Review at the set time.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Positive screens with antibiotic within the set time | At least 70% | Monthly | Sepsis lead | Escalate to clinical director |
| Positive screens with recognition time recorded | 100% | Monthly | Sepsis lead | Escalate to clinical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HOS-FRM-003 | Sepsis care record | Records the times |
| HOS-SOP-002 | Vital signs and deterioration response | Deterioration and sepsis |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Time limit set by the ASF Expert Committee against the Surviving Sepsis Campaign 2021 guidance (sccm.org). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
No e-learning course is linked to this document yet.
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)