Interactive Pilot — 2026

Sepsis Tele-Triage

Master recognition, screening, and the golden hour bundle

This isn't a lecture — it's hands-on clinical reasoning. You'll score patients, manage the SEP-1 bundle, make real decisions, and get instant feedback.

⏱ ~35 minutes · 4 modules · Earn XP as you go

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Module 1

Sepsis fundamentals

📊

Module 2

Sepsis-3 & screening

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Module 3

Hour-1 bundle & care

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Module 4

Live case scenarios

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Module 1

What Is Sepsis?

📊 The Numbers

1.7 million cases/year in the US. 270,000 deaths annually (CDC, 2024).

Every hour of delayed antibiotics increases mortality by 7.6%.

CDC, 2024 · Surviving Sepsis Campaign 2021

💡 Think of it this way

Friendly fire. Your immune system doesn't just fight the infection — it turns on your own organs. Sepsis isn't the infection. It's your body's dysregulated response to it.

A severe infection can be manageable. But sepsis? That's when your immune system becomes the enemy.

⚠️ The Progression

Infection → Sepsis (suspected infection + SOFA ≥2) → Severe Sepsis (sepsis-induced organ dysfunction) → Septic Shock (persistent hypotension requiring vasopressors despite fluid resuscitation)

🚨 Critical

Sepsis kills fast. The first hour is called the "golden hour" for a reason. Early recognition and the SEP-1 bundle are the difference between survival and death.

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Module 1

Screening Tools Timeline

Tap each tool to learn more ↓

1

SIRS Criteria

1992 — Original Screening

≥2 of: Temp >38°C or <36°C, HR >90, RR >20, WBC >12k or <4k

Problem: Too sensitive, not specific. Catches sepsis but also burns, surgery, trauma. Used to rule IN sepsis, but too many false positives.

2

qSOFA

2016 — Bedside Screening

≥2 of: RR ≥22, altered mentation, SBP ≤100 mmHg

Better specificity than SIRS. Predicts mortality in non-ICU patients. Fast to assess at the bedside.

3

NEWS2

2019 — Early Warning

12-point scoring system: HR, RR, Temp, SBP, O2 sat, ACVPU. Score ≥5 = sepsis risk.

Used in many EHRs. Automated. Flags risk but requires provider interpretation.

4

Sepsis-3 (SOFA)

2016 — Gold Standard

Suspected infection + SOFA ≥2 (or change of ≥2 from baseline). Organ-centric.

Most specific for mortality. Requires lab work. Used to confirm sepsis and measure severity.

Match each tool to its best use:

SIRS

qSOFA

Sepsis-3

NEWS2

Rule IN infection (but not sepsis specifically)

Bedside assessment for sepsis risk in non-ICU

Diagnose and grade sepsis severity (organ dysfunction)

Automated EHR alert for early warning

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Module 2

Sepsis-3 Definition

🏥 The Official Definition (2016)

Sepsis = Suspected infection + SOFA ≥2 (or change of ≥2 from baseline)

SOFA measures organ dysfunction across 6 systems. Any 2+ organs showing dysfunction = sepsis.

SOFA Score Components

System	Measure	Threshold (Score ≥1)
🫁 Respiration	PaO2/FiO2 ratio	<400
🩸 Coagulation	Platelets	<150k
🧡 Liver	Bilirubin	>1.2 mg/dL
❤️ Cardiovascular	MAP or vasopressor need	MAP <70 OR dopamine/norepi needed
🧠 Neurological	Glasgow Coma Scale	<15
🚽 Renal	Creatinine or urine output	>1.2 mg/dL OR <440 mL/24h

🔍 Key Insight: qSOFA at the Bedside

qSOFA is your screening tool at the bed (3 items, takes 30 seconds). If qSOFA ≥2 + suspected infection, get SOFA labs to confirm sepsis.

qSOFA ≥2 says "This patient is at risk." SOFA ≥2 says "This patient IS septic."

Seymour et al. (2016) JAMA — qSOFA predicts mortality better than SIRS in non-ICU sepsis patients

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Module 2

Screening Simulator

👤 Patient Presentation

72-year-old woman, admitted with UTI 36 hours ago. Now acutely confused. Nursing notes: fever, increased work of breathing, looks "septic."

HR 104

RR 24

Temp 39.1°C

SBP 98 mmHg

O2 sat 94% on RA

WBC 18.2k

Lactate 3.2 mmol/L

Assess qSOFA and key SOFA parameters. Adjust sliders to match her presentation:

RR ≥22 (qSOFA respiratory)

She has RR 24. This is abnormal. Score: 1–2

0

Altered mentation (qSOFA neurological)

She is acutely confused. Score: 1–2

0

SBP ≤100 (qSOFA cardiovascular)

She has SBP 98. This is borderline hypotension. Score: 1–2

0

PaO2/FiO2 (SOFA respiratory)

O2 sat 94% on RA suggests mild hypoxemia. Score: 0–1

0

Platelets (SOFA coagulation)

WBC is elevated but we need plate count. Assume normal for now. Score: 0

0

Creatinine/UO (SOFA renal)

UTI with no acute kidney injury mentioned. Assume baseline. Score: 0

0

—

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Module 3

The SEP-1 Hour-1 Bundle

🚨 THE GOLDEN HOUR

Antibiotics within 1 hour. Not 2. Not 3. ONE. Every 15-minute delay increases mortality risk.

1

Measure lactate

Minute 0

Assess tissue perfusion. Normal <2 mmol/L. Lactate ≥4 triggers aggressive resuscitation.

2

Blood cultures BEFORE antibiotics

Minute 0

Draw 2 sets from different sites. Cultures guide de-escalation later. Don't wait for results to start antibiotics.

3

Broad-spectrum antibiotics

Minute 0–60

Start empiric (usually piperacillin-tazobactam, meropenem, or cefepime + vancomycin). Narrow based on cultures later.

4

Rapid fluid resuscitation

Minute 0–60

30 mL/kg crystalloid if hypotensive OR lactate ≥4. (For a 70 kg patient: 2.1 L over the first hour.)

5

Vasopressors if needed

Minute 30–60

If hypotensive during or after fluids, start norepinephrine (first-line). Goal MAP ≥65.

💊 Nursing Actions During Hour 1

✓ Establish 2 large-bore IVs (18g or larger)
✓ Continuous cardiac monitoring + vitals q15min
✓ Strict I&O tracking — document every fluid push
✓ Reassess BP/perfusion after each 500 mL bolus
✓ Prepare for central line placement (for vasopressor administration)
✓ Alert provider immediately if no improvement after first liter fluids
✓ Blood cultures, lactate, CBC, CMP, coagulation studies, urinalysis, imaging per suspected source

Surviving Sepsis Campaign 2021 · Rhodes et al., Crit Care Med 2021

✓

Module 3

Knowledge Check: Bundle & Care

A 58-year-old man is admitted with community-acquired pneumonia. He has a qSOFA of 2 (RR 24, SBP 92) and lactate 2.8. His SOFA score is 2 (borderline).

What should you do right now?

A

Monitor closely for 4 hours before starting antibiotics. See if he improves on his own.

B

Start broad-spectrum antibiotics NOW. Draw blood cultures first, then give antibiotics within 60 minutes. Establish 2 IVs and start fluid bolus (500 mL over 10 min, reassess).

C

Give antibiotics, but start fluids slowly (125 mL/hr) to avoid overload. He's only borderline septic.

After 30 minutes of fluid resuscitation (1 L given), the patient's BP is still 92/54. Lactate is unchanged at 2.8. You're about to place a central line.

What is your next move?

A

Continue more fluids (another 1.5 L). Vasopressors are a last resort — you must maximize fluids first.

B

Notify provider now. Once the central line is placed, start norepinephrine (titrate to MAP ≥65). His hypotension despite initial fluids suggests septic shock.

C

Add pressors to peripheral line temporarily. Don't wait for a central line — this is taking too long.

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Module 4

Live Case: Patient A

👤 72-year-old woman

Admitted 36h ago with UTI, now acutely confused, fever, tachycardia, tachypnea, hypotensive.

HR 104

RR 24

Temp 39.1°C

SBP 98/62

O2 sat 94%

WBC 18.2k

Lactate 3.2

qSOFA is 3/3. You suspect urosepsis. Lactate is 3.2 (mildly elevated).

How should you respond?

A

Lactate of 3.2 is not high enough to warrant aggressive resuscitation. Observe first.

B

Sepsis-3 + qSOFA 3/3 = confirmed sepsis. Activate SEP-1: blood cultures, broad-spectrum antibiotics, IV fluids 30 mL/kg, prepare for central line. Notify provider NOW.

C

Start fluids but delay antibiotics until cultures come back — you don't want resistance.

It's been 50 minutes since sepsis recognition. Lactate is rechecked: 2.8 (improving). BP is now 104/68 after 2 L fluids. She's more alert. She received piperacillin-tazobactam 4.5g IV at minute 15.

What's your next assessment action?

A

She's improved enough. Stop fluids and monitor. The antibiotics are working.

B

Good progress. Continue careful reassessment q1-2h. Re-check lactate in 2-4 hours. Trending is what matters. Watch for worsening; if lactate rises or BP drops again, escalate.

C

She needs a central line now that she's stable to measure central venous pressure.

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Module 4

Live Case: Patient B

👤 45-year-old man

CRITICAL: FOUND UNRESPONSIVE IN ROOM. History of pneumonia. Now unresponsive, gasping, extremely pale.

HR 128

RR 28

Temp 35.8°C

SBP 76/40

O2 sat 88% on RA

WBC 22.1k

Lactate 6.8

MAP 52 mmHg

🚨 SEPTIC SHOCK

Sepsis + hypotension requiring vasopressors to maintain MAP ≥65. This is a code. Act NOW.

This patient is in septic shock. Lactate 6.8 is severe. MAP 52.

What is your IMMEDIATE action?

A

Call a STAT rapid response / code. Get him to ICU now.

B

✓ STAT rapid response. Establish 2 large-bore IVs. 500 mL fluid bolus wide open now. Measure lactate (done: 6.8). Blood cultures. Broad-spectrum antibiotics IV NOW (don't wait). Prepare for intubation (RR 28, unresponsive = airway at risk). Central line placement. Prepare for norepinephrine. Notify ICU / anesthesia / infectious disease. DO NOT DELAY.

C

Get him on oxygen, start fluids slowly, wait for provider evaluation before antibiotics.

After rapid intubation and 2 L fluids over 20 min, his SBP is 78/44. MAP is still 55. He needs vasopressors now.

As the bedside nurse, what is your role?

A

Wait for a pharmacy consult on which vasopressor to give.

B

Central line placed. Ensure blood cultures drawn. Provider ordered norepinephrine 5 mcg/min, titrate by 2.5 mcg q5min to target MAP ≥65. Continuous monitoring, strict I&O, re-assess lactate in 2-4h. Prepare for ongoing fluid boluses as needed. Prepare for vasopressor escalation if no response.

C

Vasopressors are too aggressive. Continue fluids and observe.

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Assessment

Final Knowledge Check

8 questions. You'll earn 15 XP per correct answer. Target: ≥75% to demonstrate competency.

What defines sepsis according to Sepsis-3?

A

Any infection with fever

B

Suspected infection + SOFA ≥2 (or change of ≥2 from baseline)

C

SIRS criteria ≥2 + positive blood culture

What is the primary benefit of qSOFA as a screening tool?

A

It requires lab results and is specific for diagnosis

B

Quick bedside assessment (3 items) that identifies patients at high risk of sepsis mortality, especially in non-ICU settings

C

It replaces SOFA scoring and is used to confirm sepsis diagnosis

Which of the following is NOT part of the SEP-1 Hour-1 bundle?

A

Measure lactate and obtain blood cultures before antibiotics

B

Start broad-spectrum antibiotics within 60 minutes

C

Administer maintenance fluids (125 mL/hr) and wait 24 hours before vasopressors

A patient has qSOFA ≥2 with suspected infection and lactate of 4.1. What fluid dose should you give?

A

500 mL total over 24 hours

B

30 mL/kg crystalloid (for 70 kg patient: 2.1 L) over the first hour, reassess after each 500 mL bolus

C

1 L then slow down; lactate of 4.1 is not high enough for aggressive fluids

When should you start vasopressors in a septic patient?

A

Immediately at the first sign of hypotension, before fluids

B

If hypotensive during or AFTER fluid resuscitation and MAP <65 despite fluids

C

Never; antibiotics alone are sufficient

What is the relationship between lactate and sepsis severity?

A

Lactate >2 always indicates sepsis

B

Lactate is not relevant to sepsis management

C

Elevated lactate indicates tissue hypoperfusion; lactate ≥4 triggers aggressive resuscitation. Trending lactate down (improving) is a sign of response to treatment

What is the target MAP for a septic patient receiving vasopressors?

A

MAP ≥100 to maximize perfusion

B

MAP ≥65 mmHg (adequate organ perfusion without excessive vasopressor load)

C

MAP 50–60 to avoid fluid overload

As a tele-triage nurse, how would you respond to a patient with qSOFA ≥2, suspected pneumonia, and lactate of 3.5 who is on a general med-surg floor?

A

Observe for 24 hours; most patients improve spontaneously

B

Activate SEP-1 protocol: notify provider STAT, draw cultures, start broad-spectrum antibiotics within 60 min, establish 2 IVs, initiate fluid boluses, prepare for transfer to ICU if not responding. Every minute counts.

C

Wait for ICU bed availability before starting interventions

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Course Complete!

You earned 0 XP.

🚀 You're Ready

Sepsis recognition is now second nature. You understand qSOFA screening, SOFA organ scoring, and the SEP-1 bundle timeline.

Remember: Early recognition + rapid action = lives saved. Every hour counts. You've got this.

📋 Next Steps

1. Share your final assessment score with your unit educator

2. Practice scoring real patients on your unit with a preceptor

3. Apply the SEP-1 bundle at the bedside — your vigilance saves lives

4. Re-take this module quarterly to keep your skills sharp

📚 Key References

Rhodes et al. (2021). "Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock." Crit Care Med, 49(11), e1063–e1143.

Seymour et al. (2016). "Assessment of the Safety, Feasibility, and Cost of Automated Notification and Improved Sepsis Care with a Sepsis Alert System." JAMA, 315(19), 2083–2094.

Singer et al. (2016). "The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)." JAMA, 315(8), 801–810.

CDC (2024). "Sepsis in the United States — Data & Surveillance." Retrieved from cdc.gov/sepsis

Olek Health Nursing Education · Sepsis Tele-Triage Module 2026