Protocols and Checklists

Colleagues share the tools they have developed in their own institutions as they implement the Surviving Sepsis Campaign. Here you’ll find locally created protocols, checklists, policies, and similar documents so you don’t have to start from scratch.​ If you have items to share based on the 2016 guidelines and guidelines and bundles, please email PDFs to Permission from your institution may be required.

Campaign Screening Tool Sample
The Surviving Sepsis Campaign provides a paper screening tool to assist when evaluating patients in the hospital emergency department; medical, surgical, or telemetry wards; or ICU.

Community Resources
The resources contained within this section of the SSC website have been provided by independent developers as samples of their own institutional processes and practices. The inclusion of these resources on the SSC website does not imply endorsement by SCCM, ESICM, or the SSC leadership. SCCM, ESICM, and SCC do not make any warranties about the completeness, reliability, and accuracy of the information. Therefore any action taken regarding application of these resources should be vetted locally and approved internally through your hospital's processes. If you have any questions, please contact the developers directly.

Sepsis CALF Sheet - University of Pittsburgh Medical Center
Pediatric Treat Before Transfer Sepsis Screening Tool - Wesley Children's Hospital
Adult Treat Before Transfer Sepsis Screening Tool - Wesley Healthcare
Outlying Physician Communication - Wesley Children's Hospital
Sepsis Screening Tool Scoring Criteria - Wesley Children's Hospital
Severe Sepsis/Septic Shock Progress Note - Cookeville Regional Medical Center
Severe Sepsis/Septic Shock Clinical Pathway - Cookeville Regional Medical Center
Pediatric Sepsis Alert Checklist - Wesley Healthcare
ICU Severe Sepsis Screening Tool - Saint Joseph Mercy Health System
Patient Units Severe Sepsis Screening Tool - Saint Joseph Mercy Health System
Sepsis Pocket Card - Saint Joseph Mercy Health System
Sepsis Recognition and Treatment Protocols - Stony Brook
Sepsis Pediatric Order Set - Stony Brook
Pediatric ICU Screening Tool - Stony Brook
Perinatal Screening Tool​ - Dignity Health​​​​​​