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 info@survivingsepsis.org. Permissions from your institution may be required.  Permissions 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/telemetry wards, or in the ICU.  

Community Resources


Pediatric Treat Before Transfer Sepsis Screening Tool - Wesley Children's Hospital
Adult Treat Before Transfer Sepsis Screening Tool - Wesley Children's Hospital
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
Adult Sepsis Management Pathway - St. Helens and Knowsley Hospitals
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


​​​