St Emlyn’s Lesson Plans

Assessing suspected sepsis

Recognise concerning infection-related deterioration without relying on fever, then use current risk-based management and repeated review.

Medical Students · 45-minute session

For learners

Before: Allow about 12 minutes in total.

When we meet: We will assess a deteriorating patient, use NEWS2 with the clinical findings and review the response to antibiotics and a fluid bolus.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: NEWS2 chart, staged observation sheet and blank fluid-response record.

Run: 45-minute session plan · 30-minute option

Before the session

If you are attending this session, complete the core preparation below before you come. Allow about 12 minutes in total.

Core preparation

NICE NG253 managing suspected sepsis · About 10 minutes

Read “People at high risk of severe illness or death from sepsis” (1.8.1–1.8.9). Focus on the antibiotic time anchor, the initial fluid bolus and reassessment after each bolus. Leave the moderate- and low-risk sections for further reading.

https://www.nice.org.uk/guidance/ng253/chapter/Managing-suspected-sepsis

Think about (allow 2 minutes): Which findings would concern you in an afebrile patient with suspected infection?

Picture the scene

A 78-year-old treated for a chest infection is now confused, breathless and requiring oxygen. They have no fever. The nurse asks whether they need resus.

By the end of the session

Recognise possible infection with organ dysfunction despite absent fever.
Use NEWS2 with clinical judgement to communicate urgency.
Explain why antibiotics, fluids and escalation must be matched to risk and reassessed.

After the session

On the next patient with suspected infection, compare the trend in oxygen need and consciousness with the NEWS2 number during supervised review.

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 12 minutes in total.

Before learners arrive

Print the current NEWS2 and NG253-aligned local pathway; remove superseded NG51 handouts.
Identify local antibiotic guidance, allergy checks, critical-care escalation and review ownership.

Equipment: NEWS2 chart, staged observation sheet and blank fluid-response record.

Setup: Pairs deliver a short concern statement before calculating the score; this prevents the arithmetic becoming the whole lesson.

If the preparation has not been completed

Replace “Establish the essentials” with five minutes using the NEWS2 chart, the high-risk NICE recommendations and case 1’s observations. Spend two minutes completing the score together, two identifying the clinical concerns and urgent actions, and one stating what must be reassessed after a fluid bolus. Continue the fluid-response discussion within the case.

Suggested session plan

0–5 min — Explore. Ask why this afebrile patient is worrying.
5–10 min — Establish the essentials. Calculate the score with the official chart and mark clinical concerns alongside it.
10–32 min — Discuss & Apply. Use 14 minutes for recognition/timing and 8 for fluid reassessment.
32–40 min — Consolidate. Ask each pair to give an escalation statement and specify what they will reassess after the fluid bolus.
40–45 min — Reflect & Transfer. Ask learners to compare oxygen requirement and consciousness with the NEWS2 trend during their next supervised infection assessment.

Start the discussion

Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.

Cases and discussion

Use these cases, or invite an anonymised case from the group that addresses the same questions.

Afebrile but deteriorating

A 78-year-old has cough, increasing confusion and lethargy after 3 days of oral antibiotics. RR 32, BP 110/60, pulse 95, temperature 37.4°C; saturation 96% requires high-concentration oxygen. Chest findings suggest a lower respiratory infection.

Add this information as the discussion develops:

Venous lactate is 3.2 mmol/L, urine output has fallen and the patient is more drowsy.
After initial treatment, the respiratory rate and oxygen requirement worsen despite a less alarming blood pressure.

Ask the group:

Which abnormalities need action despite no fever or marked tachycardia?
What are you trying to establish about infection and other diagnoses?
What would you tell the senior clinician now?

Discussion notes

Points to draw out:

Use NEWS2 and the whole presentation, including new oxygen need, mental-state change and perfusion, to identify risk and seek immediate senior review.
Investigate likely source and alternative causes while treating danger. Cultures and lactate are useful but should not create avoidable treatment delay.
For people at high risk with suspected or confirmed infection, give IV antibiotics within 1 hour of the first NEWS2 score on initial ED assessment, or on ward deterioration. Obtain senior review immediately; this limit is not permission to delay treatment in a deteriorating patient. Choice follows suspected source, allergies and local guidance.
Reassess observations, consciousness, oxygen need, perfusion and response; a changing trajectory may need critical-care escalation.

Common misconceptions:

Using absence of fever to dismiss sepsis.
Treating a fall in NEWS2 or lactate as the only marker of success.
Thinking a fixed ‘Sepsis Six’ list replaces clinical review.

For a more experienced group: Ask how treatment ceilings and patient preferences should be established without delaying appropriate urgent care.

The fluid question

The patient has signs of hypoperfusion but also known heart failure. The team is considering a fluid bolus.

Add this information as the discussion develops:

After one carefully supervised bolus, perfusion has not clearly improved and breathing is worse.
Contrast with a stable person with suspected infection and no evidence of hypoperfusion.

Ask the group:

What is the indication for fluid, and how will benefit or harm be assessed?
What does the current adult guideline recommend as the initial bolus?
Why might two people with suspected infection need different antibiotics or fluid plans?

Discussion notes

Points to draw out:

NICE NG253 uses an initial 250 mL isotonic crystalloid bolus, ideally over 10–15 minutes, with reassessment; further boluses depend on need and response.
Clinical deterioration or concern about overload requires prompt senior reassessment rather than an automatic repeated volume.
Antibiotic timing and fluid decisions vary by risk and diagnosis; the high-risk pathway must not be indiscriminately imposed on every fever.

Common misconceptions:

Confusing a maximum review time with permission to wait in a deteriorating patient.
Administering repeated fluid without documenting its effect.

For a more experienced group: Discuss source control and alternative diagnoses such as cardiogenic pulmonary oedema.

Important clinical points

New oxygen requirement and altered mental state matter even when saturation or temperature looks normal.
Use separate guidance for pregnancy/recent pregnancy and people under 16.
Do not allow score calculation, cultures or a rigid bundle to delay senior care of a deteriorating patient.

Closing the session

Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.

Give the one-sentence escalation statement for case 1.
What will you measure after a fluid bolus?
Why is a diagnosis label insufficient without a reassessment plan?

Key teaching points:

Absence of fever does not exclude serious infection-related deterioration.
Use NEWS2 alongside clinical assessment and the patient’s trajectory.
Match treatment to risk, investigate the source and reassess the response.

Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.

Adapting the discussion

Uncertainty and local practice

Infection may coexist with another cause of deterioration. Lactate is neither specific for sepsis nor required to justify escalation.

If the discussion drifts

What has changed, what are we treating, and what would make us escalate?

For a more experienced group

Compare high-risk management with a lower-risk presentation under the current pathway; clarify who can authorise diagnostic observation.

A 30-minute version

30 minutes: opening 3, pathway 5, main case 14, consolidation 5, reflection 3. Integrate fluid discussion into the main case.

Evidence and guidance

NICE NG253 — Adult risk-based sepsis management, 2025, including antibiotic timing, fluids and reassessment.https://www.nice.org.uk/guidance/ng253/chapter/Managing-suspected-sepsis