Sepsis Six: Early Recognition and Safe Escalation for Student Nurses

Sepsis is one of those words that immediately changes the atmosphere on a ward. It is dangerous, can progress quickly and needs urgent assessment, but recognising possible sepsis does not mean automatically giving every patient the same treatment.

The Sepsis Six is a practical framework that helps healthcare teams remember six important actions. These actions are considered alongside an ABCDE assessment, clinical judgement, NEWS2, investigation results and local policy.

Think of it as:

“Recognise the risk. Escalate urgently. Start the right actions.”

What Is Sepsis?

Sepsis is life-threatening organ dysfunction caused by the body’s dysregulated response to infection.

In plain English, the body’s response to an infection begins damaging its own tissues and organs. It is more than simply having a severe infection.

Without prompt recognition and treatment, sepsis can progress to septic shock, multiple-organ failure and death.

What Is the Sepsis Six?

The UK Sepsis Trust developed the Sepsis Six as a set of six actions that can support the early management of sepsis:

1. Give oxygen if required
2. Take blood cultures and other blood tests
3. Give intravenous antibiotics when indicated
4. Give intravenous fluids when indicated
5. Measure lactate
6. Monitor urine output

You may hear these described as actions to complete within one hour. That remains an important goal for people at high risk, but current practice is more individualised than simply starting the whole bundle whenever infection is suspected.

Under current NICE guidance for adults in acute hospital settings, the urgency of assessment and treatment depends on the person’s risk of severe illness or death. This is judged using their history, examination, National Early Warning Score 2 (NEWS2), response to treatment and the overall clinical picture.

1. Give Oxygen: If Required

Sepsis can impair circulation and reduce oxygen delivery to tissues. However, oxygen is a medicine and should not be given automatically when a patient’s oxygen saturation is already within their target range.

For most acutely unwell adults requiring oxygen, the usual target saturation is 94–98%. A target of 88–92% is commonly used for people at risk of hypercapnic respiratory failure, unless an individual target has been prescribed.

The aim is adequate oxygenation, not the highest possible oxygen saturation.

Student nurse focus

Check the oxygen saturation, confirm the prescribed target range and escalate any new oxygen requirement. Follow local policy and work under appropriate supervision when preparing or adjusting oxygen therapy.

2. Take Blood Cultures and Blood Tests

Blood cultures may help identify the organism responsible for an infection and overview later antimicrobial treatment.

They should ideally be collected before antibiotics, but only when doing so will not cause a clinically significant delay. Depending on the situation, the team may also request a full blood count, urea and electrolytes, C-reactive protein, liver function tests, clotting, glucose, lactate and samples from the suspected source of infection.

Use the correct aseptic technique and document the time and collection site accurately. Contaminated cultures can create confusion and lead to unnecessary treatment.

3. Give Intravenous Antibiotics: When Indicated

Antibiotics are extremely time-sensitive for patients at high risk of severe illness or death from sepsis.

For adults assessed as high risk, NICE recommends broad-spectrum intravenous antibiotics within one hour. Local antimicrobial guidance should be followed so that treatment covers the likely infection while considering allergies, previous results and antimicrobial resistance.

For patients at moderate risk, the pathway allows time for urgent senior clinical review and further assessment. If infection remains the likely cause, antibiotics should generally be given within three hours of the first NEWS2 assessment in the emergency department or ward.

This distinction matters. Antibiotics must not be delayed in someone who is seriously unwell, but they should not be given indiscriminately to every person with a possible infection.

Student nurse focus

You will not prescribe antibiotics, but you can check whether they have been prescribed, confirm allergies, prepare equipment within your competence and escalate immediately if a time-critical dose has not been administered.

4. Give Intravenous Fluids: When Indicated

Sepsis may cause vasodilation, capillary leakage and reduced circulating volume. This can lower blood pressure and impair organ perfusion.

Intravenous crystalloid fluid may be prescribed when there are signs of hypoperfusion or increased clinical risk. Current NICE guidance uses cautious 250 mL boluses, followed by reassessment, rather than assuming that every patient needs a large volume immediately.

The response should be assessed using the whole clinical picture, including blood pressure, heart rate, capillary refill, mental state, urine output, lactate and signs of fluid overload.

Extra caution may be required for people with heart failure, kidney impairment or other conditions that increase the risk of fluid overload.

Student nurse focus

Observe the prescribed fluid closely, document timings and report breathlessness, falling oxygen saturation, crackles, swelling or other signs that the patient may not be tolerating it.

5. Measure Lactate

Lactate can help identify impaired perfusion and increased illness severity, but it is not a direct “sepsis test” and does not only rise because tissues lack oxygen.

A raised lactate may occur for several reasons, including circulatory compromise, increased metabolic demand, liver dysfunction, seizures and some medicines. It must therefore be interpreted alongside the patient’s observations, examination and clinical history.

A lactate above 2 mmol/L increases concern in suspected sepsis and may affect the person’s risk assessment and treatment pathway. A normal lactate does not completely exclude sepsis.

Trends matter too. A lactate that remains elevated or continues rising despite treatment requires urgent reassessment.

6. Monitor Urine Output

The kidneys are sensitive to reduced circulating volume and impaired perfusion, so falling urine output can be an early sign of organ dysfunction.

Urine output may be monitored through fluid-balance documentation or, when clinically indicated, a urinary catheter. Catheterisation is not automatically required for every patient with suspected sepsis.

An output below approximately 0.5 mL/kg/hour is concerning, particularly when it persists or is accompanied by other signs of deterioration.

Or, in Bleepbook language:

No wee, or much less than expected, is a reason to pay attention and escalate.

Recognising Sepsis Early

Sepsis does not have one single appearance. A patient may have a fever, but they may also be cold or have a normal temperature.

Warning signs can include:

• new confusion or altered consciousness
• a rising respiratory rate
• a new oxygen requirement
• tachycardia
• hypotension
• reduced urine output
• mottled, ashen or cyanosed skin
• a non-blanching rash
• rapid deterioration or failure to improve

For adults in acute hospital settings, a NEWS2 score of 7 or more suggests high risk, while a score of 5 or 6 suggests moderate risk. However, NEWS2 does not diagnose sepsis and must not replace clinical judgement.

A patient’s risk may be higher than the number suggests, particularly if they are deteriorating, appear mottled or ashen, have cyanosis or develop a non-blanching rash.

SBAR Escalation Example

Situation

“I’m concerned that this patient may have sepsis and is deteriorating.”

Background

“They are being treated for a suspected chest infection and have become more unwell during the last hour.”

Assessment

“Their NEWS2 is 7. Their blood pressure has fallen, their respiratory rate is rising, their lactate is 3.8 mmol/L and their urine output has reduced.”

Recommendation

“Please review them urgently. I think they need immediate assessment using the sepsis pathway.”

Do not wait until you have every result before escalating a clearly deteriorating patient.

The Student Nurse’s Role

You may not diagnose sepsis or prescribe treatment, but you can still make an enormous difference.

You can recognise deterioration, repeat observations, calculate and report NEWS2, communicate concerns clearly, prepare equipment, assist with investigations and treatment within your competence, monitor the response and document timings accurately.

If something feels wrong, say so. Use objective findings, explain what has changed and escalate through the appropriate clinical team.

Bleepbook Memory Line

“Oxygen if needed. Cultures. Antibiotics. Fluids if needed. Lactate. Urine.”

The Sepsis Six helps you remember the actions, but the real skill is recognising deterioration, assessing risk and escalating without delay.

Important Practice Note

This article focuses mainly on adults aged 16 and over in acute hospital settings. Separate NICE guidance and assessment pathways apply to children, pregnancy and the postnatal period.

Sepsis pathways, antimicrobial policies and escalation processes can also differ between UK nations and individual organisations. Always follow your local NHS board or employer policy and work within your level of competence.

References

National Institute for Health and Care Excellence (2025). Suspected sepsis in people aged 16 or over: recognition, assessment and early management (NG253). Available at: NICE NG253

National Institute for Health and Care Excellence (2025). Suspected sepsis: managing and evaluating risk in all settings. Available at: NICE sepsis visual summary

Resuscitation Council UK. The ABCDE Approach. Available at: Resuscitation Council UK

UK Sepsis Trust (2024). Sepsis Manual, 7th edition. Available at: UK Sepsis Trust Sepsis Manual

UK Sepsis Trust. Healthcare Professionals: The Sepsis Six. Available at: UK Sepsis Trust