| Category |
High risk criteria |
Moderate to high risk criteria |
Low risk criteria |
| History |
Objective evidence of new altered mental state. |
History from patient, friend or relative of new onset of altered behaviour or mental state. History of acute deterioration of functional ability. Impaired immune system (illness or drugs, including oral steroids). Trauma, surgery or invasive procedures in the last six weeks. |
Normal behaviour. |
| Respiratory |
Raised respiratory rate: 25 breaths per minute or more. New need for oxygen (40% FiO2 or more) to maintain saturation of more than 92% (or more than 88% in known chronic obstructive pulmonary disease). |
Raised respiratory rate: 21-24 breaths per minute. |
No high risk or moderate to high risk criteria met. |
| Blood pressure |
Systolic blood pressure: 90 mmHg or less, or systolic blood pressure more than 40 mmHg below normal. |
Systolic blood pressure: 91-100 mmHg. |
No high risk or moderate to high risk criteria met. |
| Circulation and hydration |
Raised heart rate: more than 130 beats per minute. Not passed urine in the previous 18 hours. For catheterised patients, passed less than 0.5 ml/kg of urine per hour. |
Raised heart rate: 91-130 beats per minute (for pregnant women, 100-130 beats per minute) or new onset arrhythmia. Not passed urine in the past 12-18 hours For catheterised patients, passed 0.5-1ml/kg of urine per hour. |
No high risk or moderate to high risk criteria met. |
| Temperature |
|
Tympanic temperature less than 36ºC |
|
| Skin |
Mottled or ashen appearance. Cyanosis of skin, lips or tongue. Non-blanching rash of skin. |
Signs of potential infection, including redness, swelling or discharge at surgical site or breakdown of wound. |
No non-blanching rash. |