One Hour Sepsis Bundle

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Sepsis is now the # 1 killer of hospitalized patients in America. Worldwide it is the # 1 cause of pediatric deaths, especially in developing countries. Strategies to reduce mortality have been successful in decreasing mortality and the Surviving Sepsis Campaign has been at the forefront of the war against sepsis. In 2018 the Surviving Sepsis Campaign changed the goal time frame for initiating interventions from 3/6 hours to 1 hour. In this module we will discuss the new bundle and strategies to reduce treatment time and ensure standardization. 

Introduction

It is nothing new to healthcare workers that sepsis is a big deal and often at the top of the provider's differential diagnosis when patients begin to decompensate, and the cause is not yet clear.  

The incidence of sepsis from 1979 – 2000 increased by 8.7%, from 82.7 to 240.4 per 100,000 patients (1). The incidence of sepsis is rising as a result of the aging population, progressive increase in antibiotic resistance, reliance on implanted devices, organ transplantation, and an increasing prevalence of patients with long-term immunosuppressive diseases who are at risk for severe infection and sepsis (1). 

To understand the importance of the sepsis bundle, you must understand why there is an emphasis on treating sepsis as a medical emergency, similar to a STEMI or a CVA. 

Sepsis is a life-threatening syndrome consisting of numerous signs, symptoms, hemodynamic, and laboratory findings, caused by an exaggerated and dysfunctional immune response to severe infection that leads to organ dysfunction (2). Septic shock is a more severe subset of sepsis that commonly presents with circulatory and/or metabolic dysfunction. Septic shock carries a 30-40% mortality risk (2). 

Diagnostic Approach to Sepsis 

Early phases of sepsis can be subtle even in the carefully monitored patient, but if the subtle signs are missed, and the clinical signs of septic shock become glaringly apparent, you and your clinical team have already acted much too late.  

Below is a table depicting the most common hemodynamic changes seen in sepsis (1).  

Defining Sepsis 

The updated guidelines on sepsis use the Sequential (Sepsis Related) Organ Failure Assessment Score (SOFA) to define sepsis. The SOFA score assesses the degree of organ dysfunction across numerous domains.  

A score of 2+ reflects an overall mortality of about 10% in the setting of suspected infection (1). The laboratory data included in the SOFA score focuses on coagulopathy, hepatic dysfunction, and/or renal dysfunction (1). Other laboratory data (such as WBC) can aid in the diagnosis of infection but are not used to define sepsis or septic shock. 

A bedside tool called qSOFA (Quick SOFA) was developed to quickly identify adult patients with suspected infection who are likely to have poor outcomes (1). 

 The presence of any 2 of the following is equal to a positive qSOFA:  

1. Respiratory rate >/= 22/min 
2. Glasgow Coma Score <15  
3. SBP </= 100 mmHg (1) 

***The qSOFA is best used to identify early organ dysfunction in adults on general medical/surgical floors, whereas the SOFA score is used more in the critical care setting (1). 

The qSOFA tool can be used to quickly screen and identify patients who are at risk for deterioration. It is being used both on admission and as ongoing tool to track changes in patient condition. 

The chart below illustrates common laboratory findings seen in sepsis (1). 

A Word on Septic Shock 

Septic shock occurs in up to 15% of patients with sepsis (1). The management of the patient in septic shock hinges on prompt recognition of the patients deteriorating condition and expeditious administration of antibiotic therapy coupled with infectious source control. Simultaneously, the failing organ systems must be supported through measures such as, fluid resuscitation, vasopressors, blood transfusions, respiratory support, and inotropic agents. You can find more details regarding the initial management of sepsis in the Surviving Sepsis Campaign guidelines. 

Septic Shock is defined as hypotension requiring intravenous vasopressors to maintain a MAP ≥65mmHg and serum lactate of >2mmol/L (1). 

Early Septic Shock 

• Hemodynamics à High Cardiac Output (CO) and Low Systemic Vascular Resistance (SVR)  
• Extreme vasodilation leading to an increase in cardiac output. This is the body's attempt to preserve peripheral vascular perfusion.  

Late Septic Shock 

• As shock progresses, myocardial performance diminishes and circulating blood volume is continually lost to the interstitial space, leading to a profound hypotensive state.  
• Sepsis-induced myocardial dysfunction may ensure. This results in a potentially reversible heart failure state due to myocardial depression.

What Is a "Bundle" and Why Are They Used? 

The Surviving Sepsis Campaign developed the internationally endorsed "sepsis bundle" separately from their guidelines as a way to guide sepsis quality improvement (3).  

The bundles consist of various components of sepsis care: 

• fluid resuscitation;
  
• timely and appropriate antibiotic administration;
  
• blood cultures;
• the use of serum lactate levels (4).
  

The one hour sepsis bundle elements were designed in such a way to be updated as new evidence emerged (3). In response to the most recent guidelines published in 2016, there has been a revised "hour-1 bundle" as opposed to the previous 3 hour and 6-hour bundles (3) (5). 

Evidence has shown an association between compliance with bundles and improved survival in patients with sepsis and septic shock. In a multi-center, retrospective, observational study of adult patients with a hospital discharge diagnosis of severe sepsis or septic shock, overall mortality was lower in those who received bundle-adherent care (17.9%) when compared to those who did not (20.4%) (4). Interestingly, when the patients in the study were divided into subgroups by the suspected source of infection, there was only a statistically significant mortality benefit to one hour sepsis bundle-adherent care in patients diagnosed with pneumonia (4). 

One Hour Sepsis Bundle Components and Strategies to Expedite Care 

The most critical change in the Surviving Sepsis Campaign bundles is that the previous 3-hour and 6-hour bundles are now combined into a single "hour-1 bundle" with the intention of beginning resuscitation and management immediately upon presentation (3) (5).

While more than one hour may be needed for patient resuscitation to be completed, the initiation should begin immediately upon suspicion that the patient may be presenting with sepsis. 

Measure lactate level.

Serum lactate level serves as a surrogate for direct tissue perfusion measurement (3). In the absence of oxygen - anaerobic metabolism ensues, and lactate levels rise. It often represents the degree of tissue hypoxia present, and increased levels are associated with worse outcomes. If the initial lactate is >2mmol/L, it should be re-measured within 2-4 hours and used to guide resuscitation with the goal of achieving a lactic acid <2mmol/L (3). 

Hospitals should have a threshold of ≥2mmol/L for a critical lactic acid value, which will prompt any abnormal value to be communicated to the provider. Consider having non-nursing personnel collect the lactate level so that the nursing staff is free to focus on other tasks. The re-collection of lactates >2 can be automated by many electronic order entry systems and will help reduce fallouts due to re-collection. Point of care lactate is now readily available which can be valuable. 

All critical lactate values should be communicated to both the nurse and the provider. Traditionally this has been done by a call to the nurse, who then notifies the provider. We suggest that the lab calls both the provider and the nurse directly to reduce the potential for error. 

Obtain blood cultures prior to antibiotics.

Blood cultures can become sterile within minutes of the first dose of an appropriate antibiotic (3). By obtaining cultures before administering antibiotics, there is a better opportunity to identify pathogens and therefore improve patient outcomes. Appropriate cultures include at least two sets of both aerobic and anaerobic cultures from two separate venipuncture sites. However, administration of antibiotic therapy should not be delayed past 1 hour in an effort to obtain cultures (3). 

Administration of broad-spectrum antibiotics.

Empiric broad-spectrum antibiotic therapy with one or more intravenous antimicrobials to cover all likely pathogens should be started immediately (3). Once a pathogen is identified, and sensitivities are established, the empiric antibiotics should be narrowed or discontinued if the patient is found not to have an active infection (3). 

Since time is of the essence when treating a patient presenting with sepsis, the empiric antibiotics should be kept in the on-unit medication storage for ease of access. Nurses should have immediate access to these medications. 

All orders for one hour sepsis antibiotics should be ordered as STAT (for the first dose). The providers should be trained to enter antibiotics orders directly after examining patients, if possible. Delays in ordering obviously lead to a delay in medication delivery. The goal should be to have a culture that recognizes and treats sepsis as a medical emergency, just as a code stroke or myocardial infarction. 

Administer IV Fluid.

Early effective fluid resuscitation is critical for the stabilization of sepsis-induced tissue hypoperfusion and septic shock (3). Initial fluid resuscitation should begin immediately upon recognizing that a patient is presenting with sepsis and/or hypotension and elevated lactate (3). Fluid resuscitation should be completed within 3 hours of recognition. Current guidelines recommend that intravenous fluid resuscitation consists of 30 mL/kg bodyweight of crystalloid fluid (3). 

Providers should communicate the need for intravenous fluids verbally to the nursing staff and place orders into the order entry system directly after examining patients. The patient should have 2-3 large-bore IVs placed to facilitate the administration of IV fluids and IV antibiotics without sacrificing the timing of one or the other. Oftentimes, placing a central line takes anywhere from 15-30 minutes and will delay overall patient care during the first minutes. If additional venous access is needed, it is advisable to wait until the patient is stabilized so long as adequate, reliable IV access is obtained. 

Apply vasopressors.

A critical part of sepsis resuscitation is restoring perfusion to the vital organs. If a patient's blood pressure does not return to normal after the initial fluid resuscitation, then vasopressors should be initiated to maintain a mean arterial pressure (MAP) of >/= 65 mmHg (3). If a patient has profound hypotension and the decision is made by the medical team to initiate vasopressor therapy, there is no need to wait to initiate until central access is obtained (3). Vasopressors can be infused through a large-bore peripheral IV safely for a short amount of time (3). 

Within the ER and ICUs, there should be easy access to vasopressors, specifically norepinephrine, vasopressin, and epinephrine, in the event that a patient needs a vasopressor started. Additionally, institutions should have standing protocols for nurses to initiate a vasopressor if a patient is consistently hypotensive despite adequate fluid resuscitation. This will save vital time by allowing the nurse to use their clinical judgment and restore vital organ perfusion quickly and efficiently while awaiting provider guidance. 

Code Sepsis 

Despite one hour sepsis bundle care and the diligent work of healthcare providers and beside nurses alike, many hospitals have identified an opportunity to save lives and reduce suffering through early sepsis detection, compliance with current standards of care, and determining the appropriate level of care. 

The Emergency Department Code Sepsis Project focuses on timely implementation of the SSC care bundle to reduce mortality and costs and to ensure appropriate level of care placement. By activating a 'code sepsis,' it allows not only doctors and nurses to be aware of the urgency at hand but also pharmacists, respiratory therapists, lab technicians, nursing support staff, and unit secretaries. 

In some facilities, a 'code sepsis' is worked into the rapid response team's framework. For example, if a nurse screens a patient for SIRS criteria and the patient meets the criteria, a page can be sent out from the patient's current floor. This will mobilize the appropriate resources to facilitate swift and effective resuscitation. 

The multidisciplinary nature of the code sepsis project creates a strong sense of teamwork centered around applying best evidence-based practice, mobilizing resources, avoiding procedure variability, and improving patient care and safety (6). 

Hospitals that are struggling to meet sepsis measures should consider the addition of a "code sepsis" or "sepsis response team". 

Each organization should strive for a culture that treats sepsis with the same urgency as any other medical emergency. Much of the delay in treatment with sepsis is due to a lack of standardized processes. Hospitals should work to develop sepsis protocols and sepsis response teams, in addition to the one hour sepsis adoption, to increase compliance with bundles and decrease mortality.

Conclusion 

With sepsis being the number one killer of hospitalized patients in America and the number 1 cause of pediatric deaths, especially in developing countries, knowledge of the entire healthcare team, with an emphasis on nurses is imperative to decrease this statistic and provide expedited care to our patients to save lives. As a nurse, having the knowledge to recognize early symptoms of sepsis, one hour sepsis strategies, and the ability to act accordingly to prevent the progression, it will allow you increase care and improve patient morbidity and mortality.  

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