One Hour Sepsis Bundle

About

➀ Read and Learn

The following course content

Sepsis is now the number one killer of hospitalized clients in the U.S. Worldwide it is the number one cause of pediatric deaths. 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 one hour. Intended for nurses at all levels, this course will discuss the sepsis bundle, 2021 sepsis guidelines, and strategies to reduce treatment time and ensure standardization.

Introduction 

Sepsis is a significant problem today, so much so that the government released a 2023 report on the dire state of sepsis in the United States. Congress directed the Agency for Healthcare Research and Quality (AHRQ – the lead Federal agency charged with improving the safety and quality of healthcare for all Americans) to conduct research to help identify sepsis’ burden on the U.S. healthcare system related to morbidity, hospital readmission rates, and mortality. Congress stressed special focus on pediatrics, maternal care, nursing homes, rehabilitation, and pandemic-related changes. [1]. 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 clients 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 clients [10]. The incidence of sepsis is rising as a result of the aging population, progressive increase in antimicrobial resistance, reliance on implanted devices, organ transplantation, and an increasing prevalence of clients with long-term immunosuppressive diseases who are at risk for severe infection and sepsis [10]. 

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 heart attack or stroke. 

Sepsis is a “syndrome characterized by life-threatening organ dysfunction caused by a dysregulated host response to infection” [King, para 3]. Septic shock is sepsis with “persistent hypotension despite fluid resuscitation” characterized by a high immune and inflammatory responses that result in vascular dilation and poor perfusion of tissues [King]. 

Sepsis Statistical Evidence 

Sepsis affects over 49 million people worldwide. In the U.S., more than 1.7 million people are diagnosed with sepsis each year. While some recover, many do not; 350,000 adults die each year from the illness. In fact, sepsis is the number one cause of death in hospitals and delaying sepsis care significantly increases the risk of mortality – by 4 to 9% for every hour of treatment delay [16]. In 2021, 1 in 6 patients with sepsis died in the hospital and in cases involving septic shock, 1 in 3 hospital stays resulted in patient death [2]. 

Individuals aged 65 and over are especially at risk of dying from sepsis. In 2021, sepsis-related deaths among adults aged 65 and older was nearly 331 deaths per 100,000 people and death rates increased with age, most occurring among those age 85 and older [3]. Sepsis also causes many deaths in other age groups, particularly children. Sepsis is the largest killer of children worldwide (3.4 million each year) [16]. In the U.S., however, 6,800 children die from sepsis each year [17].  

Sepsis is the number one cost of hospitalization in the U.S, costing the hospital system more than $53 billion each year [16]. Not only is sepsis associated with increased inpattient, outpattient, and readmission costs, it leads to long-term health outcomes (like cognitive and physical impairments) that can lead to loss of employment and increased caregiving needs, adding to its economic burden [2]. Additionally in 2021, about one-third of sepsis-related hospital stays ended with a transfer to a post-acute care health facility which is also costly [2]. 

While sepsis has a high mortality rate in hospitals, it originates in the community – hence, why most sepsis diagnoses occur in the emergency room [2][16]. In recent years, sepsis has been complicated by the COVID-19 pandemic. COVID-19 has changed the epidemiology of sepsis by increasing the risk of developing sepsis in the first place and by increasing the incidence of viral sepsis, which leads to complex diagnosis and treatment [2]. 

While these numbers are bleak, sepsis death rates in the U.S. have decreased from over 35% in the early 2000s to 15–20% recently [9]. 

Diagnostic Approach to Sepsis 

Early phases of sepsis can be subtle even in the carefully monitored client, 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 [10]. 

Defining Sepsis 

The updated guidelines on sepsis use the Sequential (Sepsis Related) Organ Failure Assessment Score (SOFA) to define sepsis [19]. The SOFA score assesses the degree of organ dysfunction across numerous domains.  

The score is based on the information obtained in each domain. The higher the score, the higher the mortality risk [19].A score of 2+ reflects an overall mortality of about 10% in the setting of suspected infection [7][10]. Organ systems include neurologic, blood, liver, kidney, and blood pressure/hemodynamics. The laboratory data included in the SOFA score focuses on coagulopathy, hepatic dysfunction, and/or renal dysfunction [10][19]. Other laboratory data (such as WBC) can aid in the diagnosis of infection but are not used to define sepsis or septic shock. 

*MAP= diastolic BP + 1/3 (systolic BP – diastolic BP) 

**Adrenergic agents administered for at least 1 hour (doses given are in mcg/kg/min) 

Table 1. Sequential Organ Failure Assessment (SOFA) Score Criteria [7][19] 

A bedside tool called qSOFA (Quick SOFA) was developed to quickly identify adult clients with suspected infection who are likely to have poor outcomes [7][10][18]. 

 The presence of any 2 of the following is equal to a positive qSOFA [7][18]:  

1. Respiratory rate = 22 breaths per minute or more 
2. Altered mental state (Glasgow Coma Score <15)  
3. Systolic BP = 100 mmHg or below 

***The qSOFA is best used to identify early organ dysfunction in adults in nonhospital, emergency, or general hospital conditions, whereas the SOFA score is used more in the critical care setting [7][10][19]. 

The qSOFA tool can be used to quickly screen and identify clients who are at risk for deterioration. It is being used both on admission and as ongoing tool to track changes in client condition. Most recent sepsis guidelines recommend against using qSOFA alone for sepsis and septic shock screening as opposed to other tools like Systemic Inflammatory Response Syndrome (SIRS), National Early Warning Score (NEWS), or Modified Early Warning Score (MEWs) [4]. 

The chart below illustrates common laboratory findings seen in sepsis [10]. 

A Word on Septic Shock 

Septic shock occurs in up to 15% of clients with sepsis [10]. The management of the client in septic shock hinges on prompt recognition of the client’s 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 [10]. 

Early Septic Shock: 

• Hemodynamics: 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 Sepsis Bundle and Why Are They Used? 

The Sepsis Bundle or ‘Severe Sepsis and Septic Shock Management Bundle’ (SEP-1 Measure) is a set of priorities and interventions for hospitals to assist in identifying sepsis early, initiating treatment right away, and preventing septic shock and death [14][15]. The sepsis bundle is different from Sepsis Guidelines. The guidelines offer general recommendations/suggestions regarding sepsis screening and education, initial resuscitation, ICU admission, ventilation, and more [4]. The bundle, however, is a concise version of the clinical recommendations of the guidelines with focus on what to do once sepsis is suspected from obtaining specific labs to administering certain medications [King][14]. 

The sepsis bundles consist of various components of sepsis care [4][King][11]: 

• Early identification 

• Fluid resuscitation 

• Timely and appropriate antibiotic administration  

• Blood cultures 

• Serum lactate levels 

The sepsis bundle elements were designed in such a way to be updated as new evidence emerged [15].  

Evidence has shown an association between compliance with bundles and improved survival in clients with sepsis and septic shock. In a multi-center, retrospective, observational study of adult clients 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%) [11]. Interestingly, when the clients in the study were divided into subgroups by the suspected source of infection, there was only a statistically significant mortality benefit to bundle-adherent sepsis care in clients diagnosed with pneumonia [11]. 

While some feel that the bundle is a helpful guide, there are some critics. The bundle’s main elements are early recognition and immediate administration of broad-spectrum antimicrobials. However, some feel that this contributes to antimicrobial resistance as there’s no time permitted for determining microbial sensitivity which ideally would guide clinicians in administering the most effective antimicrobial [15]. Experts are attempting to find ways to treat sepsis early while also preventing antimicrobial resistance. For example, encouraging clinicians to continue reevaluating the client, searching for alternative diagnoses, and discontinuing broad-spectrum antimicrobials once another diagnosis is strongly suspected or confirmed [4]. Other critics of the bundle feel that the push to perform interventions within a specific timeframe “promotes harmful diagnostic tests and treatments” [14]. The bundle, however, has been proven effective in lowering mortality in hospitalized clients. 

Sepsis Guidelines Updates 

In the last section, we discussed the difference between Sepsis Guidelines and the Sepsis Bundle. The following are most recent Sepsis Guideline updates made in 2021. Some recommendations are new and others are changed from the 2016 version [4]. 

Table 2. Current 2021 Updates/Changes to the 2016 Sepsis Guidelines [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 sepsis bundles are now combined into a single "hour-1 bundle" with the intention of beginning resuscitation and management immediately upon presentation [4]. While more than one hour may be needed for client resuscitation to be completed, the initiation should begin immediately upon suspicion that the client may be presenting with sepsis. 

Measure Lactate Level 

Serum lactate level (or lactic acid level) determines the degree of tissue perfusion in the body [5]. 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 [5]. Lactate levels alone are not enough to finalize a diagnosis of sepsis but a high lactate level significantly increases the likelihood [4]. Lactate levels from 2 to 4 mmol/L are mild, and levels above 4 are severe and indicate sepsis-induced hypoperfusion with a high mortality rate [5]. If the initial lactate is >2mmol/L but <4, it should be re-measured in 3 hours and used to guide resuscitation with the goal of achieving a lactic acid <2mmol/L [King]. 

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 the lab through a call to the nurse who then notifies the provider. Depending on your facility’s protocol, the lab may call both the provider and the nurse directly to reduce the potential for error.  

Obtain Blood Cultures Prior to Antimicrobial Therapy 

Blood cultures should be obtained prior to beginning antimicrobial therapy. Drawing cultures after the first antimicrobial dose has already been started can lead to lower detection of pathogens in the blood by up to 50% [13]. By obtaining cultures before administering antimicrobials, there is a better opportunity to identify pathogens and therefore improve client outcomes. Appropriate cultures include at least two sets of both aerobic and anaerobic cultures from two separate venipuncture sites. If the client has a central venous catheter, a culture should be drawn from each lumen of the catheter as well as a peripheral site [King]. Administration of antibiotic therapy should not be delayed past 1 hour in an effort to obtain cultures, particularly for clients who are hemodynamically unstable/critically ill [4][King] . 

Administration of Empiric Antimicrobial Therapy 

Empiric broad-spectrum antibiotic therapy with one or more IV antimicrobials to cover all likely pathogens should be started immediately [4]. Once a pathogen is identified, and sensitivities are established, the empiric antimicrobials should be narrowed or discontinued if the client is found not to have an active infection [4]. 

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

All orders for sepsis antimicrobials should be ordered as STAT (for the first dose). The providers should be trained to enter antimicrobials orders directly after examining clients, 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 cardiac arrest, heart attack, or stroke. 

Administer IV Fluids 

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 client is presenting with sepsis and/or hypotension and elevated lactate [4][King]. Fluid resuscitation should be completed within 3 hours of recognition [4]. Current guidelines recommend that intravenous fluid resuscitation consists of 30 mL/kg bodyweight of crystalloid fluids (lactated ringers) [4][King]. A relative contraindication to lactated ringers is profound hyperkalemia. Fluids should be administered even in clients at a high risk for fluid overload (like those with heart or kidney failure) but the client should be monitored more frequently in this case [King]. 

Providers should communicate the need for IV fluids verbally to the nursing staff and place orders into the order entry system directly after examining clients. Rather than waiting for central line placement, the client should have a peripheral IV placed [4]. It would be beneficial to place 2-3 large-bore IVs to facilitate the administration of IV fluids and IV antimicrobials without sacrificing the timing of one or the other. Oftentimes, placing a central line takes anywhere from 15-30 minutes and will delay overall client care during the first minutes. If additional venous access is needed, it is advisable to wait until the client is stabilized so long as adequate, reliable IV access is obtained. 

Start Vasopressors 

A critical part of sepsis resuscitation is restoring perfusion to the vital organs. If a client's blood pressure does not return to normal after the initial fluid resuscitation, then vasopressors should be initiated to maintain a MAP of at least 65 mmHg [King]. If a client 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. Vasopressors can be infused through a large-bore peripheral IV (must be in or proximal to the antecubital fossa), safely for less than 24 hours [King][12]. 

Within the ER and ICU, there should be easy access to vasopressors, specifically norepinephrine, vasopressin, and epinephrine, in the event that a client needs a vasopressor started. Additionally, institutions may have standing protocols for nurses to initiate a vasopressor if a client 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 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 sepsis 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 client for SIRS criteria and the client meets the criteria, a page can be sent out from the client'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 client 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 to increase compliance with bundles and decrease mortality. 

​Conclusion 

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

➁ Complete Survey

Give us your thoughts and feedback

➂ Click Complete

To receive your certificate