The sepsis bundle is designed to take a complex process and
select elements of care that, when implemented as a group,
have an effect on outcomes beyond the individual elements
alone. Over the years, sepsis bundle utilization, as part of
a formal hospital performance improvement program, was
welcomed by many, modified by some, and resisted by others.
Yet we find ourselves in a position where all U.S. hospitals are
being held to a similar standard by the Centers for Medicare
and Medicaid Services (CMS) by way of the Severe Sepsis/
Septic Shock Management Bundles (SEP-1).1
we need to align our thoughts and actions to strive for early
identification and increase sepsis bundle compliance as a means
to improve patient outcomes.
Echoes of the Past Leading Up to Current Practice
In 2010, the Surviving Sepsis Campaign (SSC) Phase
III results showed that sepsis bundle compliance was
associated with improved outcomes.2
Despite low bundle
compliance in this study, collaborative efforts continued
lengthening to a 7.5-year period in 218 community,
academic and tertiary-care hospitals. Over that period,
volunteer sites entered sepsis bundle indicator data into the
SSC database for 29,470 severe sepsis patients.3
data were published showing that hospitals with higher (6
hour) resuscitation bundle compliance (> 15%) had lower
mortality when compared to lower-compliance hospitals
(29.0% vs. 38.6%).3
Additionally, for every 10% increase in
compliance, ICU and hospital lengths of stay were reduced
These results pose several questions: Did improved
compliance with the bundles directly lead to improvement
in survival or do guideline-compliant hospitals reflect better
care in general or was there a yet unidentified component
present that improved outcomes?
Similar to the International SSC Phase III program,
small and large groups independently collaborated to
improve sepsis care. The Michigan Health and Hospital
Association Keystone Sepsis Collaborative found that
hospitals with high bundle adherence and collaborative
participation had significantly lower in-hospital mortality
and decreased lengths of stay.4
Results from a multisite,
single-health system showed that increased compliance with
a three-hour sepsis bundle was associated with improved
survival and cost savings.5
Advantages of participating
in a system, state, regional, or national collaborative
improvement model include peer-to-peer learning; sharing
data, tools and protocols; and striving as a noncompeting
member of a group to overcome barriers through lessons
learned. Like Michigan, other states developed sepsis
collaborative programs. New Jersey hospitals aligned to
tackle sepsis mortality, reducing the rate by 11% in one
Sepsis Indicators, Challenges and Results
In the 2012 Surviving Sepsis Campaign Guidelines, the
sepsis bundles were reduced from 6- and 24-hour to 3- and
The total number of indicators decreased
from 10 to seven. However, time to complete several
indicators (initial lactate and fluid resuscitation) was moved
from 6 to 3 hours. In order to achieve goals in such a short
time window, hospitals integrated tools and technology to
increase efficiency and effectiveness.
The individual sepsis indicators have anticipated barriers
and associated potential solutions. Some solutions are more
complex than others. A primary focus in all programs is
early identification, giving the clinician the best opportunity
to initiate treatment when it will most make a difference.
Common barriers to sepsis bundle achievement and
potential solutions are provided in Table 1. With any
performance improvement activity, executive leadership
and staff engagement are essential, as are project leaders,
including physician and nurse champions.
Advancing Toward Best Outcomes
Achieving 100% compliance with sepsis bundle
indicators in patients with severe sepsis is unlikely due to a
combination of patient pathophysiology not amendable to
intervention, the large number of health care providers that
must be trained, and surges in patient volume. However,
improvement is possible and starts with the power of
one—you. One committed individual with an optimistic
mindset can inspire a team to success. Although the hope
is to engage everyone in this improvement effort, some will
be resistant to change. In order to engage these individuals,
data, data and more data will help combat the negativity.
Knowing when to pass the baton or a piece of the baton to
a new optimistic leader brings fresh ideas to the team.
Success occurs behind the scenes in preparation of
protocols, order sets, screening tools, best practice alerts and
educational rollout planning. Important in this process is
engaging the end user in all steps of the build and accepting
and modifying based on feedback. Adequate preparation
will result in ease of execution. A process to evaluate
effectiveness and use of the tools developed is essential.
The tools only work when used. If met with resistance,
one-on-one instruction can be useful. Feedback close to the
occurrence of “misses” increases effectiveness.
High compliance with sepsis bundles need to be linked
to early identification and facilitated by sepsis screening
education and tools. Empowering nursing staff to actively
screen and identify sepsis can lead to early treatment and
prevention of devastating sequelae. The primary value
of sepsis screening is early identification leading to early
Second, ongoing screening (once per shift)
can identify organ dysfunction and potentially prevent
progressing or worsening organ failure.
The addition of a sepsis nurse coordinator can bring
expertise to the multidisciplinary team to bridge gaps
among clinicians, patients and family members.9
responsibilities may include programs to develop and
monitor adherence to protocols and treatments. The
coordinator also recognizes staff and patient learning needs
with corresponding educational plans. Recall that increased sepsis bundle compliance is associated with decreased
mortality, hospital length of stay and cost. The value of the
coordinator will likely exceed the cost that he/she brings to
Annual education, ideally in September during
International Sepsis Awareness Week, can serve to energize
the hospital’s sepsis program. Daily huddles may include
feedback on sepsis bundle success or failures within the past
24 hours. It is important to highlight accomplishments to
maintain staff engagement. Negative feedback, although
important, may be deflating if not balanced with positive
Early activities of the international SSC sepsis performance
program spawned both regional and national hospital
collaboratives as well as individual hospital efforts associated
with improved sepsis outcomes. Barriers to sepsis bundle
achievement include factors associated with process, people,
communication and documentation. Solutions to overcome
these challenges consist of standardization of processes for
continuous screening surveillance, implementation of order
sets and protocols and documentation.
2. Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med. 2010 Feb;36(2):222-231.
3. Levy MM, Rhodes A, Phillips GS, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study. Intensive Care Med. 2014 Nov;40(11):1623-1633.
4. Thompson MP, Reeves MJ, Bogan BL, DiGiovine B, Posa PJ, Watson SR. Protocol-based resuscitation bundle to improve outcomes in septic shock patients: evaluation of the Michigan Health and Hospital Association Keystone Sepsis Collaborative. Crit Care Med. 2016 Dec;44(12):2123-2130.
5. Leisman D, Bianculli A, Doerfler ME, et al. Survival benefit and cost savings from emergency department compliance with a basic 3-hour sepsis bundle in a multisite, prospective, observational study. Acad Emerg Med. 2016;23:S18.
7. Dellinger RP, Levy MM, Rhodes A, et al; Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013 Feb;41(2):580-637.
8. Schorr C, Odden A, Evans L, et al. Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards. J Hosp Med. 2016 Nov;11 Suppl 1:S32-S39.
9. Schorr C. Nurses can help improve outcomes in severe sepsis. Am Nurse Today. 2016;11(3):20-25.
10. Dellinger RP, Schorr CA, Levy MM. A users’ guide to the 2016 Surviving Sepsis Guidelines. Intensive Care Med. 2017 Mar;43(3):299-303.