IMPLEMENT THE MANAGEMENT BUNDLE - WITHIN FIRST 24 HOURS OF CARE
SEVERE SEPSIS BUNDLES
The changes called for on these pages mirror the individual elements of the Severe Sepsis Bundles. Taken together, we believe these changes will substantially reduce mortality due to severe sepsis. The Severe Sepsis Bundles are a distillation of the evidence-based recommendations found in the 2008 practice guidelines promulgated by the Surviving Sepsis Campaign.
Ranking the Evidence
Choosing therapies to treat patients with severe sepsis and septic shock requires an organized approach to evaluating the evidence. The Sepsis Resuscitation and Management Bundles were derived from the 2008 Surviving Sepsis Campaign Guidelines which incorporated the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system approach to evaluating the literature.
Understanding the Bundle Concept
A "bundle" is a group of therapies for a given disease that, when implemented together, may result in better outcomes than if implemented individually. In a bundle, the individual elements included are built around best evidence-based practices. The science supporting the individual treatment strategies in a bundle is sufficiently mature such that implementation of the approach should be considered either best practice or a reasonable and generally accepted practice.
The purpose of creating a bundle strategy is to clearly articulate a therapeutic framework that will function as a lever for change. We anticipate thatmaking the Severe Sepsis Bundles standard practice will eliminate the piecemeal or chaotically applied of standards for sepsis care that characterize many clinical environments today.
The Severe Sepsis Bundles have been designed with the hope to allow teams to follow the timing, sequence, and goals in the bundles, ito achieve a 25 percent reduction in mortality due to severe sepsis or septic shock.
We hope hospitals will use the bundles to create customized protocols and pathways that will function well within their institutions. However, we encourage that each of the elements in the bundles be incorporated in those protocols. Optimally, the protocols should closely mirror the bundles, but allow flexibility for logistical and other needs specific to -each hospital. The reason to include the therapies specified in the bundles in your protocol for care is that if you use our measurement strategies and database, you will be measured as compliant (or non-compliant) with those elements. Therefore, if not all of the elements of the bundles are incorporated into your customized protocol, your performance on the quality indicators we have designed will suffer. In addition, we believe the elements to be the best strategy to improve care.
There are two Severe Sepsis Bundles. Each bundle articulates objectives to be accomplished within specific timeframes. The bundles have been developed based upon the 2008 Surviving Sepsis Campaign Guidelines for the Management of Severe Sepsis and Septic Shock. The Guidelines incorporated an evidence based review of the literature and ranked the strength of each recommendation. In the following pages, the grading of the evidence supporting each element is noted and a separate page describes the evidence ranking process.
Sepsis Management Bundle
Evidence-based goals that must be completed within 24 hours for patients with severe sepsis, septic shock and/or lactate
>4 mmol/L (36 mg/dl).
For patients with severe sepsis, as many as four bundle elements must be accomplished within the first 24 hours of presentation. Some items may not be completed if the clinical conditions described in the bundle do not prevail, but clinicians must assess for them. The goal is to perform all indicated tasks 100 percent of the time within the first 24 hours from presentation. Please note that efforts to accomplish these goals should begin immediately, but may be completed within 24 hours to qualify in the database.
Changes for Improvement
Bundle Element 1
Administer low-dose steroids for septic shock in accordance with a standardized ICU policy. If not administered, document why the patient did not qualify for low-dose steroids based upon the standardized protocol.
Bundle Element 2
Administer recombinant human activated protein C (rhAPC) in accordance with a standardized ICU policy. If not administered, document why the patient did not qualify for rhAPC.
Bundle Element 3
Maintain adequate glycemic control.
Click here to see SSC Statement on Glucose Control in Severe Sepsis (2009)
Bundle Element 4
Prevent excessive inspiratory pleateau pressures on mechanically ventilated patients.