Surviving Sepsis Campaign hour-1 bundle - This 2018 update to the sepsis bundle focuses on beginning treatment immediately - American Nurse Today
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Surviving Sepsis
Campaign
hour-1 bundle
This 2018 update to the sepsis bundle focuses on
beginning treatment immediately.
By Christa Schorr, DNP, MSN, RN, NEA-BC, FCCM
Editor’s note: September is Sepsis the years, the bundles have been Rationale and supporting
Awareness Month. Learn more at revised to reflect the best available evidence
sepsis.org/sepsisawarenessmonth. evidence; the most recent revision The hour-1 bundle includes five key
was published in June 2018. (See elements. (See SSC hour-1 bundle.)
SEPSIS is recognized as a leading Follow the evidence.) 1. Measure lactate level (remeasure
cause of death around the world, This article will review the new if initially > 2 mmol/L).
with more than 1 million patients hour-1 sepsis bundle and outline Rationale: Although serum lac-
affected each year in the United the implications for nursing practice. tate isn’t a direct measure of tissue
States. In 2002, as part of interna- perfusion, it can serve as a surro-
tional efforts to improve care for The hour-1 bundle gate for worse outcomes. Lactate-
patients with sepsis, the Surviving The most recent SSC International guided resuscitation has been as-
Sepsis Campaign (SSC) was creat- Guidelines for Management of Sep- sociated with mortality reduction.
ed to spread sepsis awareness, im- sis and Septic Shock: 2016 were This is a weak recommendation
prove diagnosis and recognition, published in March 2017, with de- with low quality of evidence.
increase use of appropriate and tailed definitions of sepsis and
timely care, educate healthcare septic shock and associated inter- 2. Obtain blood cultures prior to
providers, develop guidelines, and ventions. Updated evidence led to administration of antibiotics, but
implement performance improve- revisions of the 3- and 6-hour bun- don’t delay appropriate antibiot-
ment programs. After publication dles, resulting in a single combined ic therapy if obtaining blood cul-
of the SSC Guideline for the Man- bundle. The June 2018 update is tures is difficult.
agement of Severe Sepsis and Sep- identified as the hour-1 bundle. Rationale: Blood cultures are im-
tic Shock in 2004, the first sepsis The objective of this bundle is to portant for pathogen identification.
bundles were presented. They were begin resuscitation and management Obtaining them before administering
created to bring key elements of immediately, even though some of antibiotics is listed as a best practice
the guidelines to bedside clinicians. the resuscitation measures may re- statement, which is an ungraded
(See Bundle development.) Over quire more than an hour to complete. strong recommendation used when
16 American Nurse Today Volume 13, Number 9 AmericanNurseToday.com
Bundle development
The original sepsis bundles were developed by the Surviving Sepsis Campaign (SSC) in collaboration with the Institute for
Healthcare Improvement. The goal was to make the International Guidelines for the Management of Severe Sepsis and Septic
Shock easier to execute at the bedside.
2004 2012 2014
The initial sepsis bundles incorporat- Evidence cited in the 2012 SSC guide- Revisions in 2014 were prompted by
ed a two-phased approach using the lines supported removal of the 24- results of three large randomized con-
6-hour resuscitation bundle and the hour bundle, which resulted in the trolled trials evaluating protocol-based
24-hour management bundle, meas- 3- and 6-hour bundles measuring sev- care in septic shock. Researchers con-
uring 11 quality indicators. en quality indicators. Both the original cluded that routine use of central
6- and 24-hour bundles and the re- venous catheters (CVC) and hemo-
vised 2012 sepsis bundles were wide- dynamic monitoring aren’t required to
ly adopted in hospitals around the achieve adequate initial resuscitation
world. of septic shock, resulting in a revision
to the 6-hour bundle. CVCs are no
longer required, but are one of many
options to guide initial resuscitation.
port the 30 mL/kg fluid dose, sever-
Follow the evidence al interventional and observational
Substantial international evidence has demonstrated that implementing the studies provide support. Evaluate
Surviving Sepsis Campaign (SSC) sepsis bundles is associated with improved and assess fluid responsiveness be-
outcomes. In a single-center U.S. study, investigators described a severe sepsis fore administering additional fluid
and septic shock mortality reduction to less than 10% with improved bundle beyond the 30 mL/kg dose.
compliance.
Similar results were observed in other countries, including Spain and the 5. Apply vasopressors if the patient is
United Kingdom. Results of the sepsis bundle implementation over 7.5 years hypotensive during or after fluid
found that participation in the quality improvement program was associated resuscitation to maintain mean ar-
with decreased mortality and reduced hospital costs. Hospitals with higher bun-
terial pressure (MAP) ≥ 65 mm Hg.
dle compliance showed reductions in intensive care unit and hospital length of
stay. Developing countries, including India, Brazil, and China, reported the same.
Rationale: Restoring perfusion
Evidence for the clinical benefit of the bundles increased public awareness pressure to vital organs is essential.
and raised national interest. The 3- and 6-hour bundles were adopted by the Vasopressor administration in a hy-
National Quality Forum in 2012 and the New York State Department of Health in potensive patient is graded as a
2014. In 2015, the Centers for Medicare & Medicaid Services mandated hospital strong recommendation with mod-
reporting of the early management of sepsis and septic shock (Core Measure erate-quality evidence.
SEP-1), which closely follows the 3- and 6-hour SSC bundles.
Nursing implications
Nurses are instrumental to improv-
the benefit or harm is certain but the quired; discontinue antimicrobials if ing outcomes for patients with sep-
evidence is difficult to summarize. no infection exists. sis or septic shock. They can pro-
vide early recognition of signs and
3. Administer broad-spectrum anti- 4. Begin rapid administration of 30 symptoms, implement treatment,
biotics. mL/kg crystalloid fluids for hy- help remove barriers to care, and
Rationale: Adherence to early an- potension or lactate ≥ 4 mmol/L. promote education.
tibiotics and antibiotic stewardship Rationale: Sepsis patients with
are important to provide high-quali- tissue hypoperfusion or septic Recognizing signs and
ty care. Administering broad-spec- shock require early fluid resuscita- symptoms
trum antibiotics with one or more tion. Administration of 30 mL/kg of As nurses interact with patients in a
I.V. antimicrobials is a strong rec- crystalloid for hypotension or lac- wide variety of settings—emergency
ommendation with moderate quali- tate ≥ 4 mmol/L is graded as a departments, intensive care units,
ty of evidence. Administer narrow- strong recommendation with low medical/surgical units, skilled nurs-
spectrum antimicrobial therapy after quality of evidence. Despite the ing facilities, the community, homes,
the pathogen and sensitivity are ac- lack of controlled studies to sup- and medical offices—they’re likely
AmericanNurseToday.com September 2018 American Nurse Today 17SSC hour-1 bundle The goal of the Surviving Sepsis Campaign (SSC) hour-1 bundle is to begin resuscitation and management immediately. Reproduced from survivingsepsis.org. Copyright ©2018 Society of Critical Care Medicine and the European Society of Intensive Care Medicine. 18 American Nurse Today Volume 13, Number 9 AmericanNurseToday.com
Educational resources Educational resources and tools are
Use these resources to promote education about the Surviving Sepsis Campaign available at survivingsepsis.org. (See
(SSC) hour-1 bundle. Educational resources.)
Intensive Care Medicine: The Surviving Sepsis Campaign Bundle:
2018 Update Quality, timely treatment
Sepsis bundles are designed for
This video provides an overview of the new hour-1 bundle.
youtube.com/watch?v=y8b20TMA-7Q
bedside application of key ele-
ments of the SSC guidelines and
SSC Hour-1 Bundle infographic promote the importance of appro-
Download this infographic to share with colleagues and your organization’s priate and timely treatment. The
leadership. 2018 hour-1 bundle update focus-
survivingsepsis.org/SiteCollectionDocuments/Surviving%20-Sepsis-Hour- es on five elements within a single
1-Bundle-Infograph.pdf sepsis bundle. Nurses are instru-
SSC hour-1 bundle pocket card mental in early sepsis identifica-
Download and print this pocket card to keep with you as a reminder of the five tion and patient management. Ad-
elements of the new hour-1 bundle. hering to their role in providing
survivingsepsis.org/SiteCollectionDocuments/Surviving-Sepsis-Campaign- quality timely treatment will result
Hour-1-Bundle-2018-Print-Card.pdf in better patient outcomes.
Visit americannursetoday.com/?p=50812 for a
complete list of selected references.
to encounter patients with signs and
symptoms of sepsis. Prompt recogni-
tion is an important step in sepsis
Nurses are Christa Schorr is an associate professor of medicine at
Cooper Medical School of Rowan University and a
management, and some organiza-
tions have shown that specialty
instrumental to clinical nurse scientist—critical care at Cooper Uni-
versity Hospital in Camden, New Jersey.
trained sepsis rapid response teams
lead to improved patient outcomes. improving outcomes Selected references
De Backer D, Dorman T. Surviving sepsis
Implementing treatment for patients with guidelines: A continuous move toward better
care of patients with sepsis. JAMA. 2017;
After confirming a sepsis diagnosis 317(8):807-8.
with the provider, the nurse should sepsis or Ju T, Al-Mashat M, Rivas L, Sarani B. Sepsis
collaborate with others to initiate rapid response teams. Crit Care Clin. 2018;
guideline-recommended treatment. septic shock. 34(2);253-8.
Sepsis bundle interventions are im- Kleinpell R. Promoting early identification of
plemented in the form of an order- Removing barriers sepsis in hospitalized patients with nurse-led
set, protocol, pathway, or care plan. In addition to delayed recognition of protocols. Crit Care. 2017;21(1):10.
Screening and monitoring patients sepsis, barriers to sepsis bundle im- Levy MM, Rhodes A, Phillips GS, et al. Sur-
with sepsis may differ from hospital plementation include lack of knowl- viving Sepsis Campaign: Association be-
tween performance metrics and outcomes in
to hospital and even from unit to edge, resources, staff, and informat-
a 7.5-year study. Intensive Care Med. 2014;
unit because of the nature of the ics support. The organizations most 40(11):1623-33.
patient population. Follow your or- successful at managing sepsis are
Levy MM, Evans LE, Rhodes A. The Surviv-
ganization’s protocol, and review those with senior leadership back- ing Sepsis Campaign bundle: 2018 update.
protocols and care plans to see if ing, physician and nursing staff en- Crit Care Med. 2018;46(6):997-1000.
updates based on the new hour-1 gagement, and informatics support. Mukherjee V, Evans L. Implementation of the
bundle are indicated. Surviving Sepsis Campaign guidelines. Curr
Several studies have demonstrat- Promoting education Opin Crit Care. 2017;23(5):412-6.
ed that nurse-driven protocols are A sepsis education program that in- Rhodes A, Evans LE, Alhazzani W, et al. Surviv-
effective in improving adherence cludes guidance for sepsis screening, ing Sepsis Campaign: International guidelines
to SSC guideline recommendations; a process to communicate findings, for management of sepsis and septic shock:
2016. Crit Care Med. 2017;45(3):486-552.
implement protocols that align with and knowledge of the hour-1 bundle
your state’s practice acts. Whether components will keep nurses up-to- Schorr C, Odden A, Evans L, et al. Imple-
mentation of a multicenter performance im-
you work in the acute or post-acute date. Staff should know what to do provement program for early detection and
care setting, it’s essential to be aware and why; understanding why pro- treatment of severe sepsis in general med-
of the hour-1 bundle elements and vides motivation for timely appropri- ical-surgical wards. J Hosp Med. 2016;11(sup-
to promote prompt implementation. ate treatment to patients with sepsis. pl 1):S32-9.
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