- Measure serum lactate;
- Obtain blood cultures prior to antibiotic administration;
- Administer broad-spectrum antibiotics within three hours from time of presentation for ED admissions and one hour for non-ED ICU admissions;
- In the event of hypotension and/or lactate >4 mmol/L (36 mg/dL):
- Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent); and
- Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) ≥65 mm Hg;
- In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L (36 mg/dL):
- Achieve central venous pressure (CVP) of ≥8-12 mm Hg; and
- Achieve central venous oxygen saturation (ScvO2) of Surviving Sepsis Campaign70%. (Achieving a mixed venous oxygen saturation (SvO2) of 65% is an acceptable alternative.)
Sepsis Management Bundle
The severe sepsis management bundle lists four management goals. Efforts to accomplish these tasks should also begin immediately, but these items may be completed within 24 hours of presentation for patients with severe sepsis or septic shock.
- Administer low-dose steroids for septic shock in accordance with a standardized ICU policy;
- Administer drotrecogin alfa (activated) in accordance with a standardized ICU policy;
- Maintain glucose control ≥ lower limit of normal, but <150 mg/dL (8.3 mmol/L); and
- Maintain inspiratory plateau pressures <30 cm H2O for mechanically ventilated patients.
To achieve the goal of reducing mortality by 25% by 2008, everyone involved with the care of severe sepsis patients must be included, work processes must be carefully scripted and standardized, and commitment to this effort must be elevated. This must be a team effort that crosses disciplines and departments; it requires leadership, support from the entire organization, and buy-in from all stakeholders involved with the care of these patients.
Three levels of participation exist in creating successful change:
1) Active working teams are responsible for daily planning, documentation, communication, education, monitoring, and evaluation of activities. The working team must have representation from all departments involved in the change processes ICU, ED, pulmonary department, pharmacy, etc. The team should also be multidisciplinary, comprising physicians, nurses, pharmacists, respiratory therapists, and other staff with roles in the specific change process, such as clerks and technicians. Team members should be knowledgeable about the specific aims, the current local work processes, the associated literature, and any environmental issues that will be affected by these changes.
2) A leadership group or person within the team helps remove barriers, provides resources, monitors global progress, and gives suggestions from an institutional perspective. The working team needs someone with authority in the organization to overcome barriers and to allocate the time and resources the team needs to achieve its aim. Leadership needs to understand how the proposed changes will affect various parts of the system and the more remote consequences such changes might trigger.
3) Providers and stakeholders must be kept informed. Procedures are needed to keep them informed, to receive their feedback, and to ensure them that their responses are respected. This gives stakeholders a sense of ownership and facilitates implementation of the new processes.
Teams should use the bundles to create customized protocols and pathways that will function well within their institutions. However, all of the elements in the bundles must be incorporated into the protocols. The protocols should mirror the bundles but allow flexibility to accommodate the specific needs of a local hospital. The severe sepsis bundles (and thereby the hospital’s protocol) form the basis for the measurements the team will conduct. If all of the elements of the bundles are not incorporated into your customized protocol, your performance on the measures will suffer.