16 American Nurse Today Volume 13, Number 9 AmericanNurseToday.com

Editor’s note: September is SepsisAwareness Month. Learn more atsepsis.org/sepsisawarenessmonth.

SEPSIS is recognized as a leadingcause of death around the world,with more than 1 million patientsaffected each year in the UnitedStates. In 2002, as part of interna-tional efforts to improve care forpatients with sepsis, the SurvivingSepsis Campaign (SSC) was creat-ed to spread sepsis awareness, im-prove diagnosis and recognition,increase use of appropriate andtimely care, educate healthcareproviders, develop guidelines, andimplement performance improve-ment programs. After publicationof the SSC Guideline for the Man-agement of Severe Sepsis and Sep-tic Shock in 2004, the first sepsisbundles were presented. They werecreated to bring key elements ofthe guidelines to bedside clinicians.(See Bundle development.) Over

the years, the bundles have beenrevised to reflect the best availableevidence; the most recent revisionwas publish ed in June 2018. (SeeFollow the evidence.)

This article will review the newhour-1 sepsis bundle and outlinethe implications for nursing practice.

The hour-1 bundle The most recent SSC InternationalGuidelines for Management of Sep-sis and Septic Shock: 2016 werepublished in March 2017, with de-tailed definitions of sepsis andseptic shock and associated inter-ventions. Updated evidence led torevisions of the 3- and 6-hour bun-dles, resulting in a single combinedbundle. The June 2018 update isidentified as the hour-1 bundle.

The objective of this bundle is tobegin resuscitation and managementimmediately, even though some ofthe resuscitation measures may re-quire more than an hour to complete.

Rationale and supportingevidenceThe hour-1 bundle includes five keyelements. (See SSC hour-1 bundle.)1. Measure lactate level (remeasure

if initially > 2 mmol/L).Rationale: Although serum lac-

tate isn’t a direct measure of tissueperfusion, it can serve as a surro-gate for worse outcomes. Lactate-guided resuscitation has been as-sociated with mortality reduction.This is a weak recommendationwith low quality of evidence.

2. Obtain blood cultures prior toadministration of antibiotics, butdon’t delay appropriate antibiot-ic therapy if obtaining blood cul-tures is difficult.Rationale: Blood cultures are im-

portant for pathogen identification.Obtaining them before administeringantibiotics is listed as a best practicestatement, which is an ungradedstrong recommendation used when

Surviving SepsisCampaign

hour-1 bundleThis 2018 update to the sepsis bundle focuses on

beginning treatment immediately.

By Christa Schorr, DNP, MSN, RN, NEA-BC, FCCM

AmericanNurseToday.com September 2018 American Nurse Today 17

the benefit or harm is certain but theevidence is difficult to summarize.

3. Administer broad-spectrum anti -biotics. Rationale: Adherence to early an-

tibiotics and antibiotic stewardshipare important to provide high-quali-ty care. Administering broad-spec-trum antibiotics with one or moreI.V. antimicrobials is a strong rec-ommendation with moderate quali-ty of evidence. Administer narrow-spectrum antimicrobial therapy afterthe pathogen and sensitivity are ac-

quired; discontinue antimicrobials ifno infection exists.

4. Begin rapid administration of 30mL/kg crystalloid fluids for hy-potension or lactate ≥ 4 mmol/L.Rationale: Sepsis patients with

tissue hypoperfusion or septicshock require early fluid resuscita-tion. Administration of 30 mL/kg ofcrystalloid for hypotension or lac-tate ≥ 4 mmol/L is graded as astrong recommendation with lowquality of evidence. Despite thelack of controlled studies to sup-

port the 30 mL/kg fluid dose, sever-al interventional and observationalstudies provide support. Evaluateand assess fluid responsiveness be-fore administering additional fluidbeyond the 30 mL/kg dose.

5. Apply vasopressors if the patient ishypotensive during or after fluidresuscitation to maintain mean ar-terial pressure (MAP) ≥ 65 mm Hg. Rationale: Restoring perfusion

pressure to vital organs is essential.Vasopressor administration in a hy-potensive patient is graded as astrong recommendation with mod-erate-quality evidence.

Nursing implications Nurses are instrumental to improv-ing outcomes for patients with sep-sis or septic shock. They can pro-vide early recognition of signs andsymptoms, implement treatment,help remove barriers to care, andpromote education.

Recognizing signs andsymptomsAs nurses interact with patients in awide variety of settings—emergencydepartments, intensive care units,medical/surgical units, skilled nurs-ing facilities, the community, homes,and medical offices—they’re likely

The original sepsis bundles were developed by the Surviving Sepsis Campaign (SSC) in collaboration with the Institute forHealthcare Improvement. The goal was to make the International Guidelines for the Management of Severe Sepsis and SepticShock easier to execute at the bedside.

Bundle development

Substantial international evidence has demonstrated that implementing theSurviving Sepsis Campaign (SSC) sepsis bundles is associated with improvedoutcomes. In a single-center U.S. study, investigators described a severe sepsisand septic shock mortality reduction to less than 10% with improved bundlecompliance.

Similar results were observed in other countries, including Spain and theUnited Kingdom. Results of the sepsis bundle implementation over 7.5 yearsfound that participation in the quality improvement program was associatedwith decreased mortality and reduced hospital costs. Hospitals with higher bun-dle compliance showed reductions in intensive care unit and hospital length ofstay. Developing countries, including India, Brazil, and China, reported the same.

Evidence for the clinical benefit of the bundles increased public awarenessand raised national interest. The 3- and 6-hour bundles were adopted by theNational Quality Forum in 2012 and the New York State Department of Health in2014. In 2015, the Centers for Medicare & Medicaid Services mandated hospitalreporting of the early management of sepsis and septic shock (Core MeasureSEP-1), which closely follows the 3- and 6-hour SSC bundles.

Follow the evidence

2004The initial sepsis bundles incorporat-ed a two-phased approach using the6-hour resuscitation bundle and the24-hour management bundle, meas-uring 11 quality indicators.

2012Evidence cited in the 2012 SSC guide-lines supported removal of the 24-hour bundle, which resulted in the 3- and 6-hour bundles measuring sev-en quality indicators. Both the original6- and 24-hour bundles and the re-vised 2012 sepsis bundles were wide-ly adopted in hospitals around theworld.

2014Revisions in 2014 were prompted byresults of three large randomized con-trolled trials evaluating protocol-basedcare in septic shock. Researchers con-cluded that routine use of central venous catheters (CVC) and hemo -dy namic monitoring aren’t required toachieve adequate initial resuscitationof septic shock, resulting in a revisionto the 6-hour bundle. CVCs are nolonger required, but are one of manyoptions to guide initial resuscitation.

18 American Nurse Today Volume 13, Number 9 AmericanNurseToday.com

SSC hour-1 bundleThe 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.

AmericanNurseToday.com September 2018 American Nurse Today 19

to encounter patients with signs andsymptoms of sepsis. Prompt recogni-tion is an important step in sepsismanagement, and some organiza-tions have shown that specialtytrained sepsis rapid response teamslead to improved patient outcomes.

Implementing treatmentAfter confirming a sepsis diagnosiswith the provider, the nurse shouldcollaborate with others to initiateguideline-recommended treatment.Sepsis bundle interventions are im-plemented in the form of an order-set, protocol, pathway, or care plan.Screening and monitoring patientswith sepsis may differ from hospitalto hospital and even from unit tounit because of the nature of thepatient population. Follow your or-ganization’s protocol, and reviewprotocols and care plans to see ifupdates based on the new hour-1bundle are indicated.

Several studies have demonstrat-ed that nurse-driven protocols areeffective in improving adherenceto SSC guideline recommendations;implement protocols that align withyour state’s practice acts. Whetheryou work in the acute or post-acutecare setting, it’s essential to be awareof the hour-1 bundle elements andto promote prompt implementation.

Removing barriersIn addition to delayed recognition ofsepsis, barriers to sepsis bundle im-plementation include lack of knowl-edge, resources, staff, and informat-ics support. The organizations mostsuccessful at managing sepsis arethose with senior leadership back-ing, physician and nursing staff en-gagement, and informatics support.

Promoting educationA sepsis education program that in-cludes guidance for sepsis screening,a process to communicate findings,and knowledge of the hour-1 bundlecomponents will keep nurses up-to-date. Staff should know what to doand why; understanding why pro-vides motivation for timely appropri-ate treatment to patients with sepsis.

Educational resources and tools areavailable at survivingsepsis.org. (SeeEducational resources.)

Quality, timely treatmentSepsis bundles are designed forbedside application of key ele-ments of the SSC guidelines andpromote the importance of appro-priate and timely treatment. The2018 hour-1 bundle update focus-es on five elements within a singlesepsis bundle. Nurses are instru-mental in early sepsis identifica-tion and patient management. Ad-hering to their role in providingquality timely treatment will resultin better patient outcomes.

Visit americannursetoday.com/?p=50812 for acomplete list of selected references.

Christa Schorr is an associate professor of medicine atCooper Medical School of Rowan University and aclinical nurse scientist—critical care at Cooper Uni-versity Hospital in Camden, New Jersey.

Selected referencesDe Backer D, Dorman T. Surviving sepsisguidelines: A continuous move toward bettercare of patients with sepsis. JAMA. 2017;317(8):807-8.

Ju T, Al-Mashat M, Rivas L, Sarani B. Sepsisrapid response teams. Crit Care Clin. 2018;34(2);253-8.

Kleinpell R. Promoting early identification ofsepsis in hospitalized patients with nurse-ledprotocols. Crit Care. 2017;21(1):10.

Levy MM, Rhodes A, Phillips GS, et al. Sur-viving Sepsis Campaign: Association be-tween performance metrics and outcomes ina 7.5-year study. Intensive Care Med. 2014;40(11):1623-33.

Levy MM, Evans LE, Rhodes A. The Surviv-ing Sepsis Campaign bundle: 2018 update.Crit Care Med. 2018;46(6):997-1000.

Mukherjee V, Evans L. Implementation of theSurviving Sepsis Campaign guidelines. CurrOpin Crit Care. 2017;23(5):412-6.

Rhodes A, Evans LE, Alhazzani W, et al. Surviv-ing Sepsis Campaign: International guidelinesfor management of sepsis and septic shock:2016. Crit Care Med. 2017;45(3):486-552.

Schorr C, Odden A, Evans L, et al. Imple-mentation of a multicenter performance im-provement program for early detection andtreatment of severe sepsis in general med-ical-surgical wards. J Hosp Med. 2016;11(sup-pl 1):S32-9.

Use these resources to promote education about the Surviving Sepsis Campaign(SSC) hour-1 bundle.

Intensive Care Medicine: The Surviving Sepsis Campaign Bundle:2018 UpdateThis video provides an overview of the new hour-1 bundle.

youtube.com/watch?v=y8b20TMA-7Q

SSC Hour-1 Bundle infographicDownload this infographic to share with colleagues and your organization’sleadership.

survivingsepsis.org/SiteCollectionDocuments/Surviving%20-Sepsis-Hour-1-Bundle-Infograph.pdf

SSC hour-1 bundle pocket cardDownload and print this pocket card to keep with you as a reminder of the fiveelements of the new hour-1 bundle.

survivingsepsis.org/SiteCollectionDocuments/Surviving-Sepsis-Campaign-Hour-1-Bundle-2018-Print-Card.pdf

Educational resources

Nurses are

instrumental to

improving outcomes

for patients with

sepsis or

septic shock.