The Surviving Sepsis Campaign Bundle: 2018 update

Introduction The “sepsis bundle” has been central to the implementation of the Surviving Sepsis Campaign (SSC) from the first publication of its evidence-based guidelines in 2004 through subsequent editions [1–6]. Developed separately from the guidelines publication by the SSC, the bundles have been the cornerstone of sepsis quality improvement since 2005 [7–11]. As noted when they were introduced, the bundle elements were designed to be updated as indicated by new evidence and have evolved accordingly. In response to the publication of “Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016” [12, 13], a revised “hour-1 bundle” has been developed and is presented below (Fig. 1). The compelling nature of the evidence in the literature, which has demonstrated an association between compliance with bundles and improved survival in patients with sepsis and septic shock, led to the adoption of the SSC measures by the National Quality Forum (NQF) and subsequently both by the New York State (NYS) Department of Health [14] and the Centers for Medicare and Medicaid Services (CMS) [15] in the USA for mandated public reporting. The important relationship between the bundles and survival was confirmed in a publication from this NYS initiative [16]. Paramount in the management of patients with sepsis is the concept that sepsis is a medical emergency. As with polytrauma, acute myocardial infarction, and stroke, early identification and appropriate immediate management in the initial hours after development of sepsis improves outcomes [7–11, 14, 16–21]. The guidelines state that these patients need urgent assessment and treatment, including initial fluid resuscitation while pursuing source control, obtaining further laboratory results, and attaining more precise measurements of hemodynamic status. A guiding principle is that these complex patients need a detailed initial assessment and then ongoing re-evaluation of their response to treatment. The elements of the 2018 bundle, intended to be initiated within the first hour, are listed in Table 1 and presented in the following. Consistent with previous iterations of the SSC sepsis bundles, “time zero” or “time of presentation” is defined as the time of triage in the emergency department or, if referred from another care location, from the earliest chart annotation consistent with all elements of sepsis (formerly severe sepsis) or septic shock ascertained through chart review. Because this new bundle is based on the 2016 Guidelines publication, the guidelines themselves should be referred to for further discussion and evidence related to each element and to sepsis management as a whole.