Written by Vivian Lei
Sepsis bundles like the CMS SEP-1 guidelines are too restrictive, requiring an all-or-nothing approach to achieve compliance. These bundles fail to prioritize the most important bundle components while penalizing providers for meaningless omissions that have no impact on mortality.
Why does this matter?
Compliance with the SEP-1 quality bundle is a core measure for hospitals. The severe sepsis bundle includes blood cultures within 3 hours, an initial (3 hours) and repeat (6 hours) lactate measurement, and antibiotics within 3 hours. The septic shock bundle also includes fluid resuscitation of 30 cc/kg of crystalloid fluids within 3 hours and vasopressors for persistent hypotension following volume assessment and tissue perfusion assessment within 6 hours. Compliance is all-or-nothing, meaning any missed core measure equates to failure.
The real failure of SEP-1 may be SEP-1 itself
This study was a retrospective cohort of sepsis cases from 7 hospitals submitted to CMS from October 1, 2015 to September 31, 2017 (2 year period after SEP-1 went into effect). Of the 851 patients with severe sepsis in the study, 33% passed SEP-1 while 67% failed. Patients with SEP-1 failures were more likely to have septic shock, sepsis with onset during hospital admission, vague symptoms, and non-pulmonary infections. The most frequent cause of SEP-1 failure was not drawing an initial lactate or repeat lactate (40%). Unadjusted mortality rates were higher in patients with SEP-1 failure (18.4% vs 11.0% with odds ratio of 1.82). However, after adjusting for clinical characteristics and severity of illness in multi-variate analysis, the difference in mortality was no longer statistically significant. Time to antibiotics greater than 3 hours was significantly associated with death (adjusted OR 1.94) whereas all other causes of SEP-1 failure were not. Delays in appropriate antibiotic administration accounted for 15.1% of SEP-1 failures. This study shows that compliance with SEP-1 guidelines does not appear to improve sepsis mortality and that this is likely attributed to the overly rigid and prescriptive nature of the guidelines themselves.
Another Spoonful (...of controversy)
You may be aware of the new 2018 Surviving Sepsis Campaign update to shift all sepsis interventions to occur within 1 hour of emergency department triage. This has generated a great deal of exasperation, alarm, and controversy. EMCrit has links to the literature and relevant links to other opinions, as well as a petition to retract these guidelines.
Compliance With the National SEP-1 Quality Measure and Association With Sepsis Outcomes: A Multicenter Retrospective Cohort Study. Crit Care Med. 2018 Jun 28. doi: 10.1097/CCM.0000000000003261. [Epub ahead of print]
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Reviewed by Thomas Davis