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Severe Sepsis and Septic Shock: Management Bundle

CBE ID
0500
1.4 Project
Patient Safety
Endorsed
Endorsement Status
Endorsed
1.1 New or Maintenance
Maintenance
E&M Cycle
Spring 2021
Is Under Review
No
Next Planned Maintenance Review
Patient Safety Spring 2025
1.3 Measure Description

This measure focuses on adults 18 years and older with a diagnosis of severe sepsis or septic shock. Consistent with Surviving Sepsis Campaign guidelines, it assesses measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement. As reflected in the data elements and their definitions, the first three interventions should occur within three hours of presentation of severe sepsis, while the remaining interventions are expected to occur within six hours of presentation of septic shock.

    • 1.14 Numerator

      Numerator Statement: Patients who received ALL of the following:
      Within three hours of presentation of severe sepsis:
      • Initial lactate level measurement
      • Broad spectrum or other antibiotics administered
      • Blood cultures drawn prior to antibiotics
      AND received within six hours of presentation of severe sepsis. ONLY if the initial lactate is elevated:
      • Repeat lactate level measurement
      AND within three hours of initial hypotension:
      • Resuscitation with 30 mL/kg crystalloid fluids
      OR within three hours of septic shock:
      • Resuscitation with 30 mL/kg crystalloid fluids
      AND within six hours of septic shock presentation, ONLY if hypotension persists after fluid administration:
      • Vasopressors are administered
      AND within six hours of septic shock presentation, if hypotension persists after fluid administration or initial lactate >= 4 mmol/L:
      • Repeat volume status and tissue perfusion assessment is performed

    • 1.15 Denominator

      Inpatients age 18 and over with an ICD-10-CM Principal or Other Diagnosis Code of Sepsis, Severe Sepsis, or Septic Shock and not equal to U07.1 (COVID-19).

    • Exclusions

      The following patients are excluded from the denominator:
      • Patients with an ICD-10-CM Principal or Other Diagnosis Code of U07.1 (COVID-19)
      • Directive for Comfort Care or Palliative Care within six hours of presentation of severe sepsis
      • Directive for Comfort Care or Palliative Care within six hours of presentation of septic shock
      • Administrative contraindication to care within six hours of presentation of severe sepsis
      • Administrative contraindication to care within six hours of presentation of septic shock
      • Length of Stay >120 days
      • Transfer in from another acute care facility
      • Patients enrolled in a clinical trial for sepsis, severe sepsis or septic shock treatment or intervention
      • Patients with severe sepsis who are discharged within six hours of presentation
      • Patients with septic shock who are discharged within six hours of presentation
      • Patients receiving IV antibiotics for more than 24 hours prior to presentation of severe sepsis

    • Most Recent Endorsement Activity
      Endorsed Patient Safety Spring Cycle 2021
      Initial Endorsement
      Last Updated