Variation in the Contents of Sepsis Bundles and Quality Measures. A Systematic Review

Abstract

Rationale: Sepsis contributes to one in every two to three inpatient hospital deaths. Early recognition and treatment are instrumental in reducing mortality, yet there are substantial quality gaps. Sepsis bundles containing quality metrics are often used in efforts to improve outcomes. Several prominent organizations have published their own bundles, but there are few head-to-head comparisons of content.

Objectives: We sought to determine the degree of agreement on component elements of sepsis bundles and the associated timing goals for completion of each element. We additionally sought to evaluate the amount of variation between metrics associated with bundles.

Methods: We reviewed the components of and level of agreement among several sepsis resuscitation and management bundles. We compared the individual bundle elements, together with their associated goals and metrics. We performed a systematic review (PubMed 2008-2015) and searched publically available online content, supplemented by interviews with key informants, to identify eight distinct bundles. Bundles are presented as current as of April 2015.

Measurements and main results: Broadly, elements of care covered early resuscitation and short-term management. Bundles varied from 6 to 10 elements, and there were 12 distinct elements listed across all bundles. Only lactate collection and broad-spectrum antibiotics were common to all eight bundles, although there were seven elements included in at least 75% of the bundles. Timing goals for the collection of lactate and antibiotic administration varied among bundles from within 1 to 6 hours of diagnosis or admission. Notably, no bundle included metrics evaluating timeliness or completeness of sepsis recognition.

Conclusions: There is a lack of consensus on component elements and timing goals across highly recognized sepsis bundles. These differences highlight an urgent need for comparative effectiveness research to guide future implementation and for metrics to evaluate progress. None of the widely instituted bundles include metrics to evaluate sepsis recognition or diagnostic accuracy.

Keywords: bundles; guidelines; quality improvement; quality metrics; sepsis.

Figure 1.

Study flow diagram. SSC = Surviving Sepsis Campaign.

Figure 2.

Variation in timing recommended for completion of primary bundle elements. The red asterisk denotes the Surviving Sepsis Campaign bundle recommendation. CVP = central venous pressure; MAP = mean arterial pressure.

Figure 3.

Conceptual model of alternative approaches to move from evidence to intervention to improve practice. Horizontal arrows indicate bodies of evidence-based work that can be used to support a given step. AGREE = Appraisal of Guidelines for Research and Evaluation; GRADE = Grading of Recommendations, Assessment, Development, and Evaluations; Q. I. = Quality Improvement.