Shock Syndromes I
This care bundle has been adopted by the Centers for Medicare & Medicaid Services as a quality
(core) measure (SEP-1).
The slight differences between the SSC bundle and the SEP-1 quality measure are noted in Box 2.
In July 2016, a letter to the editor from the SEP-1 measure stewards and a representative from the
Centers for Medicare & Medicaid Services indicated that the SEP-1 measure would not be updated
8).
Adjustment of the SSC bundle and implementation of sepsis as a quality measure have led to a shift
in resuscitation approaches for many clinicians.
Practitioners should systematically evaluate their institutional compliance and implement broad
process steps to ensure compliance with the quality measure. These steps may include, but are not
limited to, patient identification by clinical decision support tools in the electronic medical record
and implementation of care paths and order sets for treatment.
In 2018, the SSC released an update recommending that all bundle elements be completed within
1 hour to ensure that aggressive resuscitation begins immediately in patients with septic shock.
At this time, this recommendation has not been adopted by the Centers for Medicare & Medicaid
Services.
Box 2. Sepsis and Septic Shock Management Bundlea
Accomplished within 3 hr of presentationb
If septic shocke is present, additional measures to be accomplished within 6 hr of presentationb
≥ 65 mm Hg
was ≥ 4 mmol/L, reassess volume status and tissue perfusion, and document findingsf
aApplies to all patients presenting with severe sepsis and septic shock (of note, the previous [Sepsis-2] definitions, which include the term severe sepsis, continue to
be used for this bundle). Patients are excluded from the Centers for Medicare & Medicaid Services quality measure (SEP-1) for many reasons, including (1) they are
transferred from another care facility (including an ED), (2) they have advanced directives for comfort care, (3) they have clinical conditions that preclude total measure
completion (i.e., mortality within the first 6 hr of presentation), (4) they have a length of stay > 120 days, or (5) they were administered intravenous antibiotics within 24
hr of presentation. All components outlined must be fulfilled to satisfy the SEP-1 quality measure (it is an “all-or-none” measure).
bTime of presentation is defined as the time of triage in the ED or, if the patient is located in another care venue, from the earliest chart annotation consistent with all
elements of severe sepsis or septic shock as ascertained through chart review.
cBefore July 1, 2021, specific antibiotics were outlined in the SEP-1 quality measure to qualify as “broad spectrum.” As of July 1, 2021, any IV antibiotic satisfies
the measure if given within the appropriate time.
dStarting January 1, 2022, the SEP-1 quality measure allows for resuscitation volumes < 30 mL/kg if appropriate documentation with rationale is recorded in the
medical record as outlined in the measure documents.
eSeptic shock defined as hypotension (to SBP < 90 mm Hg, MAP < 70 mm Hg, or SBP decrease > 40 mm Hg from known baseline) or a lactate concentration ≥ 4
mmol/L.
fTo meet the requirements, one of the following must be documented: (1) a focused examination by a licensed independent practitioner including vital signs,
cardiopulmonary, capillary refill, pulse, and skin findings; or (2) any two of the following: measure CVP, measure Scvo2, bedside cardiovascular ultrasonography, or
dynamic assessment of fluid responsiveness with PLR or fluid challenge.
gIn the SEP-1 quality measure, an initial lactate concentration ≥ 2 mmol/L is considered elevated.
Information from: Surviving Sepsis Campaign (SSC). Updated Bundles in Response to New Evidence [homepage on the Internet]. Available at www.survivingsepsis.
org/SiteCollectionDocuments/SSC_Bundle.pdf; and The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures. 2016. Available at
https://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx.