Severe Sepsis and Septic Shock: Management Bundle
This measure focuses on adults 18 years and older with a diagnosis of severe sepsis or septic shock. Consistent with Surviving Sepsis Campaign guidelines, the measure contains several elements, including 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, these elements should be performed in the early management of severe sepsis and septic shock.
ACP does not support NQF measure #0500: “Severe Sepsis and Septic Shock: Management Bundle.” This measure emphasizes the importance of early recognition and the need to treat septic patients expeditiously; however, implementation includes mixed benefits and detriments. As currently specified, the measure excludes clinical judgement. The benefits of treating patients who are infected need to be balanced against the harms of treating patients who at first appear as if they might have infections but in fact do not. For patients with less severe disease and in whom the presence of infection is uncertain, there is often more time to gather additional diagnostic data to generate a more informed and precise therapeutic plan. Stipulating a fixed-time period for drawing lactate levels could lead to unintended consequences, namely an increased likelihood that broad-spectrum antibiotics will be given more frequently to uninfected patients with syndromes that look like infections. Additionally, implementation has the potential to lead to indiscriminate use of central venous pressure (CVP) monitoring, which is invasive and has adverse effects. The evidence for standard infusion therapy for all patients diagnosed with sepsis is mixed; there are likely populations that benefit from standard therapy while others may require individualized infusion parameters (e.g., HF patients). While implementation of the Surviving Sepsis Campaign has been associated with improved clinical outcomes, there is no literature on the unintended consequences of this measure. We advocate for research on post-marketing surveillance (similar to that of the CAP antibiotics measure: http://annals.org/aim/fullarticle/741439/public-reporting-antibiotictiming- patientspneumonia-lessons-from-flawed-performance) to weigh the benefits of early diagnosis against the potential harms of treating patients who appear to be infected, but in fact