Sepsis Bundle Report

The Sepsis Bundle Report displays the breakdown of SEP-1 Composite into four component bundles – descriptions from CMS, below. 

The cases are categorized according to the Sepsis Bundle Algorithm published by CMS.

Printable SEP Bundle Algorithm 2020

Printable SEP Bundle Algorithm 2021 

Printable SEP Bundle Algorithm 2022

Select the quarter from the drop-down and click Go.

The Individual Bundle Results are displayed by CCN and Month.

SEP_1 Composite

Numerator:

(Patients who)

• Met all requirements and calculations for all bundle elements for which they are eligible (for more details, refer to the SEP-1 Measure Information Form on QualityNet).

Denominator:

(Patients who)

• Are age 18 years and over with an ICD-10-CM Principal or Other Diagnosis Code of Sepsis, Severe Sepsis, or Septic Shock, AND
• Have a length of stay less than or equal to 120 days, AND
• Met Severe Sepsis Present data element criteria, AND
• Did not meet any of the measure exclusion criteria (for more details, refer to the SEP-1 Measure Information Form on QualityNet).

Severe Sepsis 3-Hour Bundle

SEV_SEP_3

Percentage of patients who received an intravenous antibiotic, had blood cultures drawn prior to antibiotics, and had a lactate level drawn, all within three hours of severe sepsis presentation.

Numerator:

(Patients who)

• Met all requirements for the broad spectrum or other antibiotic administration data elements and calculations, and who were not excluded for broad spectrum antibiotic timing being less than -1440 minutes, AND
• Met all requirements for the blood culture collection data elements and calculations, AND
• Met all requirements for the initial lactate level collection data elements and calculations.

Denominator:

(Patients who)

• Are age 18 years and over with an ICD-10-CM Principal or Other Diagnosis Code of Sepsis, Severe Sepsis, or Septic Shock, with a length of stay less than or equal to 120 days, AND
• Met Severe Sepsis Present data element criteria, AND
• Were not transferred from another hospital, were not in a clinical trial, did not have an administrative contraindication to care for severe sepsis, did not have a directive for comfort care or palliative care for severe sepsis, and were not discharged more than six hours after severe sepsis presentation.

Severe Sepsis 6-Hour Bundle

SEV_SEP_6

Percentage of patients who had an elevated Initial Lactate Level Result (> 2 millimoles per litre [mmol/L]), and had a repeat lactate drawn within six hours of severe sepsis presentation.

Numerator:

(Patients who)

• Met all requirements for the repeat lactate level collection data elements and calculations.
• Met all requirements for the Severe Sepsis 3-hour bundle and had an elevated Initial Lactate Level Result (> 2 mmol/L).

Denominator:

(Patients who)

• Met all requirements for the Severe Sepsis 3-hour bundle and had an elevated Initial Lactate Level Result (> 2 mmol/L).

Septic Shock 3-Hour Bundle

SEP_SH_3

Percentage of patients who had Initial Hypotension or septic shock, and 30mL/kg of crystalloid fluids were started within three hours of septic shock or initial hypotension presentation.

Numerator:

(Patients who)

• Met all requirements for the Initial Hypotension (if present), septic shock (if present) data elements and calculations, AND
• Met all requirements for the crystalloid fluid administration data elements and calculations.

Denominator:

(Patients who)

• Met all requirements for the Severe Sepsis 3-hour bundle and Severe Sepsis 6-hour bundle (if eligible), AND
• Met criteria for Initial Hypotension (if present) or Septic Shock Present (if present) data elements, AND
• If septic shock was present, did not have an administrative contraindication to care for septic shock, did not have a directive for comfort care or palliative care for septic shock, and were not discharged more than six hours after septic shock presentation.

Septic Shock 6-Hour Bundle

SEP_SH_6

Percentage of patients who received a vasopressor, if persistent hypotension was present, and who had a repeat status and tissue perfusion assessment completed within six hours of persistent hypotension or septic shock presentation.

Numerator:

(Patients who)

• If Persistent Hypotension was present, met all requirements for the vasopressor administration

Data elements and calculations, AND met all requirements for the repeat volume status and tissue perfusion assessment data elements and calculations, OR

• If persistent hypotension was not present but septic shock was present, met all requirements for the repeat volume status and tissue perfusion assessment data elements and calculations.

Denominator:

(Patients who)

• Met all requirements for the Septic Shock 6-hour bundle for which they were eligible, AND
• Met criteria for Persistent Hypotension OR an Initial Lactate Level Result greater than or equal to 4 mmol/L.

The Help icon will open the Sepsis Bundle Breakdown Details document.

The Sepsis Bundle Report Numerator and Denominator details display the name in the header.