title: Variation in the Contents of Sepsis Bundles and Quality Measures. A Systematic Review.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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.
  
  
  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.
authors.affiliation: 1 University of Michigan Medical School, Ann Arbor, Michigan.
authors.forename: Rachel D
authors.initials: RD
authors.lastname: Kramer
authors.affiliation: 2 University of Michigan Pulmonary and Critical Care, Ann Arbor, Michigan.
authors.forename: Colin R
authors.initials: CR
authors.lastname: Cooke
authors.affiliation: 3 Kaiser Permanente, Oakland, California.
authors.forename: Vincent
authors.initials: V
authors.lastname: Liu
authors.affiliation: 4 Intermountain Medical Center, Murray, Utah.|5 University of Utah, Salt Lake City, Utah.
authors.forename: Russell R
authors.initials: RR
authors.lastname: Miller
authors.affiliation: 2 University of Michigan Pulmonary and Critical Care, Ann Arbor, Michigan.|6 VA Ann Arbor Healthcare System, Ann Arbor, Michigan; and.|7 Monash University, Melbourne, Victoria, Australia.
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Iwashyna
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D019983:Guideline Adherence / Q000592:standards*; D006801:Humans; D007902:Length of Stay / Q000191:economics*; D010043:Outcome and Process Assessment, Health Care; D018805:Sepsis / Q000188:drug therapy* / Q000401:mortality*; D012720:Severity of Illness Index
chemical_list: D000900:Anti-Bacterial Agents
keywords: bundles; guidelines; quality improvement; quality metrics; sepsis