Sepsis Bundle Compliance Criteria

The Reporting system uses the following Sepsis bundle tasks to determine Sepsis bundle compliance, in order to support Sepsis bundle compliance reporting.

Sepsis 3-Hour Bundle Compliance

  • Initial lactate measured within 6 hours prior to Sepsis Onset time to 3 hours after the Sepsis Onset Time.
  • Blood cultures obtained prior to antibiotic administration up to 48 hours prior or 3 hours after Sepsis Onset Time.
  • Broad-spectrum antibiotic administration started up to 24 hours prior or 3 hours after Sepsis Onset Time.
  • Initial crystalloid fluid administration started within 3 hours of Septic Shock Onset Time.

Sepsis 6-Hour Bundle Compliance

  • Compliance with the 3-Hour bundle compliance activities.
  • Repeated Lactate Acid measurement if initial lactate level was elevated (greater than 2.0 mmol/L) after initial measurement and within 6 hours of Sepsis Onset Time.
    • If the lactate acid measurement is not elevated, then re-evaluation is not required and is indicated as compliant.