“The other elements of the basic 3-hour bundle—drawing initial lactates and blood cultures before antibiotics—certainly seem like good practice as well,” he said. “However, most of the other bundle elements, such as 30 mL/kg fluid requirement for hypotension or lactate levels ≥4, repeat lactates for patients with initial lactate levels >2, and documentation of volume reassessment exams, seem overly prescriptive and are not well supported by evidence.”

Dr. Rhee added, “The other potential modification could be to change from an ‘all-or-nothing’ measure to allow partial credit for completion of certain aspects of the bundle, even if 100 percent of the bundle elements are not met.”

Dr. Arjun Venkatesh from Yale University School of Medicine, in New Haven, Connecticut, who recently evaluated emergency department performance on SEP-1, told Reuters Health by email, “Variation in the SEP-1 metric is broad and average performance is likely lower than many EDs or hospitals may observe in dashboard or local quality reports. This may be explained by nuances of this quality measure, and clinical leaders should use this data to reassure hospital leadership of boards that may perceive sepsis care to be inadequate based on this isolated snapshot of sepsis care.”

SEP-1 “is a process measure, and as such it will always drive improvements in documentation as much as it will drive improvements in actual care delivery,” said Dr. Venkatesh, who was not involved in the new work. “As sepsis care becomes increasingly standardized, the development of a risk-adjusted outcome measure (such as in-hospital mortality) may be a more worthy and powerful driver of practice change and improved outcomes.”

Dr. Ian J. Barbash of the University of Pittsburgh School of Medicine, in Pennsylvania, recently evaluated perceptions of hospital quality officials regarding SEP-1. He told Reuters Health by email, “The evidence from this study and others published since the beginning of SEP-1 suggest that a modified SEP-1 measure should retain a primary focus on timely sepsis recognition and antibiotic administration, but perhaps give hospitals more flexibility on other aspects of the bundle with less direct evidence that they improve patient outcomes.”

“In many ways, the message remains the same as it has for some time: physicians must be vigilant in identifying sepsis early and ensuring rapid administration of appropriate antibiotic therapy,” said Dr. Barbash, who also was not involved in the research. “This study also suggests that the problem of recognition and early treatment may be particularly vexing for patients with vague presenting symptoms or whose sepsis begins in the hospital.”