Healthcare Facility Compliance 11 items
Sepsis SEP-1 Bundle Compliance Audit
Audit of the CMS SEP-1 severe sepsis and septic shock early management bundle covering lactate measurement, blood cultures, antibiotics, fluid resuscitation, and reassessment timing.
CMS SEP-1 (NQF 0500)Surviving Sepsis CampaignTJCCMS IQR Program
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Recognition & Time Zero
- Is severe sepsis or septic shock recognized with a documented 'time of presentation' (time zero) that starts the bundle clock? *
- Are severe sepsis criteria (suspected infection plus organ dysfunction) documented? *
- Is septic shock identified by persistent hypotension or lactate >= 4 mmol/L? *
3-Hour Bundle
- Is an initial lactate level measured within 3 hours of severe sepsis presentation? *
- Are blood cultures drawn before administration of broad-spectrum antibiotics? *
- Are broad-spectrum antibiotics administered within 3 hours of presentation? *
Fluid Resuscitation
- For septic shock or lactate >= 4, is a 30 mL/kg crystalloid fluid bolus initiated within 3 hours? *
- Is the actual body weight used and volume documented for the fluid calculation? *
6-Hour Bundle & Reassessment
- Is a repeat lactate measured within 6 hours if the initial lactate was elevated? *
- For persistent hypotension after fluids, are vasopressors administered to maintain MAP >= 65 mmHg? *
- Is a documented reassessment of volume status and tissue perfusion completed for septic shock? *
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