Since the February issue of The Nurse Practitioner journal was sent to press, a critical update on the Hour-1 bundle was released. The following updates information printed in Lehman KD. Evidence-based updates to the 2016 Surviving Sepsis Guidelines and clinical implications. Nurse Pract. 2019;44(2):26-33.
The Hour-1 bundle, which combined elements of the 3-hour and 6-hour sepsis bundles, was recommended by the Surviving Sepsis Campaign (SSC) in 2018, only to be withdrawn later in the year (see Hour-1 bundle).1,2 As of January 10, 2019, the Hour-1 bundle is now recommended in US hospitals.
In 2018, the international SSC, in partnership with the European Society of Intensive Care Medicine, first announced the Hour-1 bundle, which recommends initiating sepsis treatment at the time of triage. Two US-based organizations, the Society of Critical Care Medicine (SCCM) and the American College of Emergency Physicians (ACEP), criticized the Hour-1 bundle for suitability of implementation in the US and recommended against it.2 According to email correspondence with the SCCM, these organizations felt the bundle timing and completion elements were unclear and unrealistic (L. Harmon, January 2019). The SSC responded by changing the language of the Hour-1 bundle to clarify that providers should implement the bundle upon sepsis recognition, not necessarily triage time. As of January 10, 2019, the SCCM and ACEP supported the Hour-1 bundle with its updated terminology.2
In the February article titled “Evidence-based updates to the 2016 Surviving Sepsis Guidelines and clinical implications,” the Hour-1 bundle was applied to Mr. G (the patient discussed in the case review) in the ED when the ED NP identified two qSOFA findings. The ED NP ordered a lactate level and ordered antibiotics after blood cultures were drawn. The ED NP failed to provide an appropriate fluid bolus because of hypoxemia and concern for respiratory compromise. Mr. G developed worsening hypotension in the hours following hospital admission but stabilized with additional I.V. fluids without the need for vasopressors. Prompt recognition and treatment reduces in-hospital mortality, and the Hour-1 bundle is a cornerstone of sepsis quality improvement.3-5
The Hour-1 bundle represents the latest evidence and demonstrates collaboration among international and US sepsis experts. The turbulence associated with adoption of the Hour-1 bundle is a valuable example of the imperative need for NPs to remain well-informed about sepsis updates to continue to provide quality, evidence-based patient care.
1. Rhodes A, Evans LE, Alhazzani W, et al Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med
3. Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign Bundle: 2018 update. Int Care Med
4. Pruinelli L, Westra BL, Yadav P, et al Delay within the 3-hour Surviving Sepsis Campaign Guideline on mortality for patients with severe sepsis and septic shock. Crit Care Med
5. Rhodes A, Phillips G, Beale R, et al The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study). Intensive Care Med