Reliability: Sepsis Management Bundle

Definition

This measure tells teams how often every item on the Sepsis Management Bundle was completed in each patient during the review period. It is defined as the percent of cases of severe sepsis and/or septic shock that completed all applicable Sepsis Management Bundle elements. 

Measures of the reliability inform teams about the extent of error-free operation of their clinical processes. In this case, not following every indicated bundle item in each patient constitutes an error. 

Note: The Individual Chart Measurement Tool has been carefully designed to assign credit for bundle elements that are not indicated as if they were faithfully completed so that the reliability indicator fairly evaluates your efforts.

Note: A strongly suggested goal for compliance is 95 percent.  If the reliability figures are less than 95 percent in any given month, teams should discern which specific elements are not being reliably executed. This can be accomplished by reviewing the reliabilities for individual bundle elements listed on the Monthly Measurement Worksheet. 

The reliabilities for individual bundle elements are calculated on the Monthly Measurement Worksheet, but they are not reported in the Improvement Tracker.  Once the specific poorly-performing elements are identified, teams can improve their performance on this measure in the next cycle by addressing the underlying problems.

Numerator: Number of cases of severe sepsis and/or septic shock that completed all applicable Sepsis Management Bundle elements

Denominator: Total number of patients with severe sepsis and/or septic shock 

Exclusion: Non-severe sepsis

Goal

Increase the percentage of cases completing the Sepsis Management Bundle to 100 percent.

Data Collection Plan

Data is collected for this measure on each individual patient using the Individual Chart Measurement Tool.  This can be done concurrently or retrospectively as detailed here.

Once all the Individual Chart Measurement Tools have been collected for the month, use the Monthly Measurement Worksheet to integrate the data by combining the results of all the Individual Chart Measurement Tools.

At the end of each section on the Monthly Measurement Worksheet you will find a line designated “Numerator” and a line designated “Denominator,” which are ready for input into the pre-configured Improvement Tracker for the measure.

Sample Graph

Use Improvement Tracker to enter, save, and graph your team's data.