🏥 Nursing Pathway

Workflow support for nursing teams managing SEP-1 bundle requirements.

SEP-1 Aligned

⚠️ Workflow Support Only — This page assists nurses with awareness of SEP-1 3-hour bundle tasks. It does not replace clinical judgment, physician orders, or institutional protocols. No EMR integration. No PHI stored.

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Screen for Sepsis

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Obstetric Status — CMS SEP-1

Complete SIRS criteria and infection assessment before proceeding to the workflow below.

Temperature > 38.3°C (>100.9°F) or < 36°C (<96.8°F)Fever or hypothermia

Heart Rate > 90 bpmTachycardia

Respiratory Rate > 20 /minTachypnea

WBC > 12,000 /µL or < 4,000 /µL or Bands > 10%Leukocytosis, leukopenia, or bandemia

SIRS criteria present

0 / 4

Monitoring — Fewer Than 2 SIRS Criteria Present Continue monitoring and reassess if clinical concern increases.

Treating Sepsis (Sepsis Orders In)

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Two quick checks to reduce SEP-1 bundle fallouts.

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Time of Presentation

Calculates antibiotic and fluid resuscitation targets

What time did the patient present?

Enter time as HH:MM · 0000 – 2359

Blood Culture Sequencing

Were both blood cultures drawn before antibiotics were given?

After Bundle Completed

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Follow-up monitoring and escalation tasks (only if septic shock criteria are present), to be completed within 6 hours of shock recognition.

Repeat Blood Pressure Documentation

Have we documented repeat blood pressures after IVF bolus?

Persistent Hypotension Screen

Were the repeat blood pressures hypotensive (MAP < 65, Systolic < 90, 40 point drop)?

Initial Lactate

Select the initial lactate category.

Notify and coordinate with provider for further treatment. Persistent hypotension after completed fluid bolus may require further IV fluids, vasopressors, and provider reassessment.

Have feedback or questions? jmpeffer@gmail.com

🩺 Provider Pathway

SEP-1 clinical reasoning and documentation support.

SEP-1 Aligned

⚠️ Workflow & Documentation Support Only — Sepsis IQ is a SEP-1 workflow and documentation support tool. It does not replace clinical judgment, physician orders, institutional protocols, or EMR documentation. It does not prove administration or bundle completion.

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Was the 3-hour sepsis bundle / order set used?

Verify that initial sepsis bundle elements were ordered and administered.

📋 CMS abstraction note: Antibiotic timing is abstracted from the MAR administration time; blood culture timing from the collection timestamp in the lab record. Ordering alone does not satisfy CMS data elements.

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Severe Sepsis

Do you believe this patient has severe sepsis?

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Blood Pressure & Perfusion

Did the patient have ANY hypotension during the visit?
Examples include: SBP <90 mmHg · MAP <65 mmHg · SBP decrease ≥40 mmHg from baseline

Was initial lactate ≥4 mmol/L at any point during the visit?

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IV Fluid Resuscitation

Enter Patient Weight

⚠ CMS requires documentation explaining why the full 30 mL/kg IV crystalloid was not ordered or administered. Document IBW basis or a valid clinical exclusion in the EMR.

Documentation approach

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After IVF, Blood Pressure & Perfusion

Was there any persistent hypotension after IVF?
Examples include: SBP <90 mmHg · MAP <65 mmHg · SBP decrease ≥40 mmHg from baseline

Was repeat lactate ≥4 mmol/L after IV fluid resuscitation?

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Critical Care Documentation

If clinically appropriate, enter total critical care time below. Acuity tier is auto-determined from your selections above.

Complete Severe Sepsis and Blood Pressure & Perfusion sections above to unlock critical care documentation.

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Sepsis Quick Documentation Summary

Provider responsibility: Confirm that all summarized interventions, times, and documentation are accurate and supported in the medical record.

Selections from each section will appear here as you complete the workflow above.

Have feedback or questions? jmpeffer@gmail.com

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Understanding Sepsis

High-yield SEP-1 concepts in under 60 seconds

Why Sepsis Matters

Sepsis is the body's life-threatening dysregulated response to infection — and the leading cause of death in U.S. hospitals.

Scale of the problem:
• ~1.7 million U.S. adults develop sepsis annually
• ~350,000 die during hospitalization or are discharged to hospice
• 1 in 3 hospital deaths involves sepsis
• Survivors face lasting cognitive and physical disability

Early recognition and timely bundle completion are the most powerful interventions against sepsis mortality.

Every hour of delayed treatment increases the risk of death

Surviving Sepsis Campaign

An international collaborative launched in 2002 by the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM).

Core contributions:
• Published evidence-based clinical practice guidelines
• Introduced the "bundle" approach — completing specific care elements within defined time windows
• Landmark research showed bundle compliance significantly reduces mortality
• Current guidelines emphasize antibiotics + source control within 1 hour of recognition

CMS SEP-1 operationalizes these principles into a measurable quality metric for every U.S. inpatient hospital.

Bundle compliance is evidence-based — each element completed on time matters

Annual Cost & Impact

Clinical burden:
• Longest average hospital stay of any diagnosis
• Average cost per episode: ~$18,000–$24,000
• Estimated $62 billion in annual U.S. healthcare costs

Institutional burden:
• Sepsis is a top driver of ICU utilization and 30-day readmissions
• High sepsis rates attract scrutiny from accreditors and state health departments
• Costs escalate sharply with every hour of delayed recognition and treatment

Preventing a single SEP-1 fallout protects both patient outcomes and institutional finances.

The financial case for compliance is measured in real patient outcomes

Hospitals Are Ranked & Compared

CMS publicly reports SEP-1 performance for all eligible inpatient hospitals on Care Compare (formerly Hospital Compare).

What's at stake:
• SEP-1 compliance directly affects Value-Based Purchasing (VBP) scores
• Poor performance → reduced Medicare reimbursement multiplier applied to all DRG payments
• Performance results reviewed quarterly by accreditors, payers, and state agencies
• Patients and families can compare hospital sepsis performance online

Hospitals are ranked relative to peers — a high-volume center with consistent fallout accumulates significant financial exposure.

SEP-1 performance is publicly visible to patients, accreditors, and payers

Defining Sepsis

SIRS (≥2 required)
• HR >90 • RR >20 • Temp >38°C or <36°C • WBC >12K, <4K, or bands >10%

Sepsis
≥2 SIRS criteria + suspected source of infection

Severe Sepsis
Sepsis + ≥1 organ dysfunction criterion
(e.g., lactate >2, creatinine >2.0, bilirubin >2.0, INR >1.5, platelets <100K, new respiratory failure)

Septic Shock
Hypotension: MAP <65, SBP <90, or SBP drop ≥40 mmHg
OR initial lactate ≥4 mmol/L

Abnormal vitals can have alternative causes — apply clinical judgment. SEP-1 requires documentation, not diagnosis alone.

SEP-1 is triggered by infection + organ dysfunction or shock

OB Criteria — ≥20 Weeks / ≤Day 3 Postpartum

CMS SEP-1 v5.18 uses modified thresholds for obstetric patients:

Modified SIRS (≥2 required):
• HR >110 bpm (vs >90 standard)
• RR >24 /min (vs >20 standard)
• Temp ≥38.0°C or <36°C (unchanged)
• WBC >15,000 /µL or <4,000 or Bands >10% (vs >12,000)

Modified Thresholds:
• Creatinine >1.2 mg/dL (organ dysfunction — OB threshold)
• Hypotension: SBP <85 mmHg (vs <90 standard)

⚠️ Active Labor Exclusion: Lactate obtained during active labor (uterine contractions causing cervical change through delivery) cannot be used as a SIRS or organ dysfunction criterion.

Day of delivery = Day 0. Day after delivery = Day 1, regardless of delivery time.

Use OB mode in the app for patients ≥20 weeks or ≤Day 3 post-delivery

Time Zero — Precise Definition

Time Zero = the earliest moment ALL three elements are simultaneously present on the chart:

1. ≥2 SIRS criteria documented
2. Suspected source of infection documented
3. ≥1 organ dysfunction criterion OR initial hypotension OR lactate ≥4

Critical rules:
• Use the latest consecutive confirming criterion — not the first isolated abnormal value
• All three elements must be present at the same point in time
• Time Zero is determined by the abstractor from chart documentation — not provider impression
• Time Zero may precede ED arrival (e.g., triage vitals, transfer notes)
• The clock starts even if no provider has recognized or documented "sepsis"

The SEP-1 clock may start before you see the patient — check what's already in the chart

3-Hour Bundle — Specifics

All four elements must be completed within 3 hours of Time Zero:

1. Lactate measurement
• Must be obtained and documented, even if normal
• Repeat required at 6 hrs if initial result 2–3.9 mmol/L

2. Blood cultures × 2
• Draw before antibiotics whenever possible
• Document clinical reason for any delay if antibiotics given first

3. Broad-spectrum antibiotics
• Document agent, dose, route, and administration time
• Must be appropriate for suspected source

4. 30 mL/kg crystalloid bolus
• Required for initial hypotension OR lactate ≥4
• Document volume ordered, volume given, and clinical response
• Exclusion requires explicit documentation of clinical contraindication (e.g., volume overload, CHF)

CMS measures documentation of each element's timing — not just whether it was done

Resuscitation

Initial hypotension or lactate ≥4 → triggers 30 mL/kg fluids

This applies even if hypotension is transient

Persistent hypotension → vasopressors + reassessment

Fluid exclusions / modifications:
May be appropriate based on clinical judgment (for example heart failure or volume overload risk)

Give full fluids — or clearly document why not

Documentation

Blood cultures before antibiotics
(or document acceptable delay)

Fluids: document 30 mL/kg or exclusion

Reassessment required if:
• persistent hypotension
• lactate ≥4

If it is not documented clearly, it does not count for SEP-1

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QI Review Pathway

Retrospective SEP-1 abstraction and bundle compliance review.

Retrospective Review

⚠️ Workflow Review Support Only — This pathway is for retrospective SEP-1 quality review and does not replace formal abstraction, institutional policy, or clinical judgment.

Obstetric Status — CMS SEP-1

Time format:

Step 1 — Case Qualification

Reconstruct whether this case met severe sepsis and septic shock criteria for SEP-1 inclusion.

1A — Severe Sepsis Qualification

Suspected infection documented?

Optional SIRS Review (reviewer aid — not official abstraction fields)

Temperature > 38.3°C (>100.9°F) or < 36°C (<96.8°F)Fever or hypothermia

Heart Rate > 90 bpmTachycardia

Respiratory Rate > 20 /minTachypnea

WBC > 12,000 /µL or < 4,000 /µL or Bands > 10%Leukocytosis, leukopenia, or bandemia

SIRS selected: 0 / 4

Optional Organ Dysfunction Review (reviewer aid — not official abstraction fields)

Lactate > 2 mmol/LHyperlactatemia

New need for invasive or non-invasive ventilationRespiratory failure

Creatinine > 2.0 mg/dLRenal dysfunction

Urine output < 0.5 mL/kg/hour for 2 consecutive hoursOliguria

Total bilirubin > 2.0 mg/dLHepatic dysfunction

Platelets < 100,000Thrombocytopenia

INR > 1.5Coagulopathy

aPTT > 60 secCoagulopathy

Phrase “severe sepsis” documented in medical recordDiagnostic documentation

Organ dysfunction elements selected: 0

Severe Sepsis Presentation Time

Auto-populated from element times above, or enter directly.

3-Hour Bundle Due By

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— Complete suspected infection, SIRS review, and organ dysfunction review above to show qualification support.

1B — Shock & Fluid Trigger Criteria

Select any criteria documented in this case. Each criterion triggers specific bundle requirements.

Lactate ≥ 4 mmol/L at any point Triggers: 30 mL/kg fluid requirement & 6-hr reassessment

Before IVF — triggers 30 mL/kg fluid requirement

MAP < 65 (before IVF)Mean arterial pressure — triggers 30 mL/kg fluid requirement

SBP < 90 (before IVF)Systolic hypotension — triggers 30 mL/kg fluid requirement

SBP drop ≥ 40 mmHg from baseline (before IVF)Relative hypotension — triggers 30 mL/kg fluid requirement

Vasopressors required (before IVF)Vasopressor-dependent hypotension — triggers 30 mL/kg fluid requirement

Criteria occurring after IVF (persistent hypotension, vasopressors, or "septic shock" documented) live in Step 4B, alongside the reassessment fields they trigger.

Criteria selected: 0

— Select any criteria above that apply to this case.

Step 2 — 3-Hour Bundle Review

Compare intervention times against the 3-hour window from Severe Sepsis Presentation Time.

ℹ️ Enter Severe Sepsis Presentation Time in Step 1 to activate deadline comparisons.

Antibiotics

Antibiotic Administration Time

Time broad-spectrum antibiotic was administered (from MAR).

Blood Cultures

Blood Culture Collection Time

Time blood cultures were collected (from lab record).

Initial Lactate

Initial Lactate Collection Time

Time initial lactate specimen was collected.

Step 3 — Shock & Fluid Requirement

SEP-1 fluid evaluation is conditional and depends on shock qualification.

— 30 mL/kg crystalloid requirement: Not yet determined — complete Step 1 shock qualification above.

Fluid Deadline Anchor

Crystalloid Fluid Administration Time

Time 30 mL/kg crystalloid was completed, if administered.

Fluid documentation outcome:

Full 30 mL/kg crystalloid completed within required window

Valid fluid exclusion documented (clinical contraindication or IBW basis)

Neither / unclear

Step 4 — 6-Hour Bundle Review

Conditional elements — only relevant subsections will appear based on case data entered above.

4A — Repeat Lactate

— Repeat lactate not required — no elevated lactate criterion selected in Step 1.

4B — Reassessment

Reassessment is required if lactate ≥4 was selected in Step 1, or if a septic shock (after-IVF) criterion below is selected.

Septic Shock (after IVF) — triggers 6-hr reassessment

MAP < 65 (after IVF)Mean arterial pressure — triggers 6-hr reassessment requirement

SBP < 90 (after IVF)Systolic hypotension — triggers 6-hr reassessment requirement

SBP drop ≥ 40 mmHg from baseline (after IVF)Relative hypotension — triggers 6-hr reassessment requirement

Vasopressors required (after IVF)Vasopressor-dependent hypotension despite fluid resuscitation — triggers 6-hr reassessment requirement

Phrase “septic shock” documented in medical recordDiagnostic documentation

— 6-hour reassessment not required — select Lactate ≥4 or a hypotension-after-IVF criterion in Step 1, or a septic shock criterion above, if applicable.

Step 5 — Bundle Outcome

SEP-1 is all-or-nothing. Any failed required element removes the case from the numerator.

ℹ️ Complete the review steps above to generate a bundle outcome.

All required elements must be met for SEP-1 compliance.

Step 6 — QI Summary

Auto-generated from entered data. Copy for chart review documentation.

Complete the review steps above to build summary.

Step 7 — Email Your Team

Generate a short, friendly educational email based on the review outcome.

Choose the email type below. SepsisIQ will generate a brief team message based on the case outcome.

Choose an email type above to generate preview.

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Documentation Phrase Library

Quick-copy SEP-1 documentation support phrases for common clinical and abstraction scenarios.

⚠️ Documentation Support Tool Only — These phrases are documentation support tools only. Users must edit all statements to accurately reflect the clinical facts, timing, reassessment, and provider judgment documented in the medical record.

Tap any phrase below to expand ▾

1. Positive Sepsis Screen

Use when documenting a positive sepsis screen with SIRS criteria and suspected infection.

SIRS Criteria Present

Preview

Positive Sepsis Screen — SIRS criteria present: [SIRS criteria]. Etiology consistent with infection.

2. SIRS Alternative Etiology / Exclusion

Use when SIRS criteria are present but clinical evaluation does not suggest infection or sepsis.

SIRS Criteria Present

Alternative Etiology

Preview

SIRS criteria present: [SIRS criteria]. Current evaluation does not suggest infection or sepsis. Findings are most consistent with [alternative etiology]. Sepsis bundle not initiated at this time; will reassess if concern for infection develops.

3. Severe Sepsis Criteria Present

Use when documenting organ dysfunction criteria consistent with severe sepsis.

Organ Dysfunction Criteria

Preview

Severe sepsis criteria present: • [organ dysfunction criteria]

4. Severe Sepsis Exclusion / Alternative Etiology

Use when organ dysfunction criteria are present but not believed to represent severe sepsis.

Abnormalities Reviewed

Alternative Etiology

Preview

The following abnormalities ([abnormalities]) were reviewed and are not believed to represent severe sepsis. These findings are more consistent with [alternative etiology]. Clinical evaluation does not support sepsis-related organ dysfunction at this time.

5. Hypotension / Hypoperfusion Documentation

Use when documenting early hypotension or hypoperfusion findings as sepsis-related, or when excluding findings with an alternative etiology.

Documentation Type

Preview

Hypotension/hypoperfusion acknowledged as sepsis-related, IVF resuscitation ordered.

6. 30 mL/kg Fluid Exclusion

Use when clinical judgment contraindicates full 30 mL/kg crystalloid bolus.

Concerns Despite

Lactate ≥4 Hypotension

In Setting Of

Concern for volume overload Heart failure Renal failure BP responded to lesser volume A portion of crystalloid volume was administered as colloid

Additional Clinical Reason (optional)

Alternative Fluid Volume (mL)

Fluid Type

Preview

Concerned 30 mL/kg may be harmful.

7. IBW-Based Fluid Resuscitation

Use when calculating fluid resuscitation using ideal body weight per CMS SEP-1 v5.18a criteria (physician documentation of obesity or BMI > 30).

Ideal Body Weight (kg)

Target Fluid Volume (auto-calculated at 30 mL/kg)

Preview

Due to physician documentation of obesity or BMI > 30 (CMS SEP-1 v5.18a), IBW was used for 30 mL/kg fluid calculation. IBW: [IBW] kg. Target fluid volume: [volume] mL.

8. Basic Sepsis Re-evaluation

Use for a brief re-evaluation statement when no persistent hypotension is present after IV fluid resuscitation.

Re-evaluation Time (optional)

Preview

Sepsis re-evaluation performed. No persistent hypotension after IV fluid resuscitation.

9. Full CMS 5-Component Re-evaluation

Use when documenting a complete CMS-compliant focused re-evaluation. All five components (vital signs, cardiopulmonary exam, capillary refill, peripheral pulses, skin condition) are automatically included.

Re-evaluation Context

Re-evaluation Time (optional)

Outcome

Preview

Repeat volume status and tissue perfusion assessment performed including vital signs (HR, RR, BP, temperature), cardiopulmonary exam (rate/rhythm + lung fields), capillary refill, peripheral pulses (presence/quality), and skin color/condition (post-IV fluid bolus, persistent septic shock).

10. Blood Cultures After Antibiotics

Use when clinical urgency required antibiotic administration before blood culture collection.

Preview

Blood cultures were not obtained prior to antibiotic administration due to clinical urgency requiring immediate treatment. Cultures obtained subsequently. Delay acknowledged and clinically justified.

11. Critical Care Documentation

Use when documenting critical care time for sepsis management. Phrase auto-adjusts based on acuity tier.

Acuity Tier

Critical Care Minutes

Preview

Patient had severe sepsis with acute organ dysfunction and high risk of clinical deterioration requiring urgent bedside evaluation, repeated reassessment, interpretation of laboratory and hemodynamic data, coordination of sepsis-directed management, and ongoing medical decision making. Total critical care time: [minutes] minutes, exclusive of separately billable procedures.

⚠️ Critical care time must reflect actual provider time personally spent managing the patient. Do not include separately billable procedures or time by other team members.

12. No SEP-1 Exclusions Identified

Use when no exclusions to standard SEP-1 bundle elements apply.

Preview

No SEP-1 bundle exclusions identified. Standard 3-hour and 6-hour bundle elements apply without modification. All required elements to be completed per CMS SEP-1 measure specifications.