224 Fig. 1 Resuscitation and management bundles as provided for Campaign participants’ use Severe Sepsis Bundles: Sepsis Resuscitation Bundle (To be accomplished as soon as possible and scored over first 6 hours): 1. Serum lactate measured. 2. Blood cultures obtained prior to antibiotic administration. 3. From the time of presentation, broad-spectrum antibiotics administered within 3 hours for ED admissions and 1 hour for non-ED ICU admissions. 4. In the event of hypotension and/or lactate > 4 mmol/L (36 mg/dl): a) Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent). b) Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. 5. In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L (36 mg/dl): a) Achieve central venous pressure (CVP) of > 8 mm Hg. b) Achieve central venous oxygen saturation (ScvO2) of > 70%.* Sepsis Management Bundle (To be accomplished as soon as possible and scored over first 24 hours): 1 Low-dose steroids administered for septic shock in accordance with a standardized hospital policy. 2 Drotrecogin alfa (activated) administered in accordance with a standardized hospital policy. 3 Glucose control maintained > lower limit of normal, but < 150 mg/dl (8.3 mmol/L). 4 Inspiratory plateau pressures maintained < 30 cm H2O for mechanically ventilated patients. *Achieving a mixed venous oxygen saturation (SvO2) of 65% is an acceptable alternative. © 2005 Surviving Sepsis Campaign and the Institute for Healthcare Improvement into ‘‘bundles’’ of care [25, 26]. A two-phase approach site and educational materials. For patients enrolled from was established, which included the generation of two sets of the ED, the time of presentation was deﬁned as the time performance measures: the ﬁrst to be accomplished within of triage. For patients admitted to the ICU from the 6 h of presentation with severe sepsis (the ‘‘resuscitation medical and surgical wards and for patients in the ICU bundle’’) and a second set to be accomplished within 24 h at the time of diagnosis, the time of presentation was (the ‘‘management bundle’’) (Fig. 1) [27, 28]. determined by chart review for the diagnosis of severe sepsis. Sites and patient selection Educational materials and resources Any hospital wishing to join the Campaign was eligible. Participation was voluntary. Participant sites were Educational materials available on the SSC Web site recruited at professional critical care congresses and included directions for implementing the bundles and meetings, through the SSC and IHI Web sites, and by supporting data for each bundle element. A comprehen- interest generated from publication of the SSC guidelines. sive manual, Implementing the Surviving Sepsis Campaign symposia were regularly held at international Campaign, was published in 2005 and included the data congresses and other venues between 2004 and 2008 to collection tool in CD format [30]. The manual was also increase awareness and participation. Local champions distributed at meetings. It included protocols for partici- and Campaign faculty were identiﬁed and trained to pation and links to download the database. It also develop regional and national networks. reviewed issues related to ensuring consistency and Sites were encouraged to set up screening procedures quality in data collection. The manual contents were to identify patients with severe sepsis based on previously placed on the IHI and SSC Web sites. Cards and posters established criteria [29]. Sites were provided a sample of the two sepsis bundles (Fig. 1) were printed and widely screening tool in the Campaign manual and on the Web distributed. site [30]. Participating sites were asked to screen for During the course of the study period, initiation patients in the emergency department (ED), the clinical meetings were held for participating hospital groups and wards, and the ICU. Methods of screening were ulti- regional SSC launches, at which educational materials mately established locally, and no effort to supervise the were distributed, methods for data collection described, quality or completeness of screening was attempted. institutional change concepts introduced, and examples of To be enrolled, a subject had to have a suspected site implementation discussed. Ultimately, hospital-level of infection, two or more systemic inﬂammatory response efforts and local protocol development were the purview syndrome (SIRS) criteria [29], and one or more organ of individual improvement teams at each institution or dysfunction criteria. (See Supplemental Fig. 1 online.) network. An e-mail list server with voluntary membership Clinical and demographic characteristics and time of was established to allow teams to collaborate across sites presentation with severe sepsis criteria were collected for by asking questions of their colleagues and to direct analysis of time-based measures. Time of presentation communication from the SSC to sites. List members were was determined through chart review and deﬁned in encouraged to share tools, protocols, and experiences. instructions to site data collectors on the Campaign Web Although no formal evaluation was in place to assess the