Recognizing Sepsis Early and Activating the Sepsis Bundle

Scenario

You are caring for a 67-year-old pneumonia patient whose latest vitals are:
T 38.9°C, HR 118 bpm, BP 88/52 mmHg, RR 26, SpO₂ 91%, and they appear lethargic with cool extremities.

Question: What are your immediate nursing priorities, and how do you implement the sepsis protocol safely and efficiently?

Best Practice Answer

1. Recognize Sepsis Early — Do Not Wait for Confirmation:
   The patient meets ≥ 2 SIRS criteria (T > 38°C, HR > 90, RR > 20) plus a suspected infection, which fulfills the definition of possible sepsis.
   The low BP and altered mental status suggest progression toward septic shock.
   Early recognition and rapid activation of the protocol are crucial — every hour of delay increases mortality by approximately 8%.

2. Activate the Sepsis Protocol (“Sepsis Bundle”):
   The 1-hour bundle should begin immediately upon suspicion, not after confirmation.

   Within the first 60 minutes:

   • Notify the provider or rapid response team and state your concern clearly:

     “Patient meets sepsis criteria — requesting sepsis bundle activation.”

   • Obtain blood cultures ×2 (one peripheral, one from line if present) before starting antibiotics.
   • Draw labs: lactate, CBC, CMP, coagulation panel, ABG as ordered.
   • Administer broad-spectrum antibiotics as soon as cultures are drawn.
   • Begin fluid resuscitation: 30 mL/kg normal saline for hypotension or lactate ≥ 4 mmol/L.
   • Provide supplemental oxygen to maintain SpO₂ > 94%.
   • Insert Foley catheter (if ordered) to monitor urine output, an indicator of perfusion.

3. Monitor and Reassess Continuously:

   • Check vital signs every 5–15 minutes during resuscitation.
   • Trend lactate levels — recheck within 2–4 hours; decreasing levels indicate improving perfusion.
   • Track urine output ≥ 0.5 mL/kg/hr as a marker of organ perfusion.
   • Watch for crackles or pulmonary edema during aggressive fluid administration and report immediately if present.

4. Document All Interventions with Accurate Time Stamps:
   Record the exact time of each key step for regulatory compliance and continuity of care:

   • Sepsis recognition and provider notification
   • Blood culture collection
   • Lactate draw
   • Antibiotic administration
   • Fluid bolus initiation
     These timestamps are required for CMS SEP-1 Core Measure reporting and may be audited.

5. Escalate Care if Unstable:

   • If MAP < 65 mmHg after fluids, anticipate vasopressor initiation (norepinephrine).
   • Prepare for possible transfer to a higher level of care (ICU).
   • Continue coordination with pharmacy, respiratory therapy, and the provider for ongoing management.

Real-World Application

This scenario tests your ability to apply critical thinking under pressure while following protocol-driven care.
Nurses are often the first to identify early sepsis indicators, making timely action and clear communication essential.
Hospitals closely monitor 1-hour bundle compliance — missing the window is considered a quality lapse and can affect outcomes and reimbursement.

This question commonly appears in simulation interviews for ICU, telemetry, and emergency department roles.

A strong candidate demonstrates:

• Pattern recognition (SIRS + hypotension + infection source)
• Knowledge of time-sensitive interventions
• Coordination of care with precision and urgency

Tip: During interviews, phrase it confidently —
“I’d recognize sepsis early, notify the provider, and activate the sepsis bundle — obtain cultures, draw lactate, start antibiotics and fluids within one hour. Time is life-critical.”
That concise phrasing reflects competence, urgency, and regulatory awareness — the exact qualities hospitals seek.