Bundles and Bundles and Bundles

August 30th, 2018

The situation is well known to any physician working in almost any inpatient unit in the United States in 2018.  First, a “code sepsis” is announced as nurses have found a patient with any and all abnormal vital signs.  (Please don’t confuse this code with any of the other million types of codes that exist currently in the hospital today – code blue, code purple, rapid response, code brown, code Adam, etc.  We have created the inexplicable reality that physicians now must carry around a scorecard of what each code implies, thereby defeating the entire purpose of an emergency activated system, which is what the entire code system was created to provide!) That is quickly followed by the appearance of a charge nurse with a long checklist of orders that must be entered IMMEDIATELY – broad spectrum antibiotics, large volume fluid resuscitation, extensive laboratory evaluations – all to be completed as part of the “sepsis protocol” or bundle.  Never mind that abnormal vital signs are a regular finding in the hospital (it is, after all, an inpatient facility) and that SIRS and qSOFA scores leave much to be desired in their sensitivity for determining sepsis, this protocol MUST be implemented on EVERYONE who is suspected of having sepsis.  Heart failure? Doesn’t matter.  Just went up to use the rest room?  All the same – this may be sepsis after all!  Physicians are trapped because the last thing we’d want to do is NOT order the bundle.  The decision to quell the tide of panicked checklisting and ordering is followed by an equally arduous set of paperwork explaining why the patient was not in fact septic.  “Yeah well you see I think his tachycardia and tachypnea are due to being up and running in the hallways” – good luck with that!


The absurdity of the clinical chaos aside, study after study indicates that most – if not all – of the CMS bundles do not meet with their intended consequence.  Yet another study, just published here http://www.modernhealthcare.com/article/20180727/NEWS/180729909, shows that following the sepsis protocol did not actually improve mortality. Readmission penalties, stroke excellence certificates – none seem to have the requisite mortality benefit that lawmakers sought when they turned medicine from a beautiful art form into a series of check boxes and numbers.  Please do not misunderstand; I am strongly in favor of accountability in medicine and agree with instating protocols and bundles – and enforcing them with great levels of seriousness – if they improve patient outcomes.  However, to my mind, we should be putting the protocols into place that have been shown to improve outcomes, rather than trying to scramble post-facto to justify past-implemented bundles with the hopes that some meaningful outcome is attained.