Review Article THE INDONESIAN
JOURNAL OF INFECTIOUS DISEASES
p-ISSN: 2354-6.
, e-ISSN: 2599-1698 Management of Sepsis Bundle by Nurses in Hospitals: A Scoping Review Nurdiansyah1,2*.
Yanny Trisyani3.
Ristina Mirwanti3 1Master of Nursing.
Faculty of Nursing.
Padjadjaran University Bandung.
Indonesia 2Department of Nursing.
Sulianti Saroso Infectious Disease.
Jakarta.
Indonesia 3Department of Emergency and Critical Care.
Faculty of Nursing.
Padjadjaran University.
Bandung.
Indonesia
ARTICLE INFO
Received: 23 November 2024 Reviewed: 27 November 2024 Accepted: 20 February 2025 Keywords:
Sepsis.
Sepsis bundle.
Nurses.
Hospital *Corresponding author:
Nurdiansyah Email: iandelsyah89@gmailcom ABSTRACT Background: Sepsis is one of the leading causes of mortality in hospitals, with a significant death rate.
The management of sepsis bundles was developed by the Surviving Sepsis Campaign (SSC).
Sepsis bundles include early identification, lactate measurement, antibiotic administration, and fluid resuscitation, and have been effective in reducing mortality rates.
Nurses play a strategic role in implementing these bundles, as they are often the first to recognize the early signs of However, implementation in clinical settings often faces challenges, including high workloads, limited resources, and insufficient understanding of protocols.
Methods: This study used a scoping review method to explore the implementation of sepsis bundles by nurses in hospitals.
Literature searches were conducted in PubMed.
CINAHL/MEDLINE.
Scopus, and ScienceDirect, using the following inclusion criteria: English-language articles with free full-text access and published from January 2014 to June 2024.
Results: Of the 211 identified articles, 9 met the inclusion criteria and were analyzed.
The findings reveal that effective implementation of sepsis bundles can improve nurses' adherence to protocols and reduce mortality rates.
Factors such as continuous education, protocol revisions, leadership support, and optimal staffing policies are key to successful implementation.
Conclusion: This study concludes that nurse-led sepsis bundles require a multidimensional approach to enhance clinical outcomes and operational efficiency for hospital sepsis patients.
INTRODUCTION
Sepsis is one of the leading causes of mortality in hospitals, with a death rate reaching up to 15% .
It is defined as a systemic inflammatory dysregulation and immune response to microbial invasion that leads to organ failure .
This condition represents an uncontrolled systemic response to infection, which can result in organ failure and death if not managed Copyright: A 2025 by the authors.
This is an open access article distributed under the terms and conditions of the CC BY-NC 4.
The impact of sepsis extends beyond the patient, placing a significant burden on the healthcare system, including increased treatment costs and intensive resource utilization .
Improving nurses' understanding is crucial for the proper management of sepsis .
One strategy to reduce sepsis-related mortality is implementing the sepsis bundle, a set of clinical actions developed by the Surviving Sepsis Campaign (SSC) for the management of sepsis patients.
This bundle comprises a series of time-sensitive interventions that must be implemented promptly upon sepsis diagnosis .
The core components of this bundle include early identification of sepsis, measurement of lactate levels, blood culture testing, administration of antibiotics within the first hour, fluid resuscitation, and vasopressor therapy.
Effective implementation of the sepsis bundle has been shown to significantly reduce mortality and complications in patients with sepsis .
Nurses play a strategic role in implementing the sepsis bundle in hospital settings.
This is because nurses are often the first to recognize signs and symptoms of infection .
Proper execution of the sepsis bundle by nurses has been shown to improve adherence to sepsis management standards and enhance patient clinical outcomes .
However, implementing the sepsis bundle at the clinical level often faces various These include a lack of in-depth understanding of the protocols, high workload, limited resources, and communication barriers within the care team.
These factors not only hinder consistent application of the sepsis bundle but may also affect the quality and safety of the care provided .
In hospital-based care, it is essential to systematically evaluate how nurses implement the sepsis bundle and the factors that influence its success.
Previous studies have shown that trained resources, policy-maker support for change, leadership engagement, and appropriate incentives are critical to the successful implementation of the sepsis bundle in hospitals .
However, these studies often focus on specific populations or regions, highlighting the need for broader analyses to understand variations in implementation across different healthcare settings.
This study is a scoping review that examines how nurses manage the sepsis bundle in hospital settings.
METHODS
The method used in this study is a scoping review, with the primary focus of providing an overview of how nurses manage the sepsis bundle in hospital settings.
The formulation of keywords was guided by the Participant.
Concept.
Context (PCC) framework, as outlined in Table The literature search was conducted using major research databases, including PubMed.
CINAHL/MEDLINE.
Scopus, and ScienceDirect.
IJID | Vol 11 .
December 2025 Table 1.
Keyword Framework Using the PCC Format Nurse OR Nurse Practitioners sepsis bundle management OR hospital OR hospitals OR OR Nurse Clinicians hospital medicine OR ward sepsis bundle implementation OR Sepsis bundle protocol The inclusion criteria for this review include articles on the implementation of the sepsis bundle by nurses in hospital settings, available as free full text, written in English, and published between January 2014 and June 2024.
The authors analyzed the titles and abstracts and read the full texts of the articles.
The review analysis involved summarizing the content of each journal and identifying key findings in alignment with the objectives of this scoping review.
RESULTS
The initial search yielded 211 articles.
Of these, 24 were duplicates, and 168 were excluded.
A full-text review was conducted on 19 articles.
10 were excluded for not meeting the inclusion The remaining nine articles met the inclusion criteria and were included in this review for analysis.
Figure 1.
Article Selection Process IJID | Vol 11 .
December 2025 Authors .
Research Method Title Association of Registered Nurse Staffing with Mortality Risk of Medicare Beneficiaries Hospitalized with Sepsis Developing an Mustafa Z.
To develop a Qatar QuasiAdult Sepsis Bader et.
al sepsis protocol Emergency experimental Protocol to .
for adult Department Reduce the Time to Initial patients to Antibiotic Dose reduce time to and Improve first antibiotic Outcomes dose in the ED, among Patients enhance early with Cancer in the Emergency and reduce Department Objective Country and setting Key Findings Jeannie P.
To identify the United Cross-sectional A Cimiotti.
States al .
between Acute care
nurse (RN) staffing and mortality in sepsis patients receiving acute care in Hospitals that provide more hours of Registered Nurse (RN) care can improve compliance with the SEP-1 bundle and reduce mortality rates in sepsis patients receiving Specifically, each nursing care per patient
(HPPD)
associated with a 3% likelihood of death within 60 days of hospital admission .
dds ratio, 95% CI: 0.
96Ae0.
A The sepsis bundle follows SEP-1, developed by the Centers for Medicare & Medicaid Services (CMS) A Increasing awareness of sepsis patients was achieved through education and training conducted over two months, including monthly journal clubs face-to-face education on a developed consisting of assessment, management of sepsis.
The educational content was based on the Surviving Sepsis Campaign.
International Guidelines Management of Sepsis and Septic Shock: 2016 International Consensus Definitions for Sepsis and Septic Shock (Sepsis-.
A Sepsis assessment time minutes to 6 minutes, blood collection time reduced from 44 minutes to 20 minutes, fluid minutes to 20 minutes, and the time to initial IJID | Vol 11 .
December 2025 antibiotic administration was reduced from 95 minutes to 45 minutes.
Following mortality rate decreased Emergency Gladis Kabil To explore ED Australia Qualitative al .
nurses' Emergency exploratory experiences of Department study with early fluid of early goalinitiation for directed fluid sepsis patients therapy in the management of sepsis: a Evaluation of Karen B.
To evaluate United hospital nurse- Lasater et.
al whether nurse- States to-patient .
to-patient Medicalstaffing ratios ratios impact surgical and sepsis bundles on outcomes in sepsis patients IJID | Vol 11 .
December 2025 A Barriers to Therapy Initiation: Nurses face challenges in the early recognition of sepsis and heavy workloads in the emergency department, resuscitation therapy.
A Differences Experience: Experienced nurses are more likely to make intuitive decisions and initiate fluid therapy, while less experienced nurses feel constrained scope-of-practice A Practice Change Recommendations: Many nurses, especially Clinical Initiative Nurses, recommend that nurseinitiated resuscitation be included within their scope of A Need Protocol Evaluation: There is a re-evaluate existing protocols and practice guidelines to enhance nurses' ability to improve outcomes for patients with sepsis.
Cross-sectional A Each additional patient per nurse is associated with a 12% higher likelihood of in-hospital mortality, a 7% higher chance of death within 60 days, a 7% greater likelihood of adverse outcomes, and a longer hospital stay.
A Compliance with the SEP1 bundle is associated with lower in-hospital mortality and shorter lengths of stay, although its impact is considerably smaller compared to the effect of staffing levels.
Impact of nurse- Heather To evaluate the United Retrospective A There was a significant initiated ED Rose Bruce impact of States chart review improvement in lactate sepsis protocol et.
timely nurse- Emergency level measurement and on compliance initiated sepsis Department the timing of initial with sepsis protocols in the antibiotic administration bundles, time to initial antibiotic department on implementation of the the early However, oneand in-hospital quarter of the antibiotic of antibiotics, exceeded the 3-hour with the 3-hour A Significant predictors of targets of the in-hospital Surviving Sepsis Campaign (SSC), and dysfunction, urinary tract predictors of in-hospital patient body weight.
A Patient mortality in this difference between the pre- and post-protocol implementation periods.
Providing Rachel To assess the Uganda Quasieducation and Luwaga impact of Obstetric tools increases et.
educational nurses' and and the assessment for implementation wards puerperal sepsis of a screening in a regional tool on referral hospital maternal sepsis in South screening at a Western Regional Uganda Referral Hospital in Southwestern Uganda.
Study on the Chun-Xia clinical nursing Liu pathway to al.
promote the of the sepsis bundle in septic To develop a China clinical nursing ICU pathway for the management of septic shock clusters in the Intensive Care Unit (ICU) and to promote the of septic shock A There was an increase in knowledge scores after the educational intervention, with the average score rising from 78 to 7.
A There was a statistically significant difference in the documentation of observed vital signs between the retrospective chart review and the screenings conducted after the educational by means of an A evidenceAcbased quality control and onAcsite A Before implementation, training and mentoring were conducted for all clinical nursing pathway for the sepsis bundle in After the implementation of the clinical nursing pathway for the sepsis bundle in septic shock.
IJID | Vol 11 .
December 2025 cluster The Shu-Lien To implement a Taiwan Implementation Chou et.
al sepsis bundle ICU of Sepsis .
and evaluate its Bundles on the effects on Outcome of patients with Patients with severe sepsis or Severe Sepsis or septic shock in Septic Shock in the ICU.
Intensive Care Units Time Is Survival:
Continuing Education on Sepsis for Neurosurgical Critical Care Nurses Emily Marguerite Rios and Karen Lucas Breda To implement United States education for ICU critical care nurses on the early signs and symptoms of sepsis and the management of sepsis in with SSC (Surviving Sepsis IJID | Vol 11 .
December 2025 the completion rate of the 1-hour sepsis bundle for septic shock increased 4% to 81.
4%, the 3-hour completion rate rose from 77% to 89.
4%, and 6-hour improved from 82.
3% to All of these improvements showed differences .
< 0.
compared to the control Prospective A Sepsis bundle compliance rates increased from 20% in the pre-intervention phase to 43.
3% during the education phase, 6% in the operational phase, and 79.
2% in the post-intervention phase.
A The decreased from 43.
6% to A Predictors of mortality preintervention and postintervention phases were lactate levels in the ICU A In addition to reduced mortality, there was also a trend toward shorter ICU and hospital stays, as well as lower hospital implementation of the sepsis bundle.
A Prior to the education reported a notably low level of agreement with their understanding of the SSC guidelines, with a score of 2.
After the knowledge of the SSC significantly to 4.
A There improvement in the routine assessment of sepsis patients, with a Campaig.
post-education score of A Self-assessment engaging in discussions about sepsis assessment with care providers increased by 0.
A However, the practice of initiating the 1-hour sepsis bundle from the SSC guidelines remained DISCUSSION Compliance with Sepsis Bundle Implementation in Patient Care Compliance with the implementation of the sepsis bundle in patient care has been proven to be one of the most effective approaches to improving clinical outcomes in patients with sepsis.
The sepsis bundle, which includes early detection, lactate measurement, blood culture testing, administration of antibiotics within the first hour, fluid resuscitation, and vasopressor therapy, is a well-established standard of care in sepsis management .
Implementing these steps as a unified standard protocol enables care teams to provide faster, more targeted interventions, directly contributing to reduced mortality rates.
The study by Chou et al.
provides strong evidence of the effectiveness of the sepsis bundle in reducing mortality .
In their study.
Chou et al.
reported a decrease in mortality from 43.
5%, accompanied by an increase in compliance from 20% to 72.
9% .
This finding is supported by Shiramizo et al, who reported a reduction in sepsis-related mortality from 54% to 2% following completion of the 6-hour sepsis bundle, with an increase in compliance from 6% 7% .
These reductions in mortality clearly demonstrate that adherence to sepsis bundle implementation improves clinical management and directly enhances patient survival rates.
Nurse Workload and Its Impact on Sepsis Bundle Implementation A high nurse workload is a critical factor influencing the implementation of sepsis bundles in hospital settings.
Studies by Cimiotti et al.
and Lasater et al.
highlight the significant impact of high nurse-to-patient ratios on nurses' ability to complete the sepsis bundle promptly.
A higher ratio reduces the time available for nurses to focus on each step of the sepsis bundle protocol, such as administering antibiotics within the first hour, performing fluid resuscitation, and monitoring patients' vital signs .
Lasater et al.
found that a high nurse-to-patient ratio negatively affects implementation of the sepsis bundle .
Each additional patient per nurse was associated with a 12% increase in the risk of in-hospital mortality.
Meanwhile.
Cimiotti et al.
also found that increased hours of care provided by registered nurses (RN.
could reduce the likelihood of death by 3% .
A high workload often limits nurses' ability to execute all components of the bundle on time, especially IJID | Vol 11 .
December 2025 in high-demand settings such as emergency departments (ED.
and intensive care units (ICU.
These findings align with those of Dierkes et al, who reported that a high nurse workload increases the risk of mortality.
ICU admission, prolonged hospitalization, and hospital readmission in sepsis patients .
Therefore, the nurse-to-patient ratio must be carefully considered in patient care, as it significantly affects treatment outcomesAiparticularly patient mortality during hospitalization .
Effectiveness of Education and Training in Supporting Sepsis Bundle Implementation Continuous education is an effective intervention for enhancing nursesAo competencies in sepsis management.
Studies by Luwaga et al.
and Rios & Breda demonstrated that intensive training significantly improved nursesAo knowledge of the Surviving Sepsis Campaign (SSC) guidelines .
Additionally.
Bader et al.
found that a two-month training program focused on sepsis protocols reduced the time to sepsis detection from 20 minutes to 6 minutes and decreased mortality to 11.
7% .
These findings are consistent with those of Edwards et al, who reported that training improved nursesAo knowledge, skills, and attitudes regarding early detection and management of sepsis .
Such training has been shown to increase nursesAo confidence in performing sepsis screening, potentially reducing sepsis-related mortality by ensuring faster recognition and more accurate treatment.
Barriers to Sepsis Bundle Implementation In the study by Kabil et al.
, it was identified that experienced nurses were more likely to promptly initiate fluid resuscitation, whereas less experienced nurses often felt constrained by a lack of authority and limitations within their scope of practice .
High workloads and the lack of evaluation of existing protocols further exacerbated these barriers.
Another study conducted by Abutheraa et al.
found that the main barriers to sepsis bundle implementation included difficulties in diagnosing sepsis, the appropriateness of the sepsis bundle in maternity care settings, and insufficient staff training .
Similarly.
Breen et al reported that a lack of knowledge, limited resources, and practical challenges in implementing the sepsis bundle were major obstacles identified by healthcare professionals .
Specific barriers faced by nurses included insufficient knowledge and experience, resource constraints, and the complexity of protocols.
Impact of Sepsis Bundle Implementation on Patient Outcomes The effective implementation of the sepsis bundle significantly impacts patient outcomes.
This was demonstrated in the study by Chou et al.
, which showed that compliance with the sepsis bundle reduced mortality, length of hospital stay, and overall hospital costs .
These findings are consistent with the study by Rhodes et al, which reported that adherence to the sepsis bundle could reduce the likelihood of in-hospital mortality by 36% to 40% .
IJID | Vol 11 .
December 2025 Furthermore, the study by Leisman et al.
found that adherence to the protocol significantly reduced mortality and treatment costs .
These findings affirm that evidence-based interventions are beneficial not only clinically but also economically.
The Role of Nurses in the Successful Implementation of the Sepsis Bundle Nurses play a crucial role in ensuring the timely implementation of the sepsis bundle.
This was highlighted in a study by Bruce et al, which showed that active nurse involvement in emergency department protocols improved compliance with the SSC (Surviving Sepsis Campaig.
However, the study also noted that one-quarter of antibiotics were still administered beyond the 3-hour window, indicating the need for further monitoring to ensure timely interventions.
Moore et al also found that nurse-driven protocols could improve compliance with sepsis bundle components, such as lactate level measurement, blood culture collection, and earlier antibiotic administration .
Furthermore, a study by Liu et al revealed that compliance with sepsis bundle implementation could be achieved through the application of a clinical nursing pathway .
This was evidenced by increased completion rates of the 1-hour, 3-hour, and 6-hour sepsis bundles following the implementation of the pathway.
Therefore, the critical role of nurses in the success of sepsis bundle implementation lies in their active involvement in sepsis bundle protocols.
A limitation of this scoping review is that the primary articles used were not subjected to critical appraisal, which may introduce potential bias.
CONCLUSION
Based on the nine reviewed articles, nurse-led implementation of the sepsis bundle in hospitals is a key component in effective sepsis management.
Additionally, several factors such as nurse-to-patient ratios, ongoing training, protocol revisions, and systemic support play a crucial role in determining the success of bundle implementation.
To improve clinical outcomes and operational efficiency, healthcare institutions should focus on strengthening nursesAo capacity through evidence-based education, optimal staffing policies, and supportive technologies.
multidimensional approach to sepsis bundle implementation can be further enhanced to ultimately reduce mortality rates and improve the quality of patient care.
DECLARATIONS
Ethics approval None Conflict of interest.
The authors declare no conflict of interest.
Funding None IJID | Vol 11 .
December 2025
Acknowledgments None
REFERENCES