Updated July 2026 · 10 min read
In the emergency department, sepsis is a triage-to-treatment race. The nurse who recognizes it early and drives the Hour-1 bundle changes the outcome. Here is what that looks like in practice.
Screen for sepsis on anyone with suspected infection plus signs of organ stress. Classic red flags: temperature >38°C or <36°C, heart rate >90, respiratory rate >20, altered mental status, hypotension (SBP <100), or a lactate you have not drawn yet. In older adults, the only sign may be new confusion or a fall — do not wait for a fever. A qSOFA of 2+ (altered mentation, RR ≥22, SBP ≤100) flags high risk.
The Surviving Sepsis Campaign compresses the old 3- and 6-hour bundles into a single Hour-1 set of actions initiated as soon as sepsis is suspected:
| Action | Nursing detail |
|---|---|
| Measure lactate | Draw it early; remeasure in 2–4 h if the initial is >2 mmol/L |
| Blood cultures BEFORE antibiotics | Two sets from separate sites — but do not let culture delays hold antibiotics past a few minutes |
| Broad-spectrum antibiotics | Give ASAP; have the drug at the bedside so it goes in the moment cultures are drawn |
| Fluids for hypotension or lactate ≥4 | 30 mL/kg balanced crystalloid, started rapidly |
| Vasopressors | Norepinephrine if MAP <65 after fluids — do not wait for the ICU |
Start 30 mL/kg of balanced crystalloid for hypotension or lactate ≥4 mmol/L, delivered through wide-bore access with pressure bags — a slow gravity drip is not resuscitation. After the bolus, reassess perfusion: mental status, capillary refill, urine output, MAP, and a repeat lactate. Use caution and reassess frequently in patients with heart failure or ESRD, but do not withhold indicated fluids out of reflex — reassess rather than under-resuscitate.
The CMS SEP-1 measure is timestamp-driven, and much of what gets audited is nursing documentation: time of sepsis recognition, lactate draw and result, culture times, antibiotic administration time, fluid volume and completion time, and the post-fluid reassessment. Chart these in real time. A perfect resuscitation that is documented late still fails the measure — and, more importantly, real-time charting keeps the whole team oriented to the clock.
Related: this page's companions — the ICU sepsis nursing guide, SNF sepsis recognition, and the norepinephrine and electrolyte references.
This article is general educational information for licensed clinicians and students, not medical advice or a substitute for your institution's protocols, pharmacy guidance, or a provider's orders. Always follow facility policy and verify doses independently.
Get The ICU Notebook Newsletter
Clinical tools and career insights for ICU nurses. One email per week, no fluff.
Yes, send it freeNo spam. Unsubscribe any time.