Date of Graduation

Summer 8-2022

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

Liesel Buchner



Problem: Providing high quality sepsis care is an organizational priority, however this medical center has only met the target compliance goal for the Centers for Medicare & Medicaid Service (CMS) SEP-1 sepsis management bundle 50% of the time over the past year. Root cause analysis has revealed that 40% of the fallouts have been attributed to non-compliance with the intravenous fluid bundle element.

Context: A microsystem analysis was completed on the quality department, a supporting microsystem to the larger mesosystem involved with providing acute sepsis care. A return-on-investment analysis demonstrated that efforts to improve sepsis care and reduce sepsis progression could have significant cost savings for each patient that has reduced morbidity or length of stay.

Intervention: An online education module focused on weight-based intravenous fluid orders was developed and assigned to all emergency department and inpatient nurses. A sepsis bundle checklist tool was implemented, and huddle messages were also delivered at physician staff meetings.

Measures: The outcome measure was the percent of adult patients with severe sepsis and/or septic shock that met all elements of the CMS SEP-1 sepsis management bundle. Process measures included compliance with the intravenous fluid bundle element as well as compliance with order set use.

Results: The outcome measure of overall SEP-1 compliance post project implementation rose from 69.3% to 71.4%. Intravenous fluid bundle compliance rose from 81.6% to 100% for adult patients with septic shock and from 86% to 87% for adult patients with severe sepsis. Compliance with use of the septic shock order set rose from 45.6% to 77.6% post project implementation.

Conclusions: In conclusion, the implications for practice based on this project are significant. While the specific project aim was not achieved, in the short span of 4 months substantial improvements were seen with intravenous fluid sepsis bundle element compliance as well as sepsis order set utilization. It is expected that these improvements will contribute to ongoing improved compliance with the CMS SEP-1 sepsis management bundle moving forward.