Date of Graduation

Spring 5-18-2023

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project

First Advisor

Dr. Robert Patterson


Problem: In order to properly diagnose and treat sepsis a triage nurse in an emergency room must accurately identify and follow the CMS SEP-1 bundle in a timely fashion. When delays or fallouts occur during the bundle workflow, patients have a higher mortality rate leading to a longer stay in the hospital.

Context: This quality improvement project aims to use Kurt Lewin's change theory and evidence-based practice to implement a change effort to increase the compliance with the CMS SEP-1 bundle to 90% in all categories.

Intervention: The change effort used to increase the compliance on the CMS SEP-1 bundle are to create a re-education PowerPoint voiceover video intervention, and an evidence-based practice poster.

Measures: Using the Plan, Do, Study, Act cycle model to establish a plan of how to conduct a data collection, by doing an assessment survey, EHR continuous data collection, and a post implementation survey.

Results: Due to the time constraints of this project the results will be seen in the second quarter 2023 data compilation, and the post-implementation survey feedback.

Conclusions: Encouraging staff in engaging re-educational efforts and more can allow for timely treatment and compliance 100% of the time, and ultimately reduce the mortality rate for the patient.

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