Date of Graduation

Spring 5-18-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project

First Advisor

Robert Patterson


Problem: Providing high-quality sepsis care in a San Francisco Bay Area emergency department (ED) is an organizational priority, however Centers for Medicare & Medicaid Service (CMS) SEP-1 sepsis bundle compliance has decreased to an average of 79% compliance since October of 2022. It was revealed that CMS SEP-1 sepsis bundle compliance issues have resulted in increased patient fallouts.

Context: A microsystem assessment was conducted by the quality improvement team to help identify gaps in practice. After an assessment survey of nursing staff, it was revealed that barriers such as physician order sets, lack of communication, lack of staffing during peak ED hours, and inability to gain intravenous access to patients were limiting staff to meet sepsis bundle 3- and 6-hour goals.

Intervention: A PowerPoint video presentation and a poster displayed in the nursing staff room was implemented to educate staff on recognizing the presentation of sepsis at triage under the systemic inflammatory response syndrome (SIRS) criteria, current best practices of CMS SEP-1 sepsis bundle, patient advocacy measures, and recommended next steps for action.

Measures: Outcome measures studied were the first vital sign to lactate result within 60 minutes, lactate to antibiotic administration within 60 minutes, and antibiotic order to administration within 35 minutes.

Results: The outcome measures for the CMS SEP-1 sepsis bundle compliance were not collected due to the production of results being in the second quarter of 2023.

Conclusion: The project took positive strides in increasing the compliance of CMS SEP-1 sepsis bundle care at a microsystem level, despite the ability to reach the project's aim.