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



Problem: Sepsis is a life-threatening infection that needs immediate treatment. The ED uses sepsis bundle protocols to treat sepsis but the compliance rates for the order sets are below the institution’s guidelines.

Context: A Centers for Medicare and Medicaid Services (CMS) instituted a sepsis performance measure bundle in 2015 called (SEP-1) to promote cost-effective, high-quality care for septic patients admitted to the Emergency Department (ED) (Wang et al., 2020). The ED in a chosen San Francisco, CA acute care hospital has been experiencing unsteady sepsis bundle compliance rates. Sepsis is caught by 1.7 million American adults per year (Malik et al., 2021).

Intervention: Based on our gap analysis, we decided to create a sepsis based educational PowerPoint presentation as a learning tool nurses can use to become more proficient with the sepsis order sets. We also created a 36”x48” poster explaining important steps of the QI project. The poster will be displayed on the bulletin board in the unit. Lastly, handouts were created that provided the same information.

Results: Because of time constraints, the team was not able to distribute post-intervention surveys. Based on the hospital’s standards, the team agreed that reaching a compliance rate of over 90% in any of the metrics is considered a success.

Conclusions: This QI project is considered a success because early sepsis recognition, effective two-way communication and diligent use of the order sets will increase compliance rates due to sepsis nurse education.

Keywords: sepsis, compliance, education, nurses, bundle, quality improvement