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

Nneka Chukwu, DNP-HCSL, MBA, RN, CLNC, CNL


Problem: This quality improvement project aimed to increase sepsis education and bundle compliance within the medical-surgical/telemetry unit to improve sepsis mortality and morbidity rates.

Context: A microsystem assessment was completed by Clinical Nurse Leader (CNL) students in the medical-surgical/telemetry unit at Hospital X located in the San Francisco Bay Area. This microsystem cares for patients diagnosed with sepsis, congestive heart failure (CHF), electrolyte imbalance, and alcohol withdrawal.

Interventions: Due to time constraints, an intervention was not implemented; however, the students provided recommendations for interventions to the leadership team for follow up. The recommended interventions encompass implementing sepsis protocol reference cards, signage, and an education refresher course.

Measures: After completing an assessment of the microsystem, the students collected data to evaluate nurses’ adherence to sepsis protocol and rates of sepsis-related complications in the microsystem. The post-intervention survey measured the effectiveness of the refresher course and the confidence in utilizing the sepsis bundle with the assistance of the reference cards and signage.

Results: Analysis from the pre-intervention survey revealed that 83.3% of nurses in this microsystem received sepsis bundle training, and 50% rated their sepsis bundle training at an eight or above on a scale of 0 to 10. Participants disclosed key challenges to sepsis protocol compliance were due to late documentation, substandard training, and time. This study aimed to assess the microsystem at Hospital X, determine the causal factors for decreased compliance with the sepsis bundle, and develop action plans to increase adherence and reduce mortality and morbidity.

Conclusions: The pre-intervention questionnaires demonstrate that this microsystem’s sepsis bundle is underutilized. It was revealed that there was a lack of proper sepsis protocol training and resources. The continuation of this project with the implementation of increased training and accessible resources will hopefully yield increased use of the sepsis bundle and improve sepsis mortality and morbidity rates.

Keywords: sepsis, septic shock, education, rapid response, compliance, sepsis bundle, early detection, sepsis protocol