Shirley Chen

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: This project was implemented to decrease patient fallout rates through timely compliance with sepsis management according to the SEP-1 bundle. The SEP-1 bundle is already implemented in the emergency department. However, a microsystem assessment indicated barriers are preventing the achievement of the SEP-1 bundle milestones.

Context: This 16-bed emergency department (ED) at an urban Bay Area hospital provides 24-hour emergency services to individuals who suffer from medical injuries, accidents, and other serious health conditions. A random audit of the electronic health system (EHS) revealed that this emergency department consistently fails to meet the sepsis management time goals by 90%.

Interventions: A video presentation was created based on the themes identified from the gap survey and the sepsis compliance and fallout metrics. In addition, the bulletin board in the staff break room was updated to provide a visual representation of current progress.

Measures: The outcome measure used is the percentage of patient fallouts in septic patients who received appropriate and timely sepsis management in the ED. The target goal is 0%. The process measures are the percentages of each sepsis compliance metric that has met its timed goals. The target goal is 90%. Lastly, the balancing measure includes the percentage of nursing staff engagement. The target goal is 100%.

Results: Data limitations and unavailability is restricting the outcome, process, and balancing measures from being obtained. As a result, no quantitative data is available for review.

Conclusions: Although the outcome measures were not obtained, there has been significant improvement in awareness by nursing staff on the importance of timely sepsis intervention. Further management support ensures promising results from the continuation of the project.

Included in

Nursing Commons