Date of Graduation


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


Problem: Sepsis is a potentially fatal condition that must be identified and treated immediately. Sepsis is a significant concern at Hospital X in California, as it is in many healthcare facilities worldwide. Sepsis is a life-threatening condition that occurs when the body's response to infection becomes dysregulated, leading to widespread inflammation and organ dysfunction. At Hospital X, efforts are made to identify and treat sepsis promptly and effectively. The hospital employs various strategies, such as implementing early recognition protocols, educating healthcare providers on sepsis identification, and utilizing evidence-based interventions to improve patient outcomes. By enhancing sepsis awareness, providing timely interventions, and fostering a culture of continuous improvement, Hospital X aims to address the sepsis problem and to improve patient safety and care within its facility.

Context: Clinical Nurse Leader (CNL)students from the University of San Francisco led this quality improvement project. The students started constructing a comprehensive and long-lasting plan of transformation that would benefit the patients and employees through a microsystem evaluation and strengths, weaknesses, opportunities, and threats (SWOT) analysis. The interdisciplinary team collaborated to form a unit-based and facility-wide sepsis committee that convened daily to discuss any challenging patients and monthly to discuss the ongoing management of patients suffering from sepsis. It's important to note that the specific individuals involved in a clinical study on sepsis can vary depending on the study's objectives, design, and the resources available within the hospital or research institution. key stakeholders involved in this project include, Unit Manager, data analyst, and Registered Nurses.

Intervention: This intervention involved multiple components aimed at improving sepsis bundle compliance within the microsystem. Firstly, active and passive observational data were collected, allowing for a comprehensive understanding of the current practices and challenges related to sepsis management. Additionally, anonymous questionnaires were administered to the nurses, with participation incentivized to encourage engagement and gather valuable feedback on sepsis bundle adherence. The healthcare providers received sepsis bundle training, which aimed to enhance their knowledge and skills in sepsis prevention and management. The effectiveness of the training method was assessed to determine its impact on improving bundle compliance. Furthermore, the accessibility of the electronic cardiac arrest risk triage (eCART) system was evaluated, considering its role in facilitating efficient and accurate risk assessment for sepsis. Identified barriers to sepsis bundle adherence were examined to understand the factors hindering compliance and develop targeted interventions. The significance of the rapid response process in managing sepsis cases was also explored, highlighting its role in timely interventions. Based on the findings, recommendations were formulated to improve bundle compliance, addressing identified barriers and optimizing the rapid response process. This multifaceted intervention aimed to enhance sepsis bundle adherence and ultimately improve patient outcomes in the medical-surgical unit.

Measures: Collaborated with Hospital X leadership team regarding sepsis among multiple medical-surgical units. Developed a specific aim statement on the unit of choice. Generated a PICOT question. Produced a proposal for Hospital X leadership approval. Created data collection questionnaires. Assessed the microsystem using the %ps. Conducted a SWOT analysis. Ran a root cause analysis. Collected data on the Medical-surgical unit: Passive and active observational data in the microsystem, administered questionnaires to the nurses. Analyzed data from observations and questionnaires. Reviewed the results from the gathered data. Developed recommendations based on the study’s findings. Presented the recommendation plan to Hospital X leadership on April 17, 2023

Included in

Nursing Commons