Date of Graduation

Summer 8-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project

First Advisor

Dr. Susan Mortell



Problem: In 2020, sepsis was the leading cause of mortality in this Northern California Hospital Organization. This QI project aimed to reduce the number of fallouts for collecting repeat lactate levels to less than two per month, from a baseline of five per month, within three months.

Context: This Northern California Emergency Department serves a broad range of patients, from pediatrics to geriatric patients, with an average daily census of 80-90 patients. In this 20-bed Emergency Department, approximately 650 patients were diagnosed with sepsis in 2022.

Intervention: The hospital sepsis committee collaboratively developed a new standardized workflow for sepsis bundle management of care. The CNL student-designed and summarized the standardized sepsis checklist onto a 4x6 sticky note for staff use. The checklist ensured all sepsis bundle elements were met and reminded staff when to collect repeat lactate levels.

Measurements: Data was collected from monthly regional reports ordered from EPIC. A review of fallouts for obtaining repeat Lactic Acid Levels was conducted to determine precisely where the fallout occurs through chart audits and how many.

Results: This QI project of standardizing a sepsis workflow has decreased the number of fallouts for repeat lactate collection in the ED to consistently one or fewer monthly fallouts from a baseline average of five.

Conclusion: Creating a standardized workflow for managing sepsis patients and a sepsis checklist proved effective in reducing the number of fallouts for obtaining repeat lactate levels in the Emergency Department.

Available for download on Saturday, August 10, 2024

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