Date of Graduation

Winter 12-15-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project

First Advisor



Problem: With a recent influx of sepsis cases, hospital stakeholders identified gaps between sepsis protocol and practice. This quality improvement project aimed to increase sepsis bundle compliance and utilization among registered nursing staff in the emergency department to improve sepsis management and patient outcomes ultimately.

Context: The microsystem assessed is a 44-bed emergency department at Hospital A, a level II adult trauma center within the greater San Francisco Bay Area. The current registered nurse roster within this department, excluding four on leave, is 115 individuals and represents the target population for this change project.

Interventions: Interventions were not implemented due to project time constraints. However, proposed recommendations were presented to unit leadership for future implementation. Suggested interventions would standardize the sepsis screening policy, escalation pathways, and training opportunities as well as increase unit signage with visual aids which detail sepsis guidelines.

Measures: Data collection and microsystem assessments sought to measure current sepsis protocol compliance for this change project. Post-intervention sepsis bundle adherence remains the primary metric to evaluate the effectiveness of quality improvement initiatives going forward.

Results: Pre-intervention questionnaire results revealed discrepancies in staff training frequency, chain of command, and leadership follow-up on near misses and fallout cases. The microsystem’s unpredictable patient volume presented barriers to timely sepsis management. Post-intervention results remain inconclusive and outside of this project’s allotted time frame.

Conclusions: Analysis of gaps in sepsis bundle compliance revealed multiple causative factors that delay sepsis care within the emergency department. Proposed interventions sought to increase standardization and collaboration in the unit to improve bundle compliance. Project continuation is necessary to implement proposed recommendations and study their effectiveness in enhancing sepsis bundle compliance rates.