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: Compliance and timeliness with the sepsis bundle protocol are continuously increasing, resulting in poor patient outcomes. This quality improvement project aims to increase sepsis bundle compliance and earlier sepsis management in the Emergency Department (ED) to reduce sepsis mortality rates and length of hospital stay.

Context: Hospital A’s emergency department is a level II adult trauma center located in the Greater Bay Area that treats a range of patients presenting with life-threatening diagnoses such as sepsis, traumatic injuries, and electrolyte imbalances.

Interventions: The sepsis committee team was provided recommendations to implement post-data analysis. Interventions recommended included standardizing and increasing sepsis training frequency, creating case reviews on near misses, using hands-on sepsis simulations, and refining technology-assisted intravenous (IV) placement. Additional resources included badge buddy cards with visual aids detailing sepsis guidelines and incorporating automated warning parameters into the EPIC system.

Measures: A randomized chart audit was used to find discrepancies in sepsis bundle compliance. Surveys comprised of 9 open-ended questions were distributed to staff members to assess where change is needed to achieve a higher rate of sepsis bundle compliance.

Results: Post-analysis of random audited charts regarding sepsis bundle compliance provided by Hospital A revealed a 41% compliance rate. Training, education, and barriers to the sepsis bundle were the most prominent findings in the inability to implement the bundle promptly.

Conclusion: After collecting and analyzing data from the questionnaire, the team identified opportunities such as the inability to meet sepsis protocol compliance stemmed from a lack of sepsis training frequency, insufficient remedial or debriefing processes, a missing ED sepsis screening policy, and a faulty charting system. In presenting this data to the sepsis faculty at Hospital A, our recommendations include increasing training frequency, establishing an ED-specific sepsis screening policy, creating badge reel cards that detail sepsis policies and escalation processes, and revising the current charting system to increase bundle compliance. Post-intervention data was unable to be collected due to time constraints