Date of Graduation

Fall 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: The purpose of this quality improvement (QI) project revolves around increasing overall staff nurse compliance, enhancing their sepsis education resources, and usage of their provided education and bundle. This goal was created to produce more positive patient outcomes at Hospital X, along with its improved management of sepsis. Hospital X is an acute care facility located in the San Francisco Bay Area.

Context: The unit that was studied during this QI project was the emergency department of Hospital X. This unit provides level I trauma services in addition to other types of emergency care and contains 44 beds. Not including travel nurses, there are 115 regular staff registered nurses.

Interventions: An intervention was not implemented and observed due to the time constraints presented to the CNL students. In lieu of this, several recommendations and suggestions were presented to the nursing leadership of Hospital X. The recommendations entailed enhancing and expanding the pre-existing sepsis bundle, providing a wide variety of education, improved unit-wide sepsis communication, and badge cards for staff reference.

Measures: The students were able to demonstrate a full unit assessment to best map out the strengths and needs of the microsystem. This assessment also evaluated the level of compliance reported by the nursing staff to analyze whether the need was for additional education or a reconstructed education plan altogether. Hospital X will be encouraged to distribute a post-intervention survey to measure the effectiveness and adherence to the new recommendations that have been implemented. This survey will direct the nursing leadership team to the adjustments needed to be consistent with the latest changes.

Results: The anonymous survey that was provided to the nurses showed the CNL students that there is a heavy lack of standardization and consistency within the ED at Hospital X. Furthermore, 29.3% of the nursing staff reported they rarely or never attend any type of sepsis training as well as were unaware it was provided. In addition to this, 46.3% of the nurses reported they did not receive remedial training post-sepsis patient assignment. It was also reported that the delay in sepsis treatment also stemmed from failure to achieve difficult venous access, with 27.4% reporting this as a barrier. Some of the participants agree that a complete protocol revision to address these gaps would benefit the unit. Furthermore, 42% of nurses agreed that the team would benefit from new education and additional training on sepsis.

Conclusions: The results of the questionnaire highlighted several opportunities including communication, escalation, education/training, and inconsistencies in following the current sepsis protocols. There is a need to reevaluate the current process including staff training and sepsis timeframes and policies. A lack of resources such as adequate staffing, advanced IV access trained nurses, and communication pushed Hospital X farther from their ultimate goal of positive patient outcomes. This quality improvement project aims to provide evidence-based recommendations to the leadership team to address the gaps and opportunities identified and ultimately enhance care outcomes.

Keywords: septic shock, sepsis protocols, sepsis policies, compliance, sepsis, optimizing sepsis management.