Date of Graduation

Fall 12-15-2017

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Sepsis is a serious complication which is initiated by the body’s extreme response to an infection. If sepsis is not identified and treated promptly, it can rapidly lead to tissue damage, organ failure and death. Accounting for high morbidity and mortality rates in the United States, sepsis has become an area of focus within the healthcare spectrum as it is frequently unrecognized and undertreated. The focus of this project is for the Clinical Nurse Leader (CNL) students to evaluate the policies and processes in place within a large metropolitan hospital as well as the hospitals ability to recognize and treat sepsis in a timely manner. The hospital was first assessed with the use of the 5 P’s assessment tool: purpose, patients, professionals, processes, and patterns. Once the assessment tool was completed, the students then conducted a root cause analysis, which helped them identify any issues with compliance in completing the sepsis screening tool, contributing factors in the delay of identification and treatment of sepsis, and discrepancies within the hospital sepsis policies and algorithms. The root cause analysis included student-to-nurse observations, retrospective chart reviews, and nursing sepsis surveys. Upon the conclusion of the root cause analysis, the students then assessed their data. The data resulted with the sepsis screening tool being completed within the nurses first three hours on the clock at 42% during the student-to-nurse observation and 72% of the time during the chart audits. The students discovered that this discrepancy could have resulted due to the nurses manually inputting and altering the time they actually conducted the sepsis screening tool within the electronic medical record. The nursing sepsis survey data indicated that 88% of the nurses knew the definition of a positive sepsis screening and that 94% of the nurses were able to identify the correct systemic inflammatory response syndrome (SIRS) criteria.

Upon analysis the data, the CNL students developed an implementation plan to help improve the hospitals early identification and treatment of sepsis. The plan encompassed the implementation of annual sepsis education session, the implementation of sepsis protocol badge cards, the revised process map, and the unit sepsis champions. Overall, the students were able to develop a full understanding of what the CNL leadership role entails and how it encompasses the competencies that support quality improvement projects.

Included in

Diseases Commons