DNP Final Report: Improving Adherence with CMS SEP-1 Sepsis Bundle in the Emergency Department

Adherence to the CMS SEP-1 Sepsis bundles is critical to sepsis management and leads to lower sepsis mortality, lower incidence of readmission, reduced length of hospital stay, and improved patient outcomes. This medical center has struggled to meet the required 71% adherence rate set by the Center for Medicaid and Medicare, representing the benchmark of acceptable care of sepsis patients. Therefore, the following PICOT question arises: among the hospitals’ ED physicians and nursing staff (P), how does a multimodal approach consisting of education, visual reminders, and audit and feedback (I) compared to a single approach (education) (C) affect adherence to sepsis protocol (O) within six months (T)? A comprehensive review of literature was conducted using CINAHL, PubMed, Medline, the Cochrane Database of Systematic Reviews (CDSR), Scopus, and ProQuest to review various interventions that improved adherence to SEP-1 in the emergency department. The interventions implemented for this project were a multi-modal approach that included the use of visual reminders (one-pagers and informational sheets highlighting often missed necessary steps in sepsis care), education, and audit and feedback. The evidence from literature suggested that implementing these interventions will improve adherence to SEP-1 bundles. The outcome result showed an improvement in adherence rate from 62% pre-implementation to 76% during implementation and 82% post-implementation. This EBP project has led to significant improvement in adherence to SEP-1 sepsis protocol beyond the implementation period and integration of the interventions into the daily workflow at the clinical site.