Protocol Into Practice: A Multi-Year Sepsis Quality Improvement Project in the Emergency Department

Monday, March 23, 2026

11:30 AM - 12:30 PM Central Time

Location: Connections Central - RST 11

CR

Carly Redstone, MSN, RN

University of Michigan

Disclosure(s): No relevant financial relationship(s) to disclose.
RH

Renee Havey, DNP

Clinical Nurse Specialist
Michigan Medicine

Disclosure information not submitted.
TG

Tami Garcia, MSN, RN

Sepsis Team Manager
University of Michigan

Disclosure information not submitted.
Patricia Posa, BSN, CCRN, MHSA

Michigan Medicine

Disclosure(s): Baxter Healthcare: Advisory Board (Terminated, February 1, 2025), Speaker/Honoraria (includes speakers bureau, symposia, and expert witness) (Terminated, February 1, 2025)
AG

Andrew Gutting, BSE

Business Systems Analyst Sr.
University of Michigan

Disclosure information not submitted.
JK

Jessie King, MD, PhD

Assistant Professor
University of Michigan

Disclosure information not submitted.
JB

Jamie Beach, RN, BSN

Administrative Director
University of Michigan

Disclosure information not submitted.
JL

Jingze Li, N/A

Research Assistant
University of Michigan

Disclosure information not submitted.
JC

Jim Cranford, PhD

Associate Research Scientist
University of Michigan

Disclosure information not submitted.
PE

Peter C. England, MD

Assistant Professor of Emergency Medicine
University of Michigan, Michigan

Disclosure information not submitted.

Introduction: The Surviving Sepsis Campaign provides clear and established guidelines for the management of patients with severe sepsis and septic shock. However, translation and application of these guidelines to create meaningful clinical improvements have been inconsistent, with varying degrees of success. We aim to share our multi-year experience with sepsis quality improvement.

Methods: We performed a single-site retrospective evaluation of our sepsis quality improvement interventions at our tertiary Emergency Department (ED) from 1/1/2020 to 6/30/2025. Our interventions occurred over two distinct time periods. Phase 1, from January 2020 to December 2022, involved passive electronic medical record (EMR) support and retrospective feedback, typically delivered 1-3 months after care. Phase 2, from January 2023 to June 2025, saw the full integration of a dedicated sepsis coordinator, the introduction of real-time feedback, and the implementation of an active EMR workflow. Additionally, sepsis huddles were introduced to quickly assess sepsis criteria, enabling the rapid initiation of the sepsis treatment bundle.

Results: 3469 patients were included in our analysis with 1622 patients in phase 1 and 1847 in phase 2. Three-hour bundle compliance remained stagnant over phase 1 (2020 35%, 2021 38%, 2022 39%), and severe sepsis/septic shock mortality remained high (2020 22.3%, 2021 23.6%, 2022 23.0%). Implementation of phase 2 resulted in increasing bundle compliance (2023 42%, 2024 44%, 2025 54%) and reductions in mortality (2023 19.4%, 2024 17.6%, 2025 18.2%). There was a statistically significant increase in bundle compliance in phase 2 compared to phase 1 (45.6% v 37.4%, CI 4.9-11.4%, p< 0.001) and a reduction of mortality (18.4% v 23.0%, CI 1.9-7.3%, p< 0.001).

Conclusions: A comprehensive, active, multi-pronged quality improvement strategy appears essential for achieving sustained improvements in sepsis care. The implementation of a robust, interdisciplinary sepsis program within the adult ED was associated with a sustained improvement in three-hour sepsis bundle compliance and reduction of in-hospital mortality in patients with severe sepsis and septic shock.