Improving Sepsis Core Measure Compliance in the ICU Setting

Sharp Chula Vista Medical Center (Chula Vista, California)

CSI Summary

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CSI Presentation

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CSI Toolkit

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Project Topic

Increasing sepsis core measure compliance

CSI Participants

Ruby Escalada‐Lacson, RN, MSN, CCRN
Marie Claire Pajaron, RN, BSN, CCRN

Project Goals/Objectives

  1. To increase sepsis core measure compliance 50 percent from baseline data (19.5 percent)
  2. To decrease sepsis mortality rate 25 percent from baseline data (16.05 percent)
  3. To decrease sepsis patients’ average length of stay (LOS) to 8.49 days from baseline data (8.99 days)

Project Outcomes

  1. Increased sepsis bundle compliance from 19.5 percent (baseline) to 31.47 percent, a 61 percent improvement from baseline
  2. Reduced sepsis mortality rate from 16.05 percent (baseline) to 13.9 percent, a 13.4 percent improvement
  3. Decreased sepsis patients’ LOS from 8.99 days (baseline) to 8.44 days, a 0.55 day reduction
  4. These outcomes resulted in an estimated annual fiscal impact of $2,360,324.

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The materials associated with this AACN Clinical Scene Investigator (CSI) Academy project are the property of the participating hospital noted above, not AACN. Requests to use content contained in the CSI team’s summary, presentation or toolkit should be directed to the hospital. We suggest reaching out to the hospital’s Communications, Marketing or Nursing Education department for assistance.

The AACN CSI Academy program supports change projects based on quality improvement methods. Although CSI teams seek to ensure linkage between their project and clinical/fiscal outcomes, data cannot be solely attributed to the project and are estimations of impact.