1. Laux, Lori MSN, RN-BC, CRNP
  2. Campbell, Thomas MD, MPH
  3. Latouf, Kathleen M. DO, MPH
  4. Saunders, Kerry MSN, RN
  5. Schultz, Joyce MSN, CPHQ, CPPS
  6. Schwartzmier, Michelle RT(R)


The topic of sepsis has been realized among the last 20 years. A majority of patients with sepsis enter the health system through the emergency department, and health professionals need to provide evidence-based care. Within the health system, interdepartmental teams were formed with the purpose to set a system-wide standard to meet the evidence-based practice standards for sepsis. Participants were recruited from every department that was involved with the care delivery of emergency department patients with sepsis. The team developed a team charter to state the group objectives. A gap analysis was completed to set group priorities. The first priority was to develop a system-wide sepsis alert process. The Operational Excellence coach conducted direct observations and interviews at each system facility and then a sepsis alert plan was developed. Two hospitals volunteered to pilot the sepsis alert within their emergency departments, and education was completed at each hospital. Informatics nurses developed electronic medical record workflow and outcome elements to help the team with the process. The pilot process showed an increase in compliance for core measures and laid the groundwork for each hospital to develop an individualized process.