Improving Compliance with the Severe Sepsis Protocol: Putting Guidelines into Practice

Sunday, 17 November 2013: 11:40 AM

Lisa Y. Hurst, BSN
Surgical ICU, UPMC Hamot, Erie, PA
Kim M. Raines, BSN
MICU, UPMC Hamot, Erie, PA

Learning Objective 1: The learner will be able to list three interventions for increasing compliance with EGDT as defined by the Survivng Sepsis (SSC) guidelines.

Learning Objective 2: The learner will be able to state the significance of utilizing the severe sepsis order set to improve compliance with the resuscitation and management bundles.

                                                                  Improving Compliance with the Severe Sepsis Protocol: Putting Guidelines into Practice

Lisa Hurst RN, BSN, CCRN; Kim Raines RN, BSN, CCRN; Emily Shears MPH, CIC



In 2011, a retrospective baseline analysis of severe sepsis patients was performed demonstrating use of the severe sepsis order set for only 18% of these patients.  These results served as a catalyst.  The subsequent performance improvement initiative was implemented to increase compliance at UPMC Hamot with the Surviving Sepsis Campaign (SSC) Guidelines.  A descriptive analysis was performed between August 2011 and January 2012 using 102 patients that met the severe sepsis criteria.


A multi-disciplinary severe sepsis team was formed which provided education as well as case review and data analysis. A screening tool for early identification was created and implemented to assist in capturing severely septic patients. 102 patients thus identified were evaluated for having each element of the resuscitation and management bundles.  Utilization of the existing UPMC Hamot Severe Sepsis order set was captured on all patients.  The resuscitation elements including time to blood cultures, antibiotics, and lactate were evaluated for being completed within the specified goal times.  These measures were also compared to the 2011 severe sepsis baseline study patients.


Utilization of the severe sepsis order set for study patients increased from 18% in 2011 to 51% in 2012.   Timing of blood cultures, antibiotics and lactate were all shown to have statistically significant improvements (all measures P< 0.0001) when compared to 2011. Overall, the 2012 performance improvement project has demonstrated 63% compliance with all elements of the resuscitation bundle and 56% with the management bundle.


While the use of the order set does not infer compliance with all of the elements of the bundles, it may have impacted on the number of components addressed in the care of these complex patients.