Sepsis Mortality Reduction Project at Contra Costa Regional Medical Center & Health Center

Friday, 25 July 2014

Lai Ping Atalanta Wan, MS, RN, CNS, CCRN
Professional Development Department, Contra Costa Regional Medical Center & Health Center, Martinez, CA


Title: Sepsis Mortality Reduction Project at Contra Costa Regional Medical Center & Health Center

Authors: Atalanta Wan, MS, RN, Kimberly Hauer, RN, Ira-Beda Sabio, RN

Why Is This Important

Sepsis is a complex syndrome that is difficult to define, diagnose, and treat. It is a range of clinical conditions caused by the body’s systemic response to an infection. If it develops into severe sepsis complicated with single or multiple organ dysfunction or failure, sepsis may lead to death. Sepsis is a common leading cause of death in the United States, and the mortality rate of severe sepsis ranges from 28% to 50% (Daniels, 2011).

Improvement Journey

The “Stomp Out Sepsis” (SOS) initiative began at Contra Costa Regional Medical Center (CCRMC) in October 2009. Its roll-out began in January 2010 with refinements continuing to this day. A multidisciplinary team involves physicians, nurses, lab personnel, infection control practitioners, pharmacist, and other drawn from throughout the hospital to implement the SOS project. The team utilized classic quality management techniques, such as standardized work (checklists and standard sepsis order sets), inter-departmental collaboration, staff education, team building, frontline nurse champions, and close monitoring to ensure continuous improvement towards our goals.

What Are We Trying to Accomplish

By June 30, 2015, we will reduce mortality due to sepsis at CCRMC at least 15% by increasing early sepsis recognition and increased compliance with Early Goal Directed Therapy (EGDT) guidelines (Dellinger et al., 2013). Achieve 95% compliance in the use of the severe sepsis screening tool with all patients, and achieve at least 85% compliance in the use of the EGDT bundle.

Target Population


All patients age 18 years and older presenting to the emergency department (ED) or inpatients on acute care units.


Inpatients on the hospital skilled nursing facility(SNF) units, OB patients, patients transferred to ICU with severe sepsis or septic shock, patients who are “Do not Resuscitation” (DNR), “Do not Intubation”(DNI), comfort care or palliative care on admission or ordered within 24 hours, and patients who signed out “Against Medical Advice” (AMA), left the ED without being seen (LWBS), or who refuse care.


Up to date, September 2013, we reduce mortality due to sepsis at CCRMC  to less than 15%, and achieve above 50% compliance with the EDGT bundle (lactate, blood culture, antibiotic, fluid bolus) within the first hour.

Lessons Learned/Challenges

  • Development and implementation of sepsis screening tool.
  • Implementation of  ISTAT  lactate for ED patients.
  • Institution of nurse stat lactate order protocol.
  • Physicians reluctant to give fluid bolus when patients have multiple comorbidities.
  • Blood collection supplies not easily accessible for inpatient nurses to draw STAT lactates.
  • Confusion regarding which sepsis order set to use.