Date of Graduation

Spring 2026

Document Type

Culminating Project

Degree Name

Doctor of Nursing Practice (DNP)

Department

Nursing

Committee Chairperson

Jacquelyn Owens DNP, CRNP, FNP-BC

Committee Member

Christian N. Burchill PhD, MSN, RN, CEN

Abstract

Sepsis remains a leading cause of mortality, morbidity, and healthcare expenditure in the United States, with national SEP-1 compliance rates persistently near 60%. This quality improvement project evaluated whether optimizing sepsis order sets within a large, urban, Magnet-designated hospital improved adherence to the CMS SEP-1 quality measure and associated patient outcomes. Guided by the Donabedian Model, a multidisciplinary sepsis workgroup redesigned emergency department and inpatient sepsis order sets to streamline evidence-based care, enhance workflow alignment, and reduce variation in treatment. A retrospective analysis of 158 adult SEP-1 cases, with 67 cases in the preintervention group and 91 cases in the postintervention group, was conducted over a six-month period from October of 2024 to April of 2025 using data from EPIC and the MIDAS quality database. Postintervention findings demonstrated a statistically significant increase in sepsis order set utilization (47% to 68.1%, p = .010) and a clinically meaningful improvement in SEP-1 compliance (56.7% to 71.4%, p = .055). Although no statistically significant differences were observed in time to antibiotics, length of stay, in-hospital mortality, or 30-day readmissions, process reliability improved, and early trends suggested potential downstream clinical benefit. These results indicate that targeted optimization of sepsis order sets is a feasible and effective strategy for strengthening sepsis care processes and supporting SEP-1 performance. Sustained monitoring and repeated PDSA cycles will be essential to determine long-term impact on patient outcomes and organizational performance.

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