How to Boost Your Sepsis Bundle Compliance

Stormont Vail Hospital, a 586-bed acute care referral center in northeast Kansas, recognized the challenges posed by the Centers for Medicare & Medicaid Services' (CMS) Severe Sepsis and Septic Shock: Management Bundle (SEP-1) measure. To address this, they embarked on a comprehensive initiative to enhance their sepsis bundle compliance. ​

Background

More than five years ago, Stormont Vail was in the initial stages of implementing the SEP-1 bundle. Carrie Herrmann, with 27 years of diverse healthcare experience, joined the team during this period and played a pivotal role in developing and leading the hospital's sepsis committee. This committee aimed to embed sepsis bundle protocols into the hospital's culture and operations.

Challenges

The primary challenge was achieving consistent compliance with the SEP-1 bundle, given its complexity and the need for coordinated efforts across multiple departments. Additionally, there was a necessity to stay updated with the evolving specifications and ensure that all staff members understood and adhered to the protocols. ​

Strategies Implemented

1. Dedicated SEP-1 Specialist: Appointing a dedicated specialist, such as Carrie Herrmann, ensured continuous oversight of SEP-1 specifications, data analysis, and alignment with the hospital's patient population needs. This role facilitated timely updates to policies and education modules, fostering trust and clarity among staff regarding process changes. ​

2. Formation of an Interdisciplinary Sepsis Committee: The hospital established a sepsis committee comprising emergency department (ED) and hospitalist champions, nurse managers, and informaticists. This team conducted monthly reviews of non-compliant cases to identify trends and actionable items, which were then communicated to staff during regular huddles.

3. Enhanced Case Review Process: Weekly chart audits were performed to promptly identify non-compliant cases. Detailed analyses of these cases were shared with relevant managers, providers, and sepsis champions, facilitating immediate education and corrective actions. ​

4. Increased Sampling for Auditing: Given the hospital's role as a hub for smaller facilities and its substantial sepsis patient population, the team audited 40 cases monthly, double the recommended sample size. This approach ensured a comprehensive evaluation of sepsis cases and enhanced the accuracy of compliance assessments. ​

5. Comprehensive Education and Resource Provision: All new providers and hospitalists underwent standardized sepsis training, with annual competencies and updated education modules reflecting the latest bundle specifications. Staff were equipped with tools such as sepsis badge buddies, screening tools for patient handoffs, and Modified Early Warning Score (MEWS) monitors to facilitate early intervention. ​

6. Process Optimization in the ED: Recognizing documentation discrepancies between the ED and inpatient units, the hospital integrated a running infusion component into the ED's navigation tool. This change led to a significant improvement in fluid compliance, reducing documentation-related failures. ​

Outcomes

These concerted efforts resulted in a notable improvement in SEP-1 compliance rates:​

• Compliance Rate Improvement: The hospital's compliance increased from 55% at the start of the initiative to 82% over five years, with fluctuations influenced by staffing and patient population dynamics. 

• Enhanced Early Intervention: The focus on early recognition and treatment of sepsis cases contributed to a reduction in the progression to septic shock, as evidenced by improved six-hour bundle data. ​

• Documentation Accuracy: Process changes in the ED led to a significant decrease in fluid compliance failures due to missing documentation. ​

Future Directions

With SEP-1's impending inclusion in the Hospital Value-Based Purchasing Program in FY 2026, Stormont Vail is proactively integrating SEP-1 compliance into physician compensation metrics. This strategic move underscores the hospital's commitment to sustaining and further enhancing sepsis care quality. ​

Conclusion

Stormont Vail Hospital's systematic approach to improving sepsis bundle compliance—through dedicated leadership, interdisciplinary collaboration, rigorous auditing, comprehensive education, and process optimization—has yielded significant advancements in patient care quality. Their experience serves as an instructive model for other institutions aiming to enhance sepsis management and compliance.