National Daily Hospital News
Special Report
“System-Wide Sepsis Improvement Sprint”
SBAR, Case Studies and Project Plan
Friday, November 14th, 2025
1. Situation – Why a Sepsis Improvement Sprint Now
Sepsis burden is rising and financially unsustainable. AHRQ’s 2025 analysis shows sepsis inpatient caseloads in nonfederal acute care hospitals increased from 1.8 million in 2016 to 2.5 million in 2021 (nearly 40% growth), making sepsis one of the most expensive hospital conditions in the United States.
https://www.ahrq.gov/news/newsletters/e-newsletter/949.htmlHospitals with structured sepsis programs outperform peers. CDC’s 2024 NHSN sepsis survey and Sepsis Program Core Elements report that hospitals implementing multidisciplinary sepsis programs and improvement efforts have demonstrated reductions in mortality, length of stay, and costs, yet participation and resourcing remain uneven, especially in smaller and rural hospitals.
https://www.cdc.gov/sepsis/media/pdfs/hospital-2024-annual-survey-508.pdf
https://www.cdc.gov/sepsis/hcp/core-elements/index.htmlRegulatory and public expectations are tightening. State sepsis mandates (e.g., Rory’s Regulations in New York) and evolving CMS SEP-1 and quality expectations are raising the bar for early recognition, timely antibiotics, and standardized bundles, with sepsis increasingly framed as a patient safety and equity issue, not just a clinical challenge.
https://www.astho.org/communications/blog/2025/state-health-policies-reduce-sepsis-cases/
2. Background – How We Got Here
Clinical complexity and variability. Sepsis remains a heterogeneous, time-dependent syndrome; updated clinical reviews emphasize that delayed recognition and treatment drive mortality, but also note that rigid, all-or-nothing bundle compliance can miss clinical nuance and fail to account for complex presentations. PMC+1
https://pmc.ncbi.nlm.nih.gov/articles/PMC10179263/
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2831700Evidence for sepsis programs is growing. CDC’s Sepsis Program Core Elements and related MMWR analyses describe a national shift toward structured sepsis programs—sepsis committees, dedicated leadership time, dashboards, and integration with antimicrobial stewardship programs (ASPs)—with hospitals reporting measurable gains where these elements are in place. In 2024, about 80% of hospitals reported sepsis committees, 60% reported dedicated time for sepsis leaders, and 68% reported ASP integration, but smaller hospitals still lag. CDC+1
https://www.cdc.gov/sepsis/hcp/core-elements/index.html
https://www.cdc.gov/mmwr/volumes/72/wr/mm7234a2.htm
https://blogs.cdc.gov/safehealthcare/new-chapter-improving-sepsis-programs-optimizing-patient-care-nationwide/Policy and state mandates as catalysts. New York’s sepsis regulations and subsequent state mandates elsewhere have been associated with reduced mortality and improved early recognition, especially when hospitals implement protocolized sepsis pathways and bundles. PMC+1
https://pmc.ncbi.nlm.nih.gov/articles/PMC6635905/
https://www.astho.org/communications/blog/2025/state-health-policies-reduce-sepsis-cases/Bundles, but not always results. Evaluations of CMS’s SEP-1 and sepsis bundles show mixed results: some organizations report significant mortality improvements with high bundle compliance, while others show limited outcome change, underscoring the need for system-wide implementation, local adaptation, and robust data feedback loops rather than “checkbox compliance” alone. Lippincott Journals+1
https://journals.lww.com/jncqjournal/fulltext/2024/07000/evaluating_sepsis_bundle_compliance_as_a_predictor.10.aspx
https://pmc.ncbi.nlm.nih.gov/articles/PMC12015987/Toolkits now exist, but uptake is uneven. AHRQ’s toolkits for improving antibiotic use and sepsis care, Sepsis Alliance resources, and the Surviving Sepsis Campaign’s bundles provide concrete, evidence-based playbooks, yet many hospitals have not fully operationalized them across ED, inpatient, and post-acute settings. khaquality.com+3AHRQ+3Patient Safety Movement Foundation+3
https://www.ahrq.gov/news/newsletters/e-newsletter/973.html
https://psmf.org/wp-content/uploads/early-detection-and-treatment-of-sepsis.pdf
https://www.sccm.org/survivingsepsiscampaign/guidelines-and-resources
https://www.khaquality.com/programs/sepsis/sepsis-resources/
Bottom line: The science, policy pressure, and toolkits are in place; what many hospitals now need is a time-bounded, system-wide “sprint” to align leadership, frontline workflows, data, and education into a coordinated sepsis improvement push.
3. Action – What a System-Wide Sepsis Improvement Sprint Looks Like
A system-wide sepsis improvement sprint is a 90-day, hospital- or system-level initiative that applies improvement science to sepsis care, built around four pillars:
Governance and program structure. Establish or strengthen a multidisciplinary sepsis program aligned with CDC Sepsis Program Core Elements — including an executive sponsor, a physician and nursing lead, sepsis champions in ED/inpatient units, and integration with the ASP. CDC+1
https://www.cdc.gov/sepsis/hcp/core-elements/index.htmlStandardized pathways and bundles. Adopt or refine ED and inpatient sepsis pathways using Surviving Sepsis Campaign “Hour-1” bundles and CMS SEP-1 requirements as templates, while allowing for clinical judgment in complex presentations. Society of Critical Care Medicine (SCCM)+1
https://www.sccm.org/survivingsepsiscampaign/guidelines-and-resources
https://pmc.ncbi.nlm.nih.gov/articles/PMC12015987/Data, feedback, and learning systems. Use near-real-time dashboards to track recognition (screening flags), bundle elements (lactate, antibiotics, fluids, cultures), SEP-1 reporting, and outcomes (mortality, LOS, ICU transfer), leveraging CDC and AHRQ data tools to benchmark performance. CDC+2AHRQ+2
https://www.cdc.gov/sepsis/media/pdfs/hospital-2024-annual-survey-508.pdf
https://www.ahrq.gov/news/newsletters/e-newsletter/949.html
https://www.ncbi.nlm.nih.gov/books/NBK555517/Education, culture, and communication. Embed sepsis awareness into frontline education and safety huddles, using AHRQ antibiotic use toolkits and sepsis awareness campaigns to emphasize sepsis as a time-critical patient safety event, not an occasional diagnosis. AHRQ+1
https://www.ahrq.gov/news/newsletters/e-newsletter/973.html
https://www.leapfroggroup.org/sepsis-awareness-month-2025
4. Results – Five Case Studies from Recent Sepsis Improvement Efforts
Case Study 1 – Academic Medical Center Sepsis QI Initiative (Adult Inpatients)
A 2025 quality improvement initiative at a large academic medical center implemented a standardized sepsis pathway and data feedback loop; post-implementation, sepsis-associated mortality fell from 10.9% to 6.6%, and mean hospital LOS for sepsis DRG patients decreased by 0.76 days, with changes in antibiotic and blood culture utilization patterns. PMC+1
https://pmc.ncbi.nlm.nih.gov/articles/PMC12154479/
Case Study 2 – Critical Access Hospital (CAH) Bundle Compliance Project (Rural Hospitals)
Alliant Health Solutions’ 2024 initiative with Iowa critical access hospitals focused on improving SEP-1 bundle compliance via gap analysis, education, and real-time feedback; participating CAHs reported increased bundle compliance and decreasing sepsis mortality rates, despite significant resource constraints. NQIIC+1
https://quality.allianthealth.org/wp-content/uploads/2024/07/Improving-Sepsis-Bundle-Compliance-and-Decreasing-Sepsis-Mortality-Rates-in-CAHs_Slide-Handouts_08.29.24_508.pdf
https://www.khaquality.com/document/improving-sepsis-bundle-compliance-and-decreasing-sepsis-mortality-rates-in-critical-access-hospitals/
Case Study 3 – Pediatric Multi-Site Collaborative (IPSO)
The Improving Pediatric Sepsis Outcomes (IPSO) collaborative, involving 66 children’s hospitals, achieved increased recognition and bundle compliance (from 57% to 76.5%) and substantial mortality reductions—47.7% lower mortality among critical sepsis patients and 80.5% lower mortality among suspected sepsis cases—through standardization, shared data, and QI coaching. childrenshospitals.org+1
https://www.childrenshospitals.org/news/newsroom/2025/09/cha-recognized-as-2025-john-m-eisenberg-patient-safety-and-quality-award-recipient
https://www.childrenshospitals.org/news/childrens-hospitals-today/2024/04/how-to-launch-a-multi-site-quality-improvement-collaborative
Case Study 4 – ED SEP-1 Compliance Across a Multi-Hospital System
A 2025 emergency medicine study reported that implementing an EMR-embedded SEP-1 pathway and best-practice alerts across an ED network improved bundle compliance, particularly in obtaining timely blood cultures, lactate measurement, antibiotics, and fluid resuscitation, with data suggesting improvements in short-term outcomes for key subgroups. Annals of Emergency Medicine
https://www.annemergmed.com/article/S0196-0644%2825%2900786-3/fulltext
Case Study 5 – Enhanced Documentation and SEP-1 Performance
A 2025 quality improvement project implementing additional documentation tools and workflow prompts improved CMS SEP-1 bundle compliance and clarified true performance by reducing “apparent” non-compliance due to documentation gaps, enhancing the hospital’s ability to target high-risk sepsis cases and track improvement. smrj.scholasticahq.com
https://smrj.scholasticahq.com/article/144142-improving-cms-sep-1-sepsis-bundle-compliance-with-additional-documentation-measures
5. Quality Metrics from These Case Studies (and National Data)
National caseload trend. Sepsis inpatient cases at nonfederal acute care hospitals rose from 1.8 million (2016) to 2.5 million (2021) — an increase of nearly 40% in just five years.
https://www.ahrq.gov/news/newsletters/e-newsletter/949.htmlMortality reduction in adult QI initiative. After implementing a hospital-wide sepsis QI initiative, one academic center reduced sepsis-associated mortality from 10.9% to 6.6% (p < 0.001) and decreased mean LOS by 0.76 days.
https://pmc.ncbi.nlm.nih.gov/articles/PMC12154479/Pediatric bundle impact. The IPSO pediatric collaborative reported that bundle-compliant care was associated with 47.7% lower mortality among critical sepsis patients and 80.5% lower mortality among suspected sepsis cases, coupled with improved recognition and treatment timeliness.
https://www.childrenshospitals.org/news/childrens-hospitals-today/2024/04/how-to-launch-a-multi-site-quality-improvement-collaborativeProgram adoption metrics. By 2024, about 80% of U.S. hospitals reported sepsis committees, 60% reported sufficient dedicated leader time, and 68% reported antibiotic stewardship program integration into sepsis care, indicating both progress and ongoing opportunity.
https://blogs.cdc.gov/safehealthcare/new-chapter-improving-sepsis-programs-optimizing-patient-care-nationwide/Disparities and rural risk. Alliant’s CAH sepsis work highlights substantial disparities, with sepsis mortality per 100,000 population markedly higher among Black and Native American patients (81.8 and 68.0, respectively) than among White and Asian patients (47.0 and 33.7), and small rural hospitals less likely to have dedicated sepsis leadership time.
https://quality.allianthealth.org/wp-content/uploads/2024/07/Improving-Sepsis-Bundle-Compliance-and-Decreasing-Sepsis-Mortality-Rates-in-CAHs_Slide-Handouts_08.29.24_508.pdfPotential national impact (assessment).
If U.S. hospitals broadly achieved a 4.3 percentage-point absolute mortality reduction (from 10.9% to 6.6%) similar to the Thomas et al. initiative, and assuming roughly 2.5 million sepsis hospitalizations annually, this could translate (very roughly) into on the order of 100,000 or more deaths averted per year.
This figure is an assessment made today from a broad survey of currently available data and is not a robust meta study. digitalscholar.lsuhsc.edu+2AHRQ+2
https://pmc.ncbi.nlm.nih.gov/articles/PMC12154479/
https://www.ahrq.gov/news/newsletters/e-newsletter/949.html
https://www.infectiousdiseaseadvisor.com/features/improving-sepsis-bundle-compliance/Awareness and safety framing. National sepsis campaigns now routinely emphasize that sepsis is implicated in roughly 1 in 5 deaths worldwide and that strong protocols — rapid assessment, bundled treatment, and infection prevention — can significantly reduce complications and mortality.
https://www.infectiousdiseaseadvisor.com/features/improving-sepsis-bundle-compliance/
https://www.leapfroggroup.org/sepsis-awareness-month-2025
6. Leadership Project Plan – 12-Week System-Wide Sepsis Improvement Sprint
Assumption: Project start date is Monday, November 17, 2025. Adjust dates to match your calendar.
Week 1 (Nov 17–23, 2025) – Launch and Governance
Appoint an executive sponsor, physician lead, nursing lead, and data/quality lead for the sepsis sprint.
Confirm a multidisciplinary Sepsis Steering Committee (ED, hospital medicine, ICU, nursing, pharmacy, lab, case management, IT/analytics, finance, and post-acute/ACO partners).
Approve the 90-day sprint charter: goals (e.g., 10–20% relative mortality reduction, LOS reduction, SEP-1 compliance targets), scope (ED + adult inpatient), and key metrics.
Align the sprint with existing safety, quality, and financial initiatives to avoid duplication.
Week 2 (Nov 24–30, 2025) – Baseline Assessment and Data
Pull a 12–24 month baseline for sepsis cases: volume, mortality, LOS, ICU transfer, readmissions, SEP-1 compliance, and bundle elements.
Map current sepsis identification and escalation workflows in ED and inpatient units (who triggers, who responds, how orders are placed, who reviews data).
Identify gaps against CDC Sepsis Program Core Elements and SEP-1 requirements.
Draft a sprint measurement plan: daily/weekly dashboards, run charts, and feedback cadence.
Week 3 (Dec 1–7, 2025) – Pathway and Bundle Design
Convene a clinical design team to finalize a standardized sepsis pathway (ED + inpatient) using Surviving Sepsis Campaign bundles and local practice.
Define “Code Sepsis” criteria (e.g., suspicion of infection + organ dysfunction, key vitals/lab triggers) and escalation steps.
Align antibiotic selection and de-escalation rules with ASP stewardship guidance.
Review SEP-1 and documentation requirements; embed them in clinical workflows (not just checklists).
Week 4 (Dec 8–14, 2025) – EMR, Tools, and Documentation
Build or refine EMR order sets, smart phrases, alerts, and flags to support rapid implementation of the sepsis pathway.
Implement documentation supports (e.g., sepsis note templates, structured fields) to minimize “false non-compliance” in SEP-1.
Test EMR tools with a small group of clinicians and refine based on feedback.
Finalize a Code Sepsis notification workflow (who gets alerted, via what channel, with what expected response time).
Week 5 (Dec 15–21, 2025) – Education and Culture Kickoff
Launch a Sepsis Awareness Campaign for clinicians: brief huddles, posters, scripts, and short e-learning modules.
Train ED, hospital medicine, ICU, and rapid response teams on the new pathway, order sets, and documentation expectations.
Integrate sepsis prompts into daily safety huddles and bed meetings.
Share baseline data and the sprint’s improvement goals with all staff.
Week 6 (Dec 22–28, 2025) – Soft Go-Live and Rapid PDSA Cycles
Begin a soft go-live of the sepsis pathway on selected units or shifts, with close monitoring.
Run rapid Plan–Do–Study–Act (PDSA) cycles on screening criteria, alert thresholds, and response times.
Start a weekly sepsis dashboard review with the Sepsis Steering Committee.
Gather frontline feedback on barriers (e.g., lab turnaround, pharmacy delays, bed availability) and prioritize fixes.
Week 7 (Dec 29, 2025 – Jan 4, 2026) – Full Go-Live, ED and Inpatient
Move to full sepsis pathway implementation across ED and adult inpatient units.
Ensure consistent Code Sepsis activation and response, with clear roles for nurses, physicians, pharmacy, and lab.
Start shared ED–inpatient huddles focused on early sepsis identification and bed placement.
Track SEP-1 bundle elements and time-to-antibiotics at the patient-level.
Week 8 (Jan 5–11, 2026) – Integration with ASP and Transitions of Care
Deepen collaboration with the Antimicrobial Stewardship Program: early appropriate antibiotics, de-escalation thresholds, and IV-to-oral conversions.
Add post-discharge follow-up processes (phone calls, clinic visits, remote monitoring) for high-risk sepsis survivors.
Integrate sepsis flags into case management and discharge planning to reduce readmissions.
Share early sprint results (mortality, LOS, bundle compliance) with hospital leaders.
Week 9 (Jan 12–18, 2026) – Equity, Rural/High-Risk Focus
Stratify sepsis data by race, ethnicity, payer, geography, and hospital type to identify disparities.
For rural hospitals and CAHs, adapt the sprint model with tele-consults, regional transfer protocols, and simplified bundles that match local capacity.
Use Alliant’s CAH experience as a template for resource-constrained settings.
Update the leadership and board on equity findings and targeted responses.
Week 10 (Jan 19–25, 2026) – Hardwiring and Standard Work
Convert successful sprint practices into standard work (policies, protocols, and checklists).
Align performance expectations (e.g., time-to-antibiotics, bundle completion) with physician and nursing peer review and performance evaluations where appropriate.
Document handoff standards for sepsis cases between ED, inpatient units, and post-acute providers.
Begin planning for ongoing monitoring beyond the sprint.
Week 11 (Jan 26 – Feb 1, 2026) – Evaluation and Spread
Compare pre- and post-sprint outcomes (mortality, LOS, ICU transfer, readmissions, SEP-1 compliance, and equity measures).
Identify high-performing units or hospitals and capture their “bright spot” practices in playbooks and brief videos.
Develop a plan to spread successful interventions to additional service lines (surgery, oncology, OB, pediatrics) as applicable.
Draft a Sepsis Program Annual Plan built on sprint learnings.
Week 12 (Feb 2–8, 2026) – Sustainability and Board Reporting
Present sprint results to the Board Quality Committee and Medical Executive Committee, including both clinical and financial impact.
Lock in ongoing measurement and reporting cadence (monthly dashboards, quarterly deep dives).
Confirm sustainable resourcing for the sepsis program (protected time for leadership, analytics support, ASP collaboration).
Celebrate success with frontline teams and publicly reaffirm sepsis care as a strategic and moral priority for the organization.
National Daily Hospital News
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