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Sepsis Mortality Improvement

Page history last edited by dkdavis@salud.unm.edu 1 year, 8 months ago

Current Faculty in this Role:

Dana Davis



Sepsis Mortality Improvement



Sepsis is the leading cause of inpatient deaths at UNMH. There are multiple studies which show that specific therapeutic interventions within the first few hours of presentation with severe sepsis or septic shock significantly impact mortality.

The goal of this systems improvement position is to provide a physician champion from within the DOIM in studying, developing, and implementing processes to improve inpatient sepsis mortality through standardization of best practices in sepsis identification and management.



Physician Lead – Sepsis Not Present on Admission sub-committee

Hospitalist Champion – Sepsis Mortality Improvement Team

Physician Lead – Surviving Sepsis Campaign – West Coast Collaborative

Physician co-leader – Severe Sepsis Present on Admission sub-committee



Principal Duties and Responsibilities:

Conduct twice monthly tactical meetings with Nursing champions, Unit Directors, Rapid Response, IT representatives, and data support where we review updates in sepsis management best practices, UNMH current performance in identifying and then managing sepsis, mortality figures, and reviewing Core Measures fall out reports for sepsis. This group then develops strategies to address common deficiencies, recruits target units for trial implementation of those strategies, tracks and fine tunes the processes, and then disseminates the processes hospital-wide. Develop educational material and presentations which are used to disseminate standardized processes hospital-wide.

Attend twice monthly Sepsis Mortality Improvement Team meetings where the focus is on hospital-wide strategic planning for addressing sepsis.Serve as liaison between other Departments and Divisions on issues pertaining to inpatient care in relation to Internal MedicineUpdate Internal Medicine on relevant service and consult agreements between Internal Medicine and other non-Internal Medicine services



Sepsis Mortality Improvement Team

Sepsis Not Present On Admission Committee

Documentation improvement committee




Improve sepsis mortality through standardization of screening for and management of sepsis in the hospital.

Improve compliance with sepsis Core Measure

Improve documentation so as to accurately reflect prevalence, severity, and mortality rate of sepsis at UNMH.


Measures of Success:

Improved screening sensitivity so that sepsis is identified early and consistently.

Improve compliance with standard sepsis management guidelines.

Improve performance in meeting sepsis core measures

Reduce sepsis mortality.

Improve documentation practices so that documentation better reflects severity of illness.


Current Top Priorities/Projects:

Consistent screening of patients in the ED

Standardized protocol for sepsis identified in the ED

Consistent screening of inpatients

Standardized response to positive sepsis screens for inpatients (utilization of Sepsis Order Sets).

Chart review to determine if use of Sepsis Order Sets improves core measures compliance.

Tracking compliance with Sepsis Core Measures

Developing plans to address inconsistent compliance with established guidelines and core measures




Develop Web Page within the hospital intranet -

Development of hospital guidelines for sepsis management - guideline published on Hospital Intranet https://hospitals.health.unm.edu/intranet/Sepsis/index.shtml

Sepsis Screening of every inpatient at least twice each day being done consistently

Sepsis Order Sets created to facilitate ordering appropriate empiric antibiotics, fluids, and diagnostic tests.



Date Last Updated: 7/18

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