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  • To assess a clinical issue that is the focus of the Quality Improvement Project.
  • Evaluate the clinical project.
  • Putting it all together for the final Quality Improvement Project.

Content Requirements:

  1. A description of the clinical issue (SEPSIS education for providers(nurses doctors etc) to be addressed in the project.
  2. A SWOT (strengths, weaknesses, opportunities, threats) analysis for the project. Analysis of the strengths, weaknesses, opportunities, and threats related to the quality improvement process.
  3. An outline of the action plan for the project.
  4. An assessment of clinical issue that is the focus of the quality improvement project.
  5. Discuss stakeholders and decision makers who need to be involved in the quality improvement project.
  6. Discuss resources including budget, personnel and time needed for the quality improvement project.
  7. Discuss potential strategies for implementation and evaluation.


Quality Improvement Project – Sepsis

Jenna Horgan

St Thomas University

NUR 419

Professor Fibbio

April 30, 2023


The selected clinical issue is sepsis, a healthcare condition caused by the body’s response to the infection. It is a life-threatening condition that needs prompt diagnosis and treatment. The Centers for Disease Control and Prevention (CDC) reports show that approximately at least 1.7 million adults in the United States have suffered from sepsis, and about 27,000 mortality cases are linked to condition. The annual cases of sepsis in the United States are on the rise, linked to various factors (National Institute of General Medical Sciences, 2021). Most sepsis is caused by bacterial infections, but it can as well be caused by viral infections, for example, COVID-19. It also occurs as a result of fungal infections or noninfectious insults like a traumatic injury. One of the factors is the increase in awareness and the process of tracking sepsis, leading to the recognition of more cases. The other factor is that individuals with chronic diseases live longer, and sepsis is more common and harmful in individuals with other diseases and older adults (Lee et al., 2022). Some infections can no longer be eliminated using antibiotics. The common symptoms of sepsis are fever, confusion, disorientation, rapid breathing, and heart rate. Most of these symptoms are common in other conditions. Therefore, it is hard to recognize sepsis conditions in their early stages.

The reasons for changing the status quo in the management of sepsis are to ensure improved patient outcomes and reduced mortality rates. The approaches involving early recognition and treatment of sepsis help in the prevention of possible progress of sepsis or septic shock. The present status quo in managing the issue involves identifying and treating the underlying infection, initiating broad-spectrum antibiotics, and offering supportive care (National Institute of General Medical Sciences, 2021). Nevertheless, there is a greater difference in sepsis management among providers hence delay in the diagnosis and treatment and the suboptimal client outcomes.

Based on the research literature, the best practices are implementing the sepsis protocols, using early warnings, and offering education to healthcare providers. The sepsis protocols are considered evidence-based guidelines that offer a systematic strategy for managing sepsis (Kim & Park, 2019). The protocols involve early recognition, rapid administration of the antibiotics, and hemodynamic support. Many studies have shown that the use of sepsis protocols helps in the improvement of patient outcomes and the reduction of mortality rates.

The early warnings involve using the vital signs and the laboratory data that help identify the patients at risk for sepsis and trigger the alert to providers. Applying early warning systems helps reduce the time to recognize sepsis and improve overall patient outcomes (National Institute of General Medical Sciences, 2021). The education of healthcare providers is important in improving sepsis management. Education is offered to the providers to increase the knowledge of the potential signs of the disease, the importance of identifying and treating, and the utilization of the sepsis protocol the providers are educated on the signs and symptoms of sepsis, the role of early identification and treatment, and the use of the sepsis protocol. Studies have revealed that education helps improve adherence to sepsis protocols and reduce mortality rates.


Sepsis is a severe condition that demands an instant diagnosis and treatment process. The differences in the sepsis management process among healthcare professionals have resulted in delays in the diagnosis and treatment and suboptimal client outcomes. The reasonable practices involve the implementation of sepsis protocols, the adoption of early warning systems, and the education of healthcare providers. Adopting these practices enables healthcare providers to ensure an improvement in the management of sepsis conditions, reduction of mortality incidences, and improvement of patient outcomes.


Sepsis is one of the most severe medical disorders doctors treat. Excessive inflammatory response to an infection can harm tissue and organs and kill. Sepsis kills 20–50% of people worldwide. To reduce mortality, health personnel must understand sepsis diagnosis and treatment procedures (Kim & Park, 2019). Health institutions use quality improvement (QI) programs to find methods to improve care. Medical institutions must prioritize sepsis protocol improvement to reduce mortality and improve patient care. The report describes strengths, flaws, opportunities, and threats that can affect effectiveness (McVeigh, 2020).


The sepsis protocol uses evidence-based clinical recommendations and doctors’ best clinical judgment to make decisions. Sepsis protocols have early detection, established guidelines, and multidisciplinary team involvement. Early detection and treatment reduce sepsis progression and improve patient outcomes. Standardized criteria ensure that all patients receive appropriate and consistent care regardless of the healthcare provider’s competence or experience procedures (Kim & Park, 2019). Physicians, nurses, and pharmacists work together to handle all patient care needs. Physicians can apply their clinical expertise while following evidence-based standards. The sepsis protocol also standardizes the event and creates a hospital workflow.


Sepsis procedures suffer from inconsistent implementation, resource shortages, and communication issues. Healthcare providers may not follow sepsis procedures due to insufficient education, competing priorities, or resources (Roberts et al., 2021). A lack of personnel, equipment, and medication can hamper sepsis protocols. Language limitations can delay sepsis diagnosis and treatment. The sepsis protocol also needs stakeholder participation. It can cause miscommunication between the lab, nursing, and doctor staff, delaying diagnosis, treatment, and referral to higher-level medical care. Although not all hospitals follow the latest sepsis recommendations, clinical guidelines, policies, and treatments may differ (Roberts et al., 2021).


Technology, training, and quality improvement are ways to improve quality. Healthcare providers can learn sepsis protocols through training. Electronic medical records and clinical decision support technologies can enhance sepsis diagnosis and treatment. Electronic medical records and telemedicine could also improve patient-provider communication and access to test results, treatments, and drugs procedures (Kim & Park, 2019). Audits and feedback can highlight areas for improvement and help update sepsis protocols. Patient and family education and outreach are also the most significant sepsis protocol improvements. This improves patient outcomes, hospital length of stay, and resource consumption, saving the hospital money.


Limited resources, competing goals, and changing patient populations threaten sepsis protocols. Lack of protocol and practice homogeneity is the biggest sepsis protocol threat. Best practices may not be followed if each hospital uses various techniques and treatments, lowering care quality. Healthcare providers that lack sepsis protocol knowledge may delay diagnosis and treatment, resulting in lower patient outcomes. Sepsis protocols are limited by budget and staff (Roberts et al., 2021). Other quality improvement or patient care activities may overshadow sepsis protocols. Sepsis protocols might also be affected by demographic changes like an aging population or more chronically ill individuals.

Analysis and Action Plan

SWOT analysis shows many sepsis protocol quality improvement opportunities. An action plan must address weaknesses and threats to ensure optimal practices and patient outcomes. SWOT analysis and prioritization are needed to create a quality improvement action plan. Education and training, sepsis recognition and treatment technology, and quality improvement activities to monitor and enhance sepsis protocols may be priorities (Jefferson & Burns, 2020). All healthcare providers must participate, and healthcare leaders must give resources and support. The following action plan can be implemented:

1. Enhance stakeholder engagement: Laboratories, nurses, and doctors should be more involved in the sepsis protocol. This should entail establishing protocols and coding schemes to facilitate communication between parties and training on the protocol and its significant components (Jefferson & Burns, 2020).

2. Upgrade protocols to evidence-based standards to guarantee patient safety and consistent care.

3. Provide patient and family education: This reduces hospital stays, improves patient outcomes, and saves money. Sepsis symptoms, risk factors, therapies, and prevention should be taught procedures (Kim & Park, 2019).

4. Improve technology availability: Electronic medical records and telemedicine can improve patient-provider communication and access to test findings, treatments, and drugs.

The action plan will help the hospital adopt best practices and enhance sepsis protocols and patient outcomes.

In conclusion, sepsis protocols include strengths, weaknesses, possibilities, and risks. SWOT analysis and prioritization are necessary to improve sepsis care. All healthcare professionals must collaborate and get leadership and resources to implement quality improvement efforts.


Kim, H. I., & Park, S. (2019). Sepsis: Early recognition and optimized treatment. 
Tuberculosis and respiratory diseases
82(1), 6-14.

Lee, Y. C., Dore, M. P., & Graham, D. Y. (2022). Diagnosis and treatment of Helicobacter pylori infection. Annual review of medicine, 73, 183-195.

National Institute of General Medical Sciences. (2021, October 9). Sepsis. Retrieved from

Jefferson, A. E., & Burns, T. (2020). Early Recognition and Intervention of Sepsis Through Nurse Driven Sepsis Screening Protocols. 
AAACN Viewpoint
42(2), 14-15.

Kim, H. I., & Park, S. (2019). Sepsis: Early recognition and optimized treatment. 
Tuberculosis and respiratory diseases
82(1), 6-14.

McVeigh, S. E. (2020). Sepsis management in the emergency department. 
Nursing Clinics
55(1), 71-79.

Roberts, E., Baird, S. M., & Martin, S. (2021). Current Key Challenges in Managing Maternal Sepsis. 
The Journal of Perinatal & Neonatal Nursing
35(), 132-141.

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