Developing and Sustaining a Sepsis Protocol

The Problem:

Abbeville Area Medical Center (AAMC) realized they did not have standard sepsis protocols in their hospital, in part due to a lack of lab testing for lactate levels and a lack of ED documentation tools. 

The Goal:

AAMC set out to design a series of tools using Lean A3 problem solving that would then be developed and pilot tested in the hospitals. Lab lactate level testing equipment will also be put in place with appropriate documentation.

Method & Implementation:

A3 thinking involves a seven-step process that delineates your current and target states, then walks you through a root cause analysis, setting solution goals, and then encourages a series of “rapid experiments” that leads to a Completion Plan for achieving targets. For AAMC, that meant four distinct changes: 1) sepsis screening tools and order sets developed and tested, 2) lab lactate level testing equipment acquired and TAT documented, 3) ED sepsis screening questions added to triage in MedHost (ED EHR), and 4) standard of work created and implemented for communicating between ED and in-patient care.  These four changes were broken into 19 activities in the completion plan and the team tracked 7 different metrics to gauge success:

Did the team recognize sepsis

Was the initial lactate level determined within 3 hours

Were blood cultures drawn prior to administering antibiotics

If systolic blood pressure was less than 90, was mmHG IV fluid bolus given

Was fluid bolus volume adequate

Was appropriate antibiotic administered within 3 hours;

And the percentage of charts that met all criteria

Short-term items are assigned to specific staff and tracked, while long-term issues are filed away for discussion at a monthly process improvement meeting. 

Challenges & Barriers:

  • Time
  • Equipment funding
  • Staff buy-in
  • Sustainability



AAMC saw marked improvement in all 7 categories from Quarter 1 of 2016 through Quarter 3, 2017, although some fluctuation exists from quarter to quarter that suggests the need for additional process improvements and resiliency. Among the successes were:

100% recognition of sepsis up from 33%

100% initial lactate level within 3 hours to 100%

100% fluid bolus given and appropriate antibiotic administered within 3 hours

85% of charts meeting all criteria, after achieving just 33% in Quarter 1

Next Steps:

AAMC is implementing a 2nd bundle for Sepsis on the Inpatient Unit. Measures include:

Was a repeat lactate level performed within 6 hours when indicated

Was a Sepsis Screening Tool initiated

If sever sepsis is present was the tool completed correctly

Was severe sepsis/septic shock accurately documented in the diagnosis

Baseline data demonstrates a 60-80% compliance rate and the hospital continues to work towards continued improvements.

Abbeville Area Medical Center’s best practices in sepsis were highlighted during a Premier HIIN webinar series on April 4, 2017.

For more information about this story or to tell us about your own best practices, email us at

Categories and Tags