Sepsis Protocol: How Hospitals Can Boost Outcomes and Track Core Elements

Sepsis remains one of the costliest and deadliest challenges in healthcare, claiming hundreds of thousands of lives each year. In this article, you’ll discover how evidence-based protocols and leadership-backed strategies can help hospitals detect sepsis sooner, streamline patient care, and ultimately save lives. By examining recent survey data and the CDC’s newest guidelines, the piece offers actionable insights to strengthen your sepsis management efforts.

⏰ 7 min read

January 6, 2025

An effective Sepsis Protocol is essential in reducing sepsis-related mortality and improving patient outcomes. It begins with critical leadership support and follows evidence-based practices designed to track key clinical data and enhance coordinated care within hospitals.

Hospital leaders across the U.S. are making inroads in the effectiveness of their sepsis management strategies, but health officials suggest that more can be done.

Whether it is the advocacy of executive leadership, education for healthcare personnel, or access to data that would bolster sepsis protocol efforts, hospitals can take steps to improve their functioning around this costly – and deadly – condition that impacts millions of people per year.

Assessing the Impact of Sepsis on Protocol Development

The consensus definition of sepsis is “life-threatening organ dysfunction caused by a dysregulated host response to infection,” according to a widely cited JAMA article. Most often, bacterial infections are the root cause of sepsis. However, the CDC notes that viral infections, such as COVID-19 and the flu, can also cause the condition, which can lead to rapid tissue damage, organ failure, and fatality.

The incidence and costs of sepsis are high. Approximately 1.7 million people are hospitalized due to sepsis annually, resulting in 350,000 deaths or a discharge to hospice care per year. For those who survive, a past sepsis episode places them at heightened risk of new disease onset, hospital readmission, job loss, and death. From a cost perspective, research shows that sepsis is linked to $40 billion in Medicare expenditures annually.

While public health initiatives, such as the Surviving Sepsis Campaign and its international guidelines for improving sepsis protocol, have come to the fore over the past two decades, significant gaps and barriers still exist. However, those gaps create an opportunity for hospital leaders to improve care and patient outcomes across the spectrum. The Surviving Sepsis Campaign, a joint initiative of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, offers multiple sepsis guidelines and tools that enhance facilities’ efforts to improve clinical care, identify sepsis early in its disease state, and generally augment sepsis protocol.

Strengthen Your Sepsis Protocol With Free Sepsis & Septic Shock Checklists

Sepsis is a high-stakes emergency that requires swift, coordinated action to reduce mortality and complications. That’s why American Data Network has created free, easy-to-use Sepsis and Septic Shock Checklists—so your care teams can quickly recognize warning signs, implement essential treatment protocols, and save lives. Simply download, print, and laminate these checklists for immediate access in busy departments like the ER or ICU. Empower your clinicians with the key criteria for rapid diagnosis, timely interventions, and clear guidance to bolster patient safety at every step. Download the Sepsis & Septic Shock Checklists now to strengthen your sepsis protocol and improve outcomes.

Downloadable Resource: Sepsis & Septic Shock Checklists

Survey Results Show Progress and Opportunity for Sepsis Protocol Enhancement

According to recent research, many hospitals could use interventional guidance to improve sepsis protocol. A 2023 National Healthcare Safety Network (NHSN) survey found “modest initial progress in resourcing U.S. hospital sepsis programs” compared to the previous year. However, the survey also found that “many opportunities remain to further strengthen hospital sepsis programs to optimize patient care and outcomes.”

The NHSN survey included responses from more than 5,200 hospitals and it found that:

78% of hospitals reported having a specific sepsis committee.
59% of hospitals said they had “sufficient” time dedicated to sepsis leadership efforts.
67% reported that they had enough resources via data analytics.

All of those areas saw improvements in 2023 compared to 2022. However, some key areas of optimal sepsis protocol remain under-resourced. For instance, only 22-23% of hospitals reported that they provided sepsis education during onboarding and yearly sepsis education for certified nursing assistants and patient care technicians. Also, under one-third of hospitals (32%) reported “standardized processes for verbal hand-off,” according to the survey.

Executive leadership remains a big challenge as well. Smaller facilities, in particular, struggle to provide the vital leadership commitment they need to bolster sepsis protocol. While 78% of larger facilities (more than 500 beds) “indicated that sepsis program leaders were provided sufficient specified time to manage the hospital sepsis program,” just 41% of the smallest facilities reported the same, according to the NHSN survey.

7 Core Elements of an Effective Sepsis Protocol

The NHSN survey helped inform the CDC about facilities’ general awareness and aptitude with best-practice sepsis protocol. In August 2023, the agency released the Hospital Sepsis Program Core Elements, a lengthy, multifaceted roadmap centered around seven core elements meant to “aid in the fast recognition of sepsis, facilitate the implementation of evidence-based management of sepsis and support the recovery of patients after sepsis,” according to the CDC. Those seven core elements, along with a brief description, are:

1. Hospital Leadership Commitment

Dedicating the necessary human, financial, and information technology resources.

2. Accountability

Appointing a leader or co-leaders responsible for program goals and outcomes.

3. Multi-professional Expertise

Engaging key partners throughout the hospital and healthcare system.

4. Action

Implementing structures and processes to improve the identification of management of, and recovery from sepsis.

5. Tracking

Measuring sepsis epidemiology, management, and outcomes to assess the impact of sepsis initiatives and progress toward program goals.

6. Reporting

Providing information on sepsis management and outcomes to relevant partners.

7. Education

Providing sepsis education to healthcare professionals, patients, and family/caregivers.

Leadership Buy-In: A Cornerstone of a Successful Sepsis Protocol

The CDC considers buy-in from hospital leadership one of the most important elements of a successful sepsis program. For hospitals just getting started in building an optimal sepsis protocol, the agency posits that they should first identify a sepsis program leader; ensure support from the leadership or executive team; perform a “needs analysis” to pinpoint existing protocols and treatment processes, as well as gaps in such protocols; and from there develop sepsis program goals, both short- and longer-term.

Other facilities may be farther along in their sepsis program journey, but as the NHSN survey shows, there remains room for improvement.

Five Essential Areas for Improving Sepsis Practices

The CDC cites research into five ever-important areas, primarily related to staff education, empowerment, and collaboration, that are “critical for improving the delivery of recommended sepsis practices.” In short, those five areas are:

Staff knowledge. Hospital staff knowing what to do and why.
Treatment focus. Hospital staff being aware of risks and benefits of treatment options.
Collaborative spirit. Hospital staff working closely together in a collaborative effort across roles.
Empowerment and support. Hospital stuff must have the backing of leadership team.
Adequate staffing. Simply put, hospitals must have enough staff to run an effective program.

Leveraging the CDC’s Hospital Sepsis Program Core Elements

The seven “core elements” that comprise the CDC’s hospital sepsis program contain a plethora of details about each one, as well as “priority examples” that give hospital leaders an inside look at how to establish or bolster an effective sepsis protocol. For example, within the “Hospital Leadership Commitment” core element, the agency offers multiple priority examples of what that commitment looks like, e.g., “providing resources, including data analytics and information technology support, to operate the program effectively,” and “appointing a senior administrator (e.g., Chief Clinical Officer, Chief Medical Officer or Chief Nursing Officer) to serve as an executive sponsor for the sepsis program,” among many others.

Under the “Accountability” core element, the agency says that “we strongly recommend sepsis programs be co-led by a physician and a nurse.” Within the “Action” core element, the CDC urges hospitals to implement “a standardized process to screen for sepsis” and provides a link to hospital-based screening tools, as well as numerous sepsis management examples from organizations such as MD Anderson Cancer Center and Intermountain Healthcare.

With the strength of such guideline documents as the CDC’s core elements and others, hospital leaders can move sepsis protocol forward and deliver improved clinical care for some of the most at-risk patients.