Sepsis Care Improvement at Grande Ronde Hospital: A Journey to 100% Compliance

Sepsis is a life-threatening condition that occurs when the body’s immune system has an extreme response to infection, leading to widespread inflammation, organ dysfunction and potentially death, according to the World Health Organization (WHO). Early symptoms often mimic other illnesses, making timely identification challenging, and valuable time can be lost gathering health histories and awaiting diagnostic results. 

 

At Grande Ronde Hospital (GRH), varied approaches to managing severe sepsis created delays in initiating timely treatment. Staff needed a unified strategy to help with sepsis recognition. Evidence shows that patient survival decreases by 7.6 percentage points for every hour treatment is delayed in the first six hours. 

 

In 2020, data revealed critical gaps in care: among emergency department patients presenting with severe sepsis or septic shock, only 69% had blood cultures drawn, 41% received antibiotics, and 47% received a 30 mL/kg fluid bolus within the first hour. Alarmingly, only 19% received all recommended interventions within the first three hours. 

 

GRH launched a sepsis quality initiative in 2020 after performance data revealed that just 22% of patients received complete bundled care. The ED team led early progress by improving timing for blood culture collection, antibiotic administration, and fluid resuscitation. Their success galvanized collaboration with the laboratory and medical/surgical departments, expanding the initiative to include repeat lactates, vasopressors, and perfusion assessments for septic shock cases. 

Though staffing turnover in 2022 temporarily stalled progress, momentum returned in 2023 following the release of the Centers for Disease Control and Prevention’s (CDC’s) Hospital Sepsis Program Core Elements. These guidelines inspired renewed commitment and provided a framework for sustained improvement. Under the leadership of physician champions and the chief informatics medical officer, GRH implemented a suite of tools and protocols, including: 

• A standardized sepsis detection tool; 
• A dedicated sepsis order set; 
• ED checklists and handoff protocols; 
• Reflex lactate orders; and 
• Documentation pathways for clinical exceptions. 

These efforts culminated in a consistent upward trajectory in bundle compliance. Since Q3 2023, GRH has exceeded national average performance rates, achieving a milestone 100% compliance rate in Q1 2025 for the severe sepsis care management bundle. GRH’s commitment to improving care for patients with severe sepsis and septic shock has not gone unnoticed. The hospital's journey has become a model of multidisciplinary collaboration and evidence-based practice. Internally, teams across the emergency department, lab, and medical/surgical units have been recognized for their leadership, adaptability and dedication to patient safety.