Sepsis Bundle Compliance Initiative

This Doctor of Nursing Practice project focused on the development and evaluation of a clinical practice guideline (CPG) designed to improve compliance with the Centers for Medicare & Medicaid Services (CMS) SEP-1 sepsis bundle at a 300-bed Level III trauma center serving a rural population in West Virginia. Sepsis remains a leading cause of morbidity and mortality nationwide, and rural hospitals face additional challenges related to delayed presentation, limited resources, and workflow variability. Inconsistent adherence to evidence-based sepsis bundle elements have been associated with increased mortality risk, prolonged length of stay, and financial penalties (Evans et al., 2021). The purpose of this guideline development and evaluation project was to address identified gaps in standardized sepsis management by developing an evidence-based CPG and evaluating its quality using the AGREE II instrument. The AGREE II, is based on a 1-7 score on the Likert Scale, with 1 representing strong disagreement and 7 representing strong agreement. The practice-focused question guiding this project asked whether a rigorously developed sepsis CPG would demonstrate sufficient quality, clarity, and applicability to support adoption in an acute care hospital setting. Findings from expert review supported strong methodological rigor and clinical relevance, indicating readiness for organizational adoption and future pilot implementation.