Inpatient sepsis order set use and impact on SEP-1 compliance in severe sepsis and septic shock

Document Type

Conference Proceeding

Publication Date


Publication Title

Ohio Pharmacy Residency Conference


Purpose: Since 2015, hospital performance has been measured against the Centers for Medicare and Medicaid Services (CMS) “SEP-1” sepsis core measure. Beaumont Hospital-Dearborn created an inpatient order set to improve the care of patients with sepsis syndromes and to meet SEP-1 requirements. This study aims to determine the association between order set usage and CMS core measure compliance for patients who develop severe sepsis or septic shock during a hospital admission. Methods: This is a retrospective, cohort study of adult patients who developed severe sepsis or septic shock during an admission to Beaumont Hospital, Dearborn (BHD) between February 2020 and February 2021. Patients meeting CMS sampling criteria were included in this study. Groups were defined as patients receiving sepsis treatment with or without the order set. The primary endpoint of this study was to determine the percentage of cases compliant with the CMS SEP-1 measure. Results: Twenty-three patients were included in this study (7 patients were treated using the order set, 16 were not). The entire SEP-1 CMS core measure was met in 0% order set group cases versus 6% of the non-order set group cases. While SEP-1 was not met, many of the individual measure components of were achieved with a greater frequency in the order set group compared to the non-order set group, including fluid bolus (71% vs 19%), zero-hour lactate (100% vs 38%), initial blood culture draw (100% vs 75%), and antibiotics administered within 3 hours (86% vs 75%). Finally, a lower mortality rate was observed in the order set group (0%) versus the non-order set group (25%). Conclusions: In conclusion, use of the order set did not predict compliance to the overall SEP-1 measure. However, this use of the order set correlated with higher compliance to many of the individual components of the measure.

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