Don’t Get Left Behind: Three Critical Questions for Mastering SEP-1 Core Measure Compliance

July 14, 2016 Ellen Amalfitano

Did you know that sepsis is more common than a heart attack, killing one person every two minutes? Or that every year, more than one million Americans fight sepsis?

Despite major improvements in sepsis care over the last 10 years, such as the implementation of the Surviving Sepsis Campaign (SSC), sepsis still remains the leading cause of hospital mortalities in the U.S., accounting for up to 52 percent of all deaths.

New guidelines are continuing to be implemented to help hospitals overcome this challenge. With over 15 clinical care components, it’s not surprising that healthcare providers are finding the SEP-1 core measure a tough one to master, especially with the new SEP-1 5.1 changes that just went into effect on July 1, 2016.

Is your hospital struggling to master the SEP-1 core measure? Here are three critical questions to help diagnosis and correct some of todays most common SEP-1 core measure challenges:

  1. Where do my fallouts start? With so many data points, it’s easy to become overwhelmed with point of care fallouts. Start by separating them into two broad categories: 3-hour bundle compliance vs. 6-hour bundle compliance. Using this division, don’t fix the 6-hour bundle until the 3-hour bundle compliance is solid. This is particularly important as the SEP-1 5.1 changes include cessation of data collection at the first point of care fallout. If you don’t get the 3-hour bundle down, the 6-hour bundle is a non-issue.
  2. Is the root cause of my fallouts “recognition” or “reaction?” If failure to recognize sepsis is the root cause of your fallouts, processes need to be implemented that facilitate screening and detection, such as electronic best practice alerts, screening tools, surveillance of symptoms or shift-to-shift review of patients. If failure to react is the root cause of your fallouts, processes need to be implemented that ensure bundled treatment approaches, such as Code Sepsis, sepsis kits, sepsis clocks or sepsis navigators.
  3. Is my problem “high volume/high risk” or “low volume/high risk?” One advantage to high volume sepsis populations is that SEP-1 requirements will normalize into clinical practice more rapidly than low volume sepsis hospitals. A major disadvantage is the number of clinicians involved – all providers and nurses who care for sepsis patients will need to become SEP-1 experts. With continual staff turnover, maintaining a high level of expertise for a large number of healthcare providers is an ongoing challenge.

With low volume sepsis populations, it’s easier to centralize the accountability for care delivery to a few in-house experts, though fallouts for low volume hospitals do have greater impact on compliance rates. Regardless of high or low volume risk or benefits, success with compliance is dependent upon the fit of the program to the volume of patients and the number providers involved in the care of septic patients.

CLICK HERE to find out seven critical sepsis questions you need to answer at your health system.

Want to know more? Visit the National Institute of General Medical Sciences website for more tools and resources on sepsis care.

Author information

Ellen Amalfitano

Ellen Amalfitano

I’m a director of clinical performance partners from Maryland who gets inexplicably excited about mortality, hospital acquired conditions, patient safety issues and Kaizen events. When I am not working, you will find me running in the woods, skating with my local roller derby team, or sewing costumes for the local high school drama department. Connect with me on LinkedIn.


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