Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing


Background: Sepsis is a concern in healthcare, as patients are 2 to 3 times more likely to be readmitted to the hospital than those with other illnesses. Readmitted patient with sepsis costs the healthcare system $3.5 billion dollars per year. Effective care coordination is a tool that decreases readmission rates in other illnesses and is likely applicable to those with sepsis. The purpose of this quality improvement project was to determine if primary care provider follow-up appointments, increased home care utilization, and patient education would reduce sepsis readmissions.

Methods: The Transitional Care Model guided project design and The Kotter Model framed implementation of improvements. Design was a pre/post comparison in two Midwest hospitals, with nurses, social workers, care managers, and patients with sepsis. Stakeholders were engaged, the organization assessed, clinicians were educated, workflow was redesigned, and patient input obtained

Interventions: Evidence-based interventions were implemented to improve patient understanding of sepsis, discharge planning, and care coordination post-hospitalization. This included assessment of discharge need by a care manager; and increasing home health care referrals, registered nurse compliance with sepsis care plan and education documentation, and primary care follow-up appointment utilization.

Results: The convenience sample (N=17) prior (n=7) to and after (n=10) implementation were mean age 75 and 60.5 years, 71.4% and 70% male, and 71.4% and 90% white respectively. Nurse documentation of sepsis education improved 60% (Fishers Exact Test 0.02) and care plan initiation improved 3.1% (Chi-square 0.02). Patients reported somewhat (37%), fairly (50%, or very good (13%) understanding of sepsis following education by the nurse. A decline in home health referrals (11.1%) and primary care appointments (9.7%) occurred. No change in readmission rates were found.

Conclusions: Further intervention is needed to improve sepsis care plan initiation and patient education and documentation to determine if these interventions reduce the readmission rate. The majority of patients went home without a follow-up primary care appointment or home health care set up. Setting up follow-up care may improve the transition between hospitalization and home and prevent readmission of sepsis patients.