Striving to improve Sepsis Management at Fairbanks Memorial Hospital 

Our multidisciplinary frontline team, made up of physicians, nurses, pharmacists, lab technicians, informatics staff, coders, and quality professionals, has demonstrated a dogged commitment to patient safety through a system-wide overhaul of sepsis care.

Historically, Fairbanks Memorial Hospital struggled with low compliance on sepsis bundle metrics and higher-than-expected inpatient sepsis mortality. Despite multiple prior efforts to improve performance, progress was limited. Past initiatives were hindered by ineffective tools, such as an alert system that fired excessively, and skepticism from clinicians about the validity and relevance of sepsis measures.

In 2024, leadership prioritized sepsis care as a system-wide quality goal. A Sepsis Team was formed, composed entirely of front-line staff and operational leaders, who took on the challenge with fresh determination and a shared commitment to saving lives. Over the course of the year, the team tackled deep-rooted issues, built trust, and transformed care delivery. Their efforts included:

• Becoming a unified, cross-functional team committed to shared goals.
• Gaining in-depth understanding of complex CMS sepsis metrics.
• Identifying and correcting serious gaps in patient identification, discovering the existing alert only identified 8% of septic patients.
• Detecting and fixing a long-missed failure in the reflex lactate testing process, a key sepsis safety tool.

Key safety and process improvement outcomes include:

• A new, clinically-relevant sepsis alert—developed collaboratively with informatics, nursing, and physicians—now identifies 60% of sepsis cases, a dramatic improvement.
• A rebuilt reflex lactate protocol that ensures timely lab testing critical for early intervention.
• A hospital-wide clinician education program that increased awareness and engagement in sepsis recognition and treatment.
• Implementation of an outlier review process to identify gaps, drive continuous improvement, and tailor provider education.
• Integration of sepsis bundle compliance into the ongoing professional performance evaluation (OPPE) for providers—embedding safety into provider accountability.

The results of this work have been transformational:

Since October 2024, Fairbanks Memorial Hospital has consistently met or exceeded the national average for sepsis bundle compliance. Sepsis-related mortality has decreased to "as expected" levels, representing a significant improvement in patient outcomes and safety.