RapidEval Study Identifies Key Barriers and Opportunities to Improve Sepsis Care
A study supported by RapidEval released new findings on how frontline teams experience sepsis care delivery across a large academic health system.
Sepsis remains a major patient safety concern, causing an estimated 350,000 deaths annually in the United States. Early recognition and rapid treatment are critical, yet sepsis is notoriously difficult to diagnose and manage in real time.
Dr. Ben Webber and the RapidEval team conducted a mixed-methods study to improve sepsis care and administer antibiotics more quickly at M Health Fairview. A 30 second video on sepsis care was inserted into an existing sepsis Best Practice Alert and evaluated through a randomized stepped-wedge trial.
To better understand system-level challenges, the study team also gathered insights from 22 care team members through focus groups and another 6 via surveys, representing nurses, physicians, residents, pharmacists, lab staff, and members of the sepsis rapid response team (RRT).
No Change Made to Practice
Overall, the sepsis education tool did not lead to antibiotics being administered more quickly. The intervention did not significantly improve sepsis care outcomes either, such as emergency department visits and 30-day readmission.
However, the qualitative arm of the study provided valuable data on why the intervention did not have an impact and shed light on areas where care can be improved for septic patients.
Four Major Themes Emerged
Across interviews and surveys, 18 factors were identified and grouped into four themes:
(1) sepsis detection;
(2) approach to sepsis care;
(3) team dynamics;
(4) awareness of protocols and performance.
Detection and Workflow Challenges
Clinicians described difficulty distinguishing sepsis from other clinical conditions, and many felt current electronic alerts rely too heavily on lactate levels. While the alert provides clear parameters, its high frequency—especially among complex patients—contributes to alert fatigue.
The RRT and standardized sepsis order sets were widely viewed as strengths, improving communication and care consistency. Yet workflow barriers such as lab delays, staffing shortages, and difficulty transferring patients to higher-acuity units frequently disrupted timely care.
Team Dynamics and Role Clarity
Communication breakdowns—during shift changes, between units, and across specialties—were among the most common concerns. Nurses and physicians reported uncertainty about responsibilities once the RRT arrives, including who should complete key sepsis tasks. RRT members also described situations where teams declined their help, leaving their role unclear.
Multiple participants called for additional staffing support, including more lab personnel and expanded pharmacist availability for sepsis huddles.
Awareness and Transparency
Participants noted growing awareness of sepsis across the system but emphasized the need for more accessible resources for frontline staff. Clinicians also expressed a strong desire for real-time performance data to track progress and identify gaps.
Looking Ahead
The study highlights both the value and complexity of interdisciplinary sepsis care. While resources such as the RRT and order sets provide structure, system-level barriers—including communication, staffing, and alert fatigue—continue to affect care delivery. Future improvement strategies may focus on clarifying team roles, enhancing communication, refining alert logic, and increasing transparency through data dashboards.
By centering the voices of frontline clinicians, RapidEval provides critical insight into how health systems can strengthen sepsis care and better support the teams delivering it.
