Emergency Sepsis Management & HSMR Improvements

Rationale / Objectives

Baylor Scott & White - North Texas Division found that the Hospital Standardized Mortality Ratio (HSMR) was at a record high for patients with sepsis. Objectives were to reduce sepsis mortality and improve sepsis care.

Project/Program Description & Major Achievements

In order to reduce the HSMR, new diagnostic and management processes were implemented. Sustainability has been achieved through ongoing tracking and transparent reporting to maintain awareness. Staff are also frequently recognized for their achievements.

Lessons Learned

Faster diagnostic testing and managing early sepsis risk factors are key to improvement in this area.

Further Description

Hospital Standardized Mortality Ratio (HSMR) measures real versus expected mortality over time. HSMR is used to monitor service quality for hospital inpatients with common diagnoses.1 From 2007-09, Baylor Scott & White - North Texas Division (Baylor) recorded a high HSMR for inpatients with sepsis; more deaths occurred than expected based on the US national average.1 Baylor’s goal was to reduce the HSMR for inpatients with sepsis. The organization needed to involve staff and manage change to create a sustainable solution. It aimed to develop a reporting system to drive ongoing engagement, awareness, and accountability for sepsis mortality reduction.1 Baylor’s Emergency Department Practice Council developed tools, expectations, and a reporting process, which led to better care processes and lower mortality rates (HSMR).1

Diagnosis Process: The new process begins with faster diagnostic testing after patients register at the emergency department. The triage nurse is responsible for screening patients for sepsis upon arrival. If the result is positive, the patient receives an expedited lactate test to confirm sepsis.


  • Online sepsis screening tool in the ED information system
  • Difficult IV-Start algorithm

Management Process: A new protocol is followed to manage early sepsis risk factors, following a positive lactate test. Clinicians deliver faster treatment by following the ‘difficult IV-start’ protocol, expediting IV access to administer antibiotics and intravenous fluids. Inpatient admission orders are standardized to maintain continuity of care.


  • Daily huddle boards to engage frontline clinicians
  • Standardized transparent compliance reporting for expected processes

Major Achievements

Metric Goal  Result (Mar. 2012 → Jun. 2014)
Time to ABX in ED: % cases within 180 min increased ↑ 28% (66% → 94%)
Time to ABX in ED: Avg minutes decreased ↓ 54 min (120 → 66 min)
Time to IVF bolus completion: % cases within 180 min increased ↑ 17 % (66 → 83%)
Time to IVF bolus completion: Avg minutes decreased ↓ 45 min (135 → 90 min)
Time Period 2007 2008 2009 2010 2011 2012 2013
HSMR (Target: <1.0) 1.205 1.128 0.964 0.895 0.815 0.709 0.754