Improving Sepsis Management Through the Emergency Quality Network Sepsis Initiative

Published:August 04, 2022DOI:


      Public reporting of the Centers for Medicare & Medicaid (CMS) SEP-1 sepsis quality measure is often too late and without the data granularity to inform real-time quality improvement (QI). In response, the American College of Emergency Physicians (ACEP) Emergency Quality Network (E-QUAL) Sepsis Initiative sought to support QI efforts through benchmarking of preliminary draft SEP-1 scores for emergency department (ED) patients. This study sought to determine the anticipatory value of these preliminary SEP-1 benchmarking scores and publicly reported performance.


      Cross-sectional analysis was performed on QI data collected from hospital-based ED sites participating in the E-QUAL Sepsis Collaborative in 2017 and 2018. Participating EDs submitted SEP-1 benchmarking scores semiannually, which were compared to publicly reported CMS SEP-1 data. EDs also reported implementation data on a variety of sepsis-related QI activities for comparison based on SEP-1 performance.


      Among 220 EDs participating in E-QUAL, SEP-1 benchmarking scores showed weak but statistically significant correlation with CMS SEP-1 scores (r = 0.189, p = 0.01). Mean E-QUAL SEP-1 benchmarking scores were higher than mean CMS SEP-1 scores (74.1% vs. 57.2%), with 83.2% of sites reporting a benchmarking score higher than the CMS SEP-1 score. EDs with SEP-1 scores in the bottom 20% reported completion of more sepsis-related QI activities than EDs with average or top 20% SEP-1 scores.


      Preliminary benchmarking results demonstrate a weak, statistically significant correlation with subsequent publicly reported CMS SEP-1 scores and suggest that ED performance in sepsis care may exceed overall hospital performance inclusive of all inpatients. Sepsis quality measurement and sepsis QI efforts may be best guided by separating ED sepsis cases from in-hospital sepsis cases as is done for other acute time-sensitive conditions.
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      1. Agency for Healthcare Research and Quality. HCUP Statistical Brief 122. Septicemia in U.S. Hospitals, 2009. Elixhauser A, Friedman B, Stranges E. Oct 2011. Accessed Aug 11, 2022.

        • Ferrer R
        • et al.
        Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour.
        Crit Care Med. 2014; 42: 1749-1755
        • Dellinger RP
        • et al.
        Surviving Sepsis Campaign.
        Crit Care Med. 2013; 41: 580-637
        • Djurkovic S
        • et al.
        A survey of clinicians addressing the approach to the management of severe sepsis and septic shock in the United States.
        J Crit Care. 2010; 25 (658.e1–658.e6)
        • Barbash IJ
        • Davis B
        • Kahn JM.
        National performance on the Medicare SEP-1 sepsis quality measure.
        Crit Care Med. 2019; 47: 1026-1032
      2. Centers for Medicare & Medicaid Services. Specifications Manual for National Hospital Inpatient Quality Measures: Discharges 10-01-15 (4Q15) Through 06-20-16 (2Q16). Accessed Aug 11, 2022lable from:,

        • Pepper DJ
        • et al.
        Evidence underpinning the Centers for Medicare & Medicaid Services’ Severe Sepsis and Septic Shock Management Bundle (SEP-1).
        Ann Intern Med. 2018 Apr 17; 168: 558-568
        • Kalantari A
        • Mallemat H
        • Weingart SD.
        Sepsis definitions: the search for gold and what CMS got wrong.
        West J Emerg Med. 2017; 18: 951-956
        • Rhee C
        • et al.
        Compliance with the national SEP-1 quality measure and association with sepsis outcomes: a multicenter retrospective cohort study.
        Crit Care Med. 2018; 46: 1585-1591
        • Kahn JM
        • et al.
        Association between state-mandated protocolized sepsis care and in-hospital mortality among adults with sepsis.
        JAMA. 2019 Jul 16; 322: 240-250
        • Barbash IJ
        • et al.
        Treatment patterns and clinical outcomes after the introduction of the Medicare sepsis performance measure (SEP-1).
        Ann Intern Med. 2021; 174: 927-935
        • Rhee C
        • et al.
        Association between implementation of the Severe Sepsis and Septic Shock Early Management Bundle performance measure and outcomes in patients with suspected sepsis in US hospitals.
        JAMA Netw Open. 2021 Dec 1; 4e2138596
        • Wang HE
        • Jones AR
        • Donnelly JP.
        Revised national estimates of emergency department visits for sepsis in the United States.
        Crit Care Med. 2017; 45: 1443-1449
        • Bradley EH
        • et al.
        The Door-to-Balloon Alliance for Quality: who joins national collaborative efforts and why?.
        Jt Comm J Qual Patient Saf. 2009; 35: 93-99
      3. American College of Emergency Physicians. E-QUAL Network Sepsis Initiative. Accessed Aug 11, 2022.

        • Bradley EH
        • et al.
        National efforts to improve door-to-balloon time.
        J Am Coll Cardiol. 2009 Dec 15; 54: 2423-2429
        • Prabhakaran S
        • Lee J
        • O'Neill K
        Regional learning collaboratives produce rapid and sustainable improvements in stroke thrombolysis times.
        Circ Cardiovasc Qual Outcomes. 2016; 9: 585-592
        • Montoye CK
        • et al.
        A rapid-cycle collaborative model to promote guidelines for acute myocardial infarction.
        Jt Comm J Qual Saf. 2003; 29: 468-478
      4. Centers for Medicare & Medicaid Services. Timely and Effective Care—Hospital. (Updated: Jul 7, 2022.) Accessed Aug 11, 2022.

        • Venkatesh AK
        • et al.
        Preliminary performance on the new CMS Sepsis-1 national quality measure: early insights from the Emergency Quality Network (E-QUAL).
        Ann Emerg Med. 2018; 71 (e1): 10-15
        • Cannon CM
        • et al.
        The GENESIS project (GENeralized Early Sepsis Intervention Strategies): a multicenter quality improvement collaborative.
        J Intensive Care Med. 2013; 28: 355-368
        • Miller 3rd, RR
        • et al.
        Multicenter implementation of a severe sepsis and septic shock treatment bundle.
        Am J Respir Crit Care Med. 2013 Jul 1; 188: 77-82
        • Schorr C
        • et al.
        Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards.
        J Hosp Med. 2016; 11: S32-S39
        • Afshar M
        • et al.
        Patient outcomes and cost-effectiveness of a sepsis care quality improvement program in a health system.
        Crit Care Med. 2019; 47: 1371-1379
        • Leisman DE
        • et al.
        Sepsis Presenting in hospitals versus emergency departments: demographic, resuscitation, and outcome patterns in a multicenter retrospective cohort.
        J Hosp Med. 2019 Jun 1; 14: 340-348
        • Rhee C
        • et al.
        Epidemiology of hospital-onset versus community-onset sepsis in U.S. hospitals and association with mortality: a retrospective analysis using electronic clinical data.
        Crit Care Med. 2019; 47: 1169-1176
        • Page DB
        • Donnelly JP
        • Wang HE.
        Community-, healthcare-, and hospital-acquired severe sepsis hospitalizations in the University HealthSystem Consortium.
        Crit Care Med. 2015; 43: 1945-1951
        • Tonai M
        • et al.
        Hospital-onset sepsis and community-onset sepsis in critical care units in Japan: a retrospective cohort study based on a Japanese administrative claims database.
        Crit Care. 2022 May 13; 26: 136
        • Wakabayashi T
        • Iwata H.
        Outcome, diagnosis, and microbiological profile comparison of community- and hospital-acquired bacteremia: a retrospective cohort study.
        J Gen Fam Med. 2021 May 14; 22: 327-333
        • McNally B
        • et al.
        CARES: Cardiac Arrest Registry to Enhance Survival.
        Ann Emerg Med. 2009; 54 (e2): 674-683
        • Hong Y
        • LaBresh KA.
        Overview of the American Heart Association “Get With The Guidelines” programs: coronary heart disease, stroke, and heart failure.
        Crit Pathw Cardiol. 2006; 5: 179-186