Morbidity and Mortality Weekly Report

Sepsis Program Activities in Acute Care Hospitals — National Healthcare

Safety Network, United States, 2022
Raymund B. Dantes, MD1,2; Hemjot Kaur, MPH2; Beth A. Bouwkamp, MPH2,3; Kathryn A. Haass, MPH2; Prachi Patel, MPH2; Margaret A. Dudeck, MPH2;
Arjun Srinivasan, MD2; Shelley S. Magill, MD, PhD2; W. Wyatt Wilson, MD1,2; Mary Whitaker, MSN2; Nicole M. Gladden2; Elizabeth S. McLaughlin4;
Jennifer K. Horowitz4; Patricia J. Posa, MSA5; Hallie C. Prescott, MD4

Abstract multiprofessional programs to monitor and optimize early

Sepsis, life-threatening organ dysfunction secondary to infec- identification, management, and outcomes of sepsis.
tion, contributes to at least 1.7 million adult hospitalizations CDC’s National Healthcare Safety Network (NHSN)* is
and at least 350,000 deaths annually in the United States. the nation’s most widely used surveillance system for track-
Sepsis care is complex, requiring the coordination of multiple ing patient and health care personnel safety measures, such
hospital departments and disciplines. Sepsis programs can coor- as prevention of health care–associated infections. Hospitals
dinate these efforts to optimize patient outcomes. The 2022 reporting data to NHSN are required to complete an annual
National Healthcare Safety Network (NHSN) annual survey survey with questions regarding patient volume, laboratory
evaluated the prevalence and characteristics of sepsis programs practices, patient safety practices, and facility characteristics
in acute care hospitals. Among 5,221 hospitals, 3,787 (73%) used in risk adjustment for quality measures.† Questions
reported having a committee that monitors and reviews sepsis regarding hospital sepsis program practices were added to the
care. Prevalence of these committees varied by hospital size, 2022 NHSN annual survey to evaluate baseline practices.
ranging from 53% among hospitals with 0–25 beds to 95%
among hospitals with >500 beds. Fifty-five percent of all hospi- Methods
tals provided dedicated time (including assigned protected time All U.S. hospitals (approximately 6,129) are eligible to enroll
or job description requirements) for leaders of these committees in NHSN (6). Enrolled hospitals were required to complete
to manage a program and conduct daily activities, and 55% of the 2022 NHSN Patient Safety Component Annual Hospital
committees reported involvement with antibiotic stewardship Survey by March 1, 2023. Hospital staff members completed
programs. These data highlight opportunities, particularly in the survey electronically, on the basis of hospital practices dur-
smaller hospitals, to improve the care and outcomes of patients ing 2022, using the NHSN web-based application. Responses
with sepsis in the United States by ensuring that all hospitals were provided to four required questions and to three additional
have sepsis programs with protected time for program leaders, required questions, conditional upon responses to the initial
engagement of medical specialists, and integration with antimi- questions. The first question asked about the presence of a
crobial stewardship programs. CDC’s Hospital Sepsis Program committee that monitors and reviews sepsis care and outcomes
Core Elements provides a guide to assist hospitals in developing (sepsis committees), followed by three conditional questions
and implementing effective sepsis programs that complement regarding the functions of and staff member representation on
and facilitate the implementation of existing clinical guidelines the committee. The following three questions asked about lead-
and improve patient care. Future NHSN annual surveys will ership support for sepsis-related activities, approaches to rapid
monitor uptake of these sepsis core elements. sepsis identification, and sepsis management protocols. Survey
respondents were instructed to consult with persons leading
Introduction sepsis efforts or other local expertise as needed to accurately
Sepsis, life-threatening organ dysfunction secondary to complete the survey. Descriptive analysis, stratified by hospital
infection (1), contributes to at least 1.7 million adult hospi- size (number of beds), was completed on a data set generated
talizations and at least 350,000 deaths annually in the United on June 1, 2023, using SAS (version 9.4; SAS Institute). This
States (2). Hospital quality improvement programs focused activity was reviewed by CDC and was conducted consistent
on sepsis have been associated with reductions in mortality, with applicable federal law and CDC policy.§
length of stay, and health care costs (3,4). In 2023, CDC has * https://www.cdc.gov/nhsn/about-nhsn/index.html
published the new Hospital Sepsis Program Core Elements † https://www.cdc.gov/nhsn/forms/57.103_pshospsurv_blank.pdf
§ 45 C.F.R. part 46, 21C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect.
(5) (Sepsis Core Elements), a guide to help hospitals develop
552a; 44 U.S.C. Sect. 3501 et seq.

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Results hospitals, 3,787 (73%) reported having a sepsis commit-

As of June 1, 2023, among 5,397 hospitals enrolled in the tee. These committees were least common in hospitals with
NHSN Patient Safety Component, 5,228 had completed the 0–25 beds (53%), and progressively more prevalent as hos-
survey. Seven surveys were excluded because of incomplete pital size increased (Table 2). Antimicrobial stewardship and
responses, which resulted in inclusion of 5,221 hospitals in infectious disease representatives were integrated into 55%
the analysis (97% completion rate) (Table 1). Among these and 45% of sepsis committees, respectively. Monitoring and
review of antimicrobial use in sepsis care was reported for 61%
TABLE 1. Hospitals completing annual survey — Patient Safety
of sepsis committees.
Component, Annual Hospital Survey, National Healthcare Safety Approximately one half (55%) of all hospitals
Network, United States, 2022 (range = 35% [0–25 beds] to 78% [>500 beds]) reported that
Hospital size, no. of beds No. (%) of hospitals* hospital leadership provided leaders of committees supervis-
0–25 1,580 (30) ing sepsis activities with dedicated time as required to lead
26–50 618 (12) these activities as part of their job description or granted or
51–100 703 (13)
101–250 1,301 (25)
assigned protected time from their other clinical or other job
251–500 759 (15) responsibilities to dedicate to sepsis activities (Table 3). Other
>501 260 (5) indications of leadership support for hospital sepsis programs,
Total 5,221 (100)
such as data analytic or information technology resources, were
* Among 5,397 National Healthcare Safety Network–enrolled hospitals (overall
97% completion rate).
reported more commonly by larger hospitals.

TABLE 2. Sepsis committee utilization, responsibilities, and representation in acute care hospitals — Patient Safety Component, Annual Hospital
Survey, National Healthcare Safety Network, United States, 2022
% of facilities responding
Hospital size, no. of beds
All hospitals 0–25 26–50 51–100 101–250 251–500 >501
Survey questions and responses N = 5,221 n = 1,580 n = 618 n = 703 n = 1,301 n = 759 n = 260
Total, % 100 30 12 13 25 15 5
Our facility has a committee charged with monitoring 3,787 (73) 831 (53) 409 (66) 542 (77) 1,088 (84) 671 (88) 246 (95)
and reviewing sepsis care and/or outcomes,* no. (%)
Responsibilities of this committee, % of facilities†,§,¶
Monitor and review compliance with CMS SEP-1 measure 84 77 85 86 87 85 83
Monitor and review effectiveness of early sepsis 82 77 77 82 85 86 87
identification strategies
Update sepsis identification and management protocols 81 77 78 80 84 85 84
based on current evidence
Monitor and review outcomes among patients with sepsis 81 78 79 81 83 85 82
Develop educational materials for facility staff to 79 72 75 79 82 84 83
improve sepsis care
Monitor and review antimicrobial use in sepsis care 61 59 56 58 64 65 62
Hospital location or service representation of this committee, % of facilities†,§,¶
Emergency department 85 83 80 84 87 90 86
Hospital medicine 76 73 71 77 78 81 75
Neonatal intensive care 6 2 2 6 7 12 13
Critical care or intensive care 65 31 57 72 78 80 83
Labor and delivery 17 11 18 18 17 22 23
Pediatrics 11 7 9 10 9 16 20
Infectious disease 45 39 42 40 48 49 52
Antimicrobial stewardship 55 61 46 52 55 54 54
Infectious disease or antimicrobial stewardship** 65 69 60 61 65 65 64
Pharmacy 71 73 65 70 72 73 68
Laboratory 55 55 50 57 59 55 46
Information technology 41 28 34 40 45 48 55
Other 22 21 22 21 23 22 26
Abbreviation: CMS = Centers for Medicare & Medicaid; SEP-1 = CMS Severe Sepsis and Septic Shock: Management Bundle.
* Required survey question completed by all hospitals that submitted a 2022 Annual Hospital Survey; affirmative responses are shown.
† Conditional required survey question completed by facilities that answered in the affirmative to the required question.
§ Numerator is the number of facilities with a committee that reported a responsibility or type of representation; denominator is the number of facilities with a
committee (responded in the affirmative to the required question) (example: 3,180 / 3,787 × 100 = 84%).
¶ Hospitals could select more than one response per question.
** Hospitals that responded with either infectious disease or antimicrobial stewardship representation, or both.

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TABLE 3. Sepsis leadership, rapid identification, and management practices in acute care hospitals — Patient Safety Component, Annual
Hospital Survey, National Healthcare Safety Network, United States, 2022
% of facilities responding
Hospital size, no. of beds
All hospitals 0–25 26–50 51–100 101–250 251–500 >501
Survey questions and responses N = 5,221 n = 1,580 n = 618 n = 703 n = 1,301 n = 759 n = 260
Total, % 100 30 12 13 25 15 5
Facility leadership has demonstrated commitment to improving sepsis care*,†
Providing sepsis program leaders dedicated time to manage a sepsis 55 35 49 59 65 73 78
program and conduct daily activities
Allocating resources (e.g., information technology or data analyst 65 47 56 69 75 83 89
support, training for stewardship team) to support sepsis efforts
Having a senior executive who serves as a point of contact or 60 40 50 62 71 79 85
champion to help ensure the program has resources and support to
accomplish its mission
Presenting information on sepsis activities and outcomes to facility 71 52 65 77 82 88 88
leadership and/or board at least annually
Ensuring the sepsis program has an opportunity to discuss resource 60 40 52 62 71 78 83
needs with facility leadership or board, at least annually
Communicating to staff members about sepsis activities, via email, 70 56 61 75 78 82 83
newsletters, events, or other avenues
Providing opportunities for hospital staff training on sepsis protocols 74 61 66 78 81 85 87
Ensuring that staff members from key support departments and 70 49 62 74 80 89 92
groups (e.g., information technology and emergency medicine) are
contributing to sepsis activities
None of the above 12 20 18 10 7 3 2
Our facility uses the following approaches to assist in the rapid identification of patients with sepsis, % of facilities*,†
EHR-generated alert based on SIRS criteria 65 58 58 65 70 76 75
EHR-generated alert based on qSOFA 13 10 14 12 13 17 18
EHR-generated alert based on a predictive model 33 21 28 30 39 45 54
EHR-generated alert using other criteria not already specified 15 10 11 15 18 21 27
Manual screening (e.g., use of a checklist) using SIRS or similar criteria 47 41 48 51 50 49 38
No standardized process 10 15 15 9 6 3 1
Other§ 5 4 5 4 6 6 8
Our facility uses the following approaches to assist in the management of patients with sepsis, % of facilities*,†
Protocols that help identify and tailor care for patients with septic 79 65 73 82 88 90 94
shock (e.g., vasopressor orders)
Protocols that prompt the ordering of sepsis diagnostic tests such as 85 76 78 88 91 94 97
blood cultures, lactate, urinalysis, chest radiography, etc.
Protocols that prompt the ordering of preferred antimicrobial 77 64 70 78 84 88 92
treatment regimens for sepsis or underlying infection types
Protocols that prompt the ordering of intravenous fluids 80 69 75 83 86 89 92
Protocols that prompt the reassessment of resuscitative efforts 64 51 60 65 70 74 80
Protocols that are tailored to specific populations (e.g., neonates, 34 21 28 34 40 47 57
pregnant, oncology, or neutropenic patients, etc.)
Automated systems (e.g., EHR timers, prompts, or dashboards) that 46 32 39 45 53 62 70
facilitate compliance with time sensitive aspects of sepsis care
No standardized sepsis protocols or automated systems for sepsis 10 17 15 9 6 3 1
care prompting or monitoring
Other systematic approach§ 4 4 4 4 4 4 5
Abbreviations: EHR = electronic health record; qSOFA = quick sequential organ failure assessment; SIRS = systemic inflammatory response syndrome.
* Required survey question completed by all hospitals that submitted a 2022 Annual Facility Survey.
† Hospitals could select more than one response per question.
§ This included a free-text option and because of low response rate was not included in analysis.

Hospitals reported using various approaches to rapidly iden- common in hospitals with 0–25 beds (15%) than in hospitals
tify patients with sepsis; the most frequent (65%) was electronic with >500 beds (1%).
health record–generated alerts based on systemic inflammatory Hospitals frequently reported the existence of protocols to
response syndrome criteria (7), followed by manual screening assist in the management of sepsis care, including those that
(47%), and predictive models (33%). Ten percent of hospitals prompt the ordering of diagnostic tests (85%), followed by
reported having no standardized process for assisting with rapid those that prompt the ordering of intravenous fluids (80%),
sepsis identification. Having no standardized process was more those that identify and tailor care for septic shock (79%), and
those that prompt the ordering of preferred antimicrobials

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tools and protocols for sepsis detection and early management.

Summary
To achieve further improvements in sepsis care for patients
What is already known about this topic?
throughout hospitalization and after discharge, CDC has
Sepsis is a life-threatening organ dysfunction contributing to at developed Sepsis Core Elements (5). Sepsis Core Elements
least 350,000 deaths annually in the United States. Sepsis care is
complex, requiring multidisciplinary coordination within a hospital.
will provide a guide for creating, structuring, and resourcing
comprehensive sepsis programs, so that hospitals can provide
What is added by this report?
optimal sepsis care. Sepsis Core Elements are intended as a
In 2022, 73% of hospitals reported having a sepsis program,
manager’s guide to complement and support the implementa-
ranging from 53% among hospitals with 0–25 beds to 95%
among hospitals with >500 beds. Only 55% of all hospitals tion of existing sepsis guidelines.
provide sepsis program leaders with dedicated time to manage Sepsis Core Elements was modeled after CDC’s Core Elements
a sepsis program and conduct daily activities. of Hospital Antibiotic Stewardship Program (ASP),** (5) which
What are the implications for public health practice? provides a framework for structuring ASPs that lead to improve-
Opportunities exist to increase institutional support and ments in antibiotic prescribing and reductions in length of
improve the structure of hospital-based sepsis programs, which hospitalization (10). In the 2022 NHSN survey, approximately
is the focus of CDC’s Hospital Sepsis Program Core Elements. one half of sepsis programs reported involvement of ASPs. This
survey also indicated that only 61% of sepsis committees moni-
for sepsis or underlying infection (77%). Sepsis protocols tor and review antimicrobial use in sepsis care, although these
tailored to specific patient populations were available in one responsibilities might overlap with those of ASPs. Sepsis Core
third (34%) of hospitals, ranging from 21% among hospitals Elements recommends inclusion of ASP personnel on sepsis
with 0–25 beds to 57% among those with >500 beds. Overall, committees to facilitate rapid and optimized antimicrobial use
10% of hospitals reported having no standardized protocol to in sepsis and discontinuation of antibiotics when underlying
assist in the management of sepsis care. Having no standard- infection has been ruled out. Coordination and other respective
ized protocol to assist in the management of sepsis care was ASP and sepsis program practices will continue to be tracked in
more common in hospitals with 0–25 beds (17%) than those future NHSN annual surveys.
with >500 beds (1%).
Limitations
Discussion The findings in this report are subject to at least five limita-
This survey of the majority of U.S. hospitals describes the tions. First, the survey is limited to acute care hospitals enrolled
current state of sepsis programs and identifies potential areas in NHSN and might not reflect practices among all U.S. acute
of improvement. Although sepsis committees are present in care hospitals; however, hospitals enrolled in NHSN represent
most hospitals, they occur less frequently in smaller hospitals, at least 88% of U.S. acute care hospitals (5). Second, although
which might have access to fewer personnel and specialty hospitals reported whether specialty services such as pediatrics
resources. Further, just over one half of responding hospitals and labor and delivery were included in sepsis committees, these
reported that dedicated time or assigned protected time was services are not within the scope of practice at all hospitals, and
provided to sepsis program leadership. This survey highlights thus conclusions cannot be made regarding the frequency with
opportunities to further improve the institutional support and which these services might be missing or absent from sepsis
structure of hospital-based sepsis care. committees. Third, although many sepsis committees do not
Sepsis care is complex and requires coordination across mul- monitor antimicrobial use in sepsis, these responsibilities overlap
tiple clinical disciplines and hospital care locations (e.g., emer- with those of ASPs. Collaboration among sepsis programs and
gency departments, intensive care units, and hospital wards). ASPs is emphasized in Sepsis Core Elements to ensure optimal
Evidence-based care guidelines (8), along with state-based (e.g., antimicrobial use in treating sepsis. Fourth, NHSN surveys were
New York State Department of Health Sepsis Regulations)¶ self-reported, and answers were not independently confirmed.
and federal initiatives (e.g., Centers for Medicare & Medicaid Finally, this survey did not strictly define criteria for a sepsis
Services Severe Sepsis and Septic Shock: Management Bundle) program and is subject to respondent interpretation. Sepsis Core
(9) have emphasized the importance of protocols for early Elements defines specific components of sepsis programs that
sepsis identification and prompt management. This survey will be tracked in future surveys.
demonstrated that most U.S. hospitals report having some
** https://www.cdc.gov/antibiotic-use/core-elements/index.html https://www.
health.ny.gov/regulations/public_health_law/section/405/
¶ https://www.health.ny.gov/regulations/public_health_law/section/405/

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Implications for Public Health Practice References

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