Reducing Unnecessary Variation in Care – Sepsis QI Project

The World Health Organization has designated sepsis as a global priority – one that Island Health shares.

The Sepsis Quality Improvement Project aims to improve patient outcomes through standardization of early sepsis recognition and management at all Island Health facilities.

The areas of focus are:

  1. Review and standardization of care pathways in the emergency department
  2. Review and optimization of clinical care pathways in in-patient medical units
  3. Review of the sepsis antibiotic module within the Spectrum App
  4. Development of electronic support tools.

Emergency Department, Medicine, Infection Management and Adult ICU Quality Councils are leading this work.

Sepsis Quality Improvement Project Timeline and Updates

An order set and clinical care pathways review identified variation in the processes to recognize and manage sepsis. This variation in processes, combined with variation in practice confirms an opportunity for standardization of practice and improvement of outcomes. Emergency department and in-patient working groups were formed to support the development of electronic support tools to standardize care.

What do I need to know about the Sepsis QI Project as a physician?

Any physician or medical staff member who is providing care to a single adult patient or a group of adult patients with a suspected or confirmed sepsis diagnosis will be required to use the tools developed as part of the Sepsis Quality Improvement Project.  

A resource has been developed for physicians which can be viewed here. (Updated March 2022)

An infographic has been developed to highlight ‘What’s New, What’s Changed, and Why?'. This one-pager shares details of what is new and what has changed for Emergency Department Clinical Order Sets and Protocol for those familiar with previous tools for sepsis recognition or management. (Updated March 2022)

Please visit the Sepsis Resource Centre on the Island Health Intranet to learn more about nursing key competencies, education resources and other tools developed to support sepsis care. **Island Health login is required**

Clickhere Sepsis Resource Centre
**Island Health login is required**
Intranet resource hosting clinical tools and educational materials.

Sepsis Physician Package
Developed for Emergency Department and Inpatient physicians involved in early recognition and management of sepsis.

What’s New, What’s Changed, and Why? Infographic
Document to highlight changes and additions to emergency department clinical order sets.

(Updated March 2022)


**Island Health login is required**

The Sepsis QI Project Report is located on the ‘Quality Improvement’ section of the Report PORTAL under the heading ‘Medical Quality’.

Reducing Unnecessary Variation In Care - Sepsis QI Project Timeline



Reducing Unnecessary Variation in Care – Sepsis QI Project Timeline

Driving Quality Improvement through Data Analysis

A three-year analysis of 4,261 inpatient sepsis episodes have been as identified and analyzed. 7.4% of sepsis episodes developed after admission. Island Health is one of only five health regions in Canada with an extraordinarily low in-hospital sepsis rate (below 99.8% confidence limits).

The majority of sepsis episodes began in the emergency department (95.7%), and nearly a third (31.4%) were eventually admitted to an intensive care unit. Analysis exploring both predisposing and precipitating risk factors showed a relationship between outcome and time to first blood culture. This variation in initial management of sepsis confirms an opportunity for standardization of practice and improvement of outcomes.


To learn more about this work, read the Sepsis QI Project Report located on the Report PORTAL. **Island Health login is required**.

To find the report:

1. Login to the Report PORTAL using your Island Health Login:

2. Navigate to ‘Quality Improvement


3. The report is located under the heading ‘Medical Quality’.

VGH Pilot Launch – March 2021

New order sets landed at VGH for the launch of our Sepsis QI Project Pilot on March 15, 2021

The Sepsis QI Project Oversight Committee launched a pilot at VGH on March 15, 2021 introducing new tools and resources essential to reduce variations in care and improve outcomes, including a new clinical order set for inpatient and the ED areas. Click here to see the Sepsis Pilot Benefits Map developed in consultation with our incredible clinical nurse educators at VGH.

Training leading up to, and during the pilot, leveraged ‘gamification’ - an approach that uses elements of game-design and game principles in non-game contexts. Gamification is exciting and novel and transforms how VGH staff engage in the pilot, honing their skills and knowledge to improve recognition of early sepsis.

Starting in early fall 2021 the Sepsis QI Project Oversight Committee are scaling out the pilot learnings across Island Health.

Click here to learn more about how Gamification is taking learning about Sepsis to the Next Level.

Clickhere What is Sepsis infographic? VGH is the pilot site for the Sepsis Quality Improvement Pilot
Clickhere Sepsis Pilot Benefits Map Infographic


September is Sepsis Awareness Month 

Island Health is committed to continued sepsis awareness and invites medical staff and our multidisciplinary team members to participate in Sepsis Awareness month each September!

September 13 is World Sepsis Day!

Island Health continues to be committed to raising awareness of sepsis through acknowledgement of World Sepsis Day on September 13, 2021.

In recognition of World Sepsis Day, the Sepsis QI Improvement Project Oversight Committee is excited to share the new Sepsis Resource Centre on the Island Health Intranet (*Island Health Login Required*). The Oversight Committee will be connecting with sites individually to promote and support the rollout of these new and updated tools for use in Emergency Department and Adult Inpatient Acute Care in the coming months! Stay tuned for your turn to join in this journey to reduced variation and improved care.  

To learn more about how Island Health is acknowledging World Sepsis Day in 2021, click here.

Acknowledging World Sepsis Day, September 13, 2020

In acknowledgement of World Sepsis Day, September 13, 2020, Island Health partnered with The BC Sepsis Network to raise awareness of sepsis. We launched the Great Island Health Sepsis Challenge on September 1 and invited our medical staff and those in patient care to take part, surpassing our goal of 1,000 participants!  

An infographic summarizing the results from the Great Island Health Sepsis Challenge can be viewed here.

Planning is already underway for how we can continue to create awareness by acknowledging World Sepsis Day in September 2021. 

Clickhere Great Island Health Sepsis Challenge Infographic