Adopt leading care workflows and clinical analytics for optimal sepsis care

In 2019, UCLA Health wanted to reduce mortality associated with sepsis and to increase organizational compliance with the SEP-1 bundle, a National Quality Forum measure adopted by CMS.

The health system joined the Vizient Sepsis Early Recognition Collaborative to hear insights and best practices from peer health systems and looked at using Vizient tools like the Clinical Data Base (CDB) to monitor performance and identify areas to improve.

Processes and solutions to streamline care workflows

Ronald Reagan UCLA Medical Center, part of the UCLA Health system, used tools such as sepsis handover progression banners within its electronic health record (EHR).

According to Russell Kerbel, MD, MBA, medical director of sepsis prevention at UCLA Health, the banners display the status of SEP-1 bundle orders, including blood cultures, initial and repeat lactate levels, antibiotics and IV fluid bolus.

The banners use a color scheme to indicate which tests and treatments have been ordered and which are awaiting collection. With repeat lactate levels, the EHR then calculates the dosage of normal saline and lactated ringers based on the formula of 30cc/kg (based on patients’ body weight in kilograms).

“It’s helpful to see that you’re not alone…and helpful to see what similar institutions as yourself nationwide are doing as far as best practices and new tools."

Summer Gupta, RN, MSN, CPHQ
Sepsis Program Manager, UCLA Health

Hardwired alerts and clinical tools help drive and sustain improvements 

UCLA Health uses the CDB to monitor metrics such as expected length of stay, readmissions and mortality risk index which helps identify when process adjustments are needed. The improvements noted above—and Ronald Reagan UCLA Medical Center’s ongoing commitment to improve patient care—have also contributed to a higher ranking in the Vizient Quality and Accountability (Q&A) performance scorecard, jumping from No. 35 to No. 8 among academic medical centers nationwide.

The health system’s commitment to improving quality has been sustained in 2022. In fact, Ronald Reagan UCLA Medical Center was a recipient of the Bernard A. Birnbaum, MD, Quality Leadership Award, recognizing academic medical centers that provide superior performance as measured by the Vizient Quality and Accountability Ranking program.


compliance with the persistent
hypotension element in 2021
compared to 81% in 2019


improvement in SEP-1 bundle compliance since 2019


mortality index for patients with sepsis present on admission in 2021
compared to .72 in 2019


UCLA Health attributes their success to several key initiatives

  • The development of a Tissue Perfusion Smart Phrase in the EHR for providers to document the patient’s history and physical (H&P).
  • The addition of a sepsis lactate prompt for providers when a non-sepsis lactate is ordered.
  • Including both recorded and ideal body weight in the IV fluid bolus portion of order sets.
  • Having a dedicated sepsis program manager is “essential,” according to Dr. Kerbel, who also highlights having sepsis subcommittees in areas such as education, nursing, data display and emergency room. This helps to ensure a multi-faceted approach to constant sepsis improvement.
  • Conducting weekly case reviews for adverse sepsis events, sepsis mortalities with low expected mortalities based on the Vizient Mortality Model helping identify opportunities to improve their high reliability sepsis infrastructure.
  • Reviewing all SEP-1 bundle fallouts within 30 days of discharge to identify opportunities to optimize or clarify documentation.

Building on its previous wins, UCLA Health joined the 2021 Vizient Performance Improvement Sepsis Early Recognition Collaborative to continue its sepsis care improvement journey.

Resources to increase patient safety and lower sepsis mortality

Improving patient survival and reducing in-hospital mortality are more important than ever. Healthcare leaders can use the following expert-led research and insights to help their system realize top-tier performance in quality, safety and cost effectiveness.

Want to know the top performers in healthcare?

Hear from five health systems leaders on the principles that underpin high performance

We brought together CEOs from five health systems to share how they build a first-class culture by focusing on benchmarking, systemness, innovation and health equity.

Read the report on how to harness high performance principles