UMMS Sepsis Program

NEW! Survey Available March 23-April 8, 2022

The UMMS Sepsis Program is asking for provider feedback from across the System to better understand the factors that providers use to assess whether or not a patient has sepsis and to decide whether or not to order a lactate level, cultures, or antibiotics.

We are asking for feedback from Intensivists, Hospitalists, and Emergency Physicians, as well as Physician Trainees (residents and fellows) and Advance Practice Providers who work in intensive care units, med-surg units, and emergency departments from across the System. 

Access the survey here:

The survey will take about 15 minutes to complete and works best when completed on a desktop computer. Responses will be analyzed for themes and insights that will inform how we shape refreshed education and early identification interventions as we work towards adopting a UMMS-wide shared definition of sepsis in 2022.

UMMS is taking action within its member hospitals to standardize the System’s response to sepsis, which a recent study suggests is one of the leading causes of mortality in hospitals worldwide. Current processes to identify, evaluate and intervene to decrease deaths from sepsis vary across UMMS member organizations. Therefore, UMMS developed the Sepsis Program to develop a consistent practice across the System to decrease morbidity and mortality secondary to sepsis.

“Tackling the overall sepsis clinical performance improvement initiative is one of the most important tasks that falls under the umbrella of clinical transformation for the University of Maryland Medical System.”

Andrew N. Pollak, M.D.Senior Vice President for Clinical Transformation & Chief of Orthopedics



Three subgroups of team members from UMMS member organizations are exploring the barriers and opportunities around establishing a better understanding of when and how clinician’s diagnose sepsis.

<center>Thomas Scalea, MD, FACS, MCCM</center>

Thomas Scalea, MD, FACS, MCCM

Executive Sponsor
<center>Samuel M. Galvagno, DO, PhD</center>

Samuel M. Galvagno, DO, PhD

Clinical Sponsor 2014-2021

Chief Medical Officers and other Clinical Leaders from:

  • UM Upper Chesapeake & Harford Memorial
  • UM St. Joseph Medical Center
  • UM Baltimore Washington Medical Center
  • UM Charles Regional Medical Center
  • UM Shore Regional Health Easton, Chestertown, Dorchester
  • UM Rehabilitation & Orthopaedic Institute
  • UM Capital Region Health – pending post transition

Information Technology Representatives:

  • Clinical Informatics
  • Business Intelligence
  • Data & Analytics

Project Facilitator:

  • Dorsey Dowling, Senior Performance Consultant


This UMMS Sepsis Program’s objective is early identification, standardized evaluation and rapid, standardized intervention to decrease morbidity and mortality:

  1. Decrease mortality rates to O/E < 0.8
  2. Decrease readmissions to O/E < 0.8
  3. Decrease ICU Utilization by unplanned admissions

A Tableau dashboard aids the interrogation of data for promoting timely antibiotic administration within 60 minutes. Related diagnostic processes reduce the time from blood culture order to bacterial identification and antimicrobial susceptibility results.

The program’s core components include:

  • Patients presenting to UMMS hospitals via ED or on IP floor with signs of sepsis (patients transferred into the hospital with severe sepsis aren’t currently a part of this evaluation)
  • A workflow for evaluating potentially avoidable deaths from sepsis
  • A workflow regarding the causes & how to potentially decrease sepsis mortality
  • Assessment of the efficacy of the work implemented
  • Establishing best practice for earlier implementation of the sepsis bundle





The Centers for Disease Control and Prevention (CDC) defines sepsis as the body’s extreme response to an infection. It is a life-threatening medical emergency that happens when an infection you already have triggers a chain reaction throughout your body. More specific definitions of this condition vary. At UMMS, we are embarking on the difficult—and critical—path of a consistent definition and treatment that will ultimately help us save more lives of patients in our hospitals.

Despite the significant contribution that sepsis has on morbidity, mortality, and critical care resource utilization, there is notable variation in the diagnosis of sepsis across UMMS—a two-fold difference in diagnosis rate ranging across our hospitals. This rate of sepsis diagnosis varies provider-to-provider, department-to department, and hospital-to-hospital. Standardization of diagnostic criteria is further complicated by the varying criteria used for core measures, the MHAC program, and other quality metrics and reporting requirements around sepsis.

A shared definition of sepsis will enable us to obtain a deep understanding of the impact of our current sepsis processes and programs throughout UMMS. This understanding will inform the next steps in getting the most effective sepsis care to each of our patients at the most appropriate time.

No. Sepsis is a concern at all health care facilities across the country. More than 1.5 million people get sepsis each year in the United States; UMMS hospitals treat about 10,000 patients each year with a primary or secondary diagnosis of sepsis. Through this program, UMMS is working to reduce the number of patients who die from sepsis.

Team members who interact with patients, including nurses, pharmacists, lab technicians and others, will be most affected by changes in our sepsis identification and response. As the program develops, UMMS will provide education and training on all aspects of the new process.

Team members in areas of information technology, CMI coding and quality measurement will also play an integral role in this program as we refine the processes by which we define and record sepsis diagnosis and results in service to our mission of improving patient safety.

A rigorous approach to data will inform all decisions made by the Sepsis Program committees and all metrics established to measure our progress. These will be shared as they are developed.

This effort is truly a System-wide, interdisciplinary, coordinated One UMMS effort. Our work groups and committees are comprised of leaders and team members from each member organization and representing diverse stages of care. Member organizations will continue their own process improvement as we simultaneously create a One UMMS approach.