Leveraging End-Tidal Carbon Dioxide Monitoring to Improve Sepsis Bundle Compliance

Abstract

Sepsis is a life-threatening response to infection that requires early recognition and treatment to reduce morbidity and mortality. This quality improvement project evaluated whether pre-hospital end-tidal carbon dioxide values could be used to support early sepsis identification and improve sepsis bundle compliance in the emergency department. A quality improvement project was conducted in a Level III Trauma Center emergency department in central North Carolina from January 7 to April 30, 2026. Adult patients arriving by emergency medical services with a reported end-tidal carbon dioxide value of 30 mmHg or less were eligible for a nurse-driven point-of-care testing lactic acid standing order. The primary outcome measure was the administration of intravenous antibiotics within 60 minutes of arrival. During the study period, 3,481 patients arrived via emergency medical services. End-tidal carbon dioxide was documented in 467 cases, and 67 patients had values of 30 mmHg or less. After exclusions, 34 patients met the inclusion criteria. The median time from arrival to provider evaluation was 4 minutes, while the median time to antibiotic administration was 65 minutes. Fifteen patients (52%) received antibiotics within the 60-miute goal. Compliance was highest during the first month of implementation, with 68% meeting the target. Although rapid provider evaluation was achieved, time to antibiotic administration remained inconsistent, exceeding the 60-minute goal for many patients. Limited utilization of the nurse-driven point-of-care lactic acid intervention prevented meaningful assessment of its effectiveness. Future quality improvement initiatives should focus on addressing workflow barriers, improving adherence to standardized sepsis protocols, and increasing opportunities for early sepsis identification to enhance bundle compliance and treatment timeliness.