Pomona Valley Hospital Medical Center

Pomona, California

The Pomona Valley Hospital Medical Center ED implemented a nurse-led, physician-partnered sepsis recognition and response program to improve sepsis bundle compliance. Through shared governance, bedside nurses helped design and implement a standardized sepsis screening tool, a two-tier Gold Alert response process and evidence-based workflows that empowered nurses to initiate rapid interventions at triage. This resulted in sustained improvements in sepsis bundle compliance and reduced sepsis mortality from 16.9 percent in 2023 to 12.6 percent in 2024, with performance sustained through 2025. The program has since expanded to pediatric patients.

The Pomona Valley team also improved patient flow by redesigning its intake process, implementing AcceleratED Care and the Provider on Arrival models. These initiatives introduced vertical patient flow, immediate provider evaluation, nurse-initiated diagnostics and treatment and continuous performance monitoring to the 72-bed department. The results included a reduction in the rate of patients leaving without being seen from 1.9 percent to 0.7 percent; a decrease in elopements from 1.8 percent to 1.0 percent; shorter door-to-provider times; length of stay duration below national benchmarks; and improved patient satisfaction. These improvements have been sustained through standardized workflows, daily throughput huddles and ongoing “Plan-Do-Study-Act” cycles.