By Nurse on Duty · 30 October 2026 · Summarised from the original sources listed below
Nurse-initiated standing orders for sepsis are common in Michigan hospitals, but most are built to speed up testing rather than treatment, and many are rarely used, according to a survey study published in JAMA Network Open on 29 October 2026. Of 68 hospitals surveyed, 48 (71%) had a sepsis-specific standing order that lets nurses act before a physician or advanced practice provider sees the patient, yet none of those orders allowed nurses to start antibiotics.
What are nurse-initiated standing orders for sepsis?
A nurse-initiated standing order (NISO) is a pre-approved protocol that allows a registered nurse to start specific tests or treatments when a patient meets agreed criteria, without waiting for an individual prescriber order. For sepsis, where every hour can matter, these orders are meant to cut delays between recognising the warning signs and starting the care bundle.
Until now, there has been little data on how many hospitals actually have these protocols, what they contain, or how often nurses use them. This study is one of the first to describe them across several care settings.
How the study was done
- Design: a cross-sectional survey study (a research letter) led by researchers at the University of Michigan and partner hospitals.
- Who took part: 68 hospitals in the Michigan Hospital Medicine Safety Consortium, a quality initiative funded by Blue Cross Blue Shield of Michigan.
- When: the survey ran in October and November 2025.
- Settings compared: the ED, inpatient wards, and rapid response teams (RRTs).
Most participating hospitals were nonprofit (90%), urban (82%), teaching (74%), and part of a health system (93%), with a median of 277 beds.
Sepsis standing orders by care setting
The researchers counted 84 sepsis-specific standing orders across the three settings. Many hospitals had more than one: 24 hospitals (35%) had them in more than one setting, while 18 (26%) had them in the ED only.
What the sepsis standing orders included
The orders focused on diagnosis. Across the 84 orders, the most common components were:
- lactate: 80 orders (95.2%)
- blood cultures: 63 orders (75.0%)
- complete blood count: 59 orders (70.2%)
- comprehensive metabolic panel: 49 orders (58.3%)
IV fluids appeared in 27 orders (32.1%), and no sepsis-specific order included antibiotics. The authors describe the orders as “structured primarily to expedite evaluation and not initial treatment of sepsis.”
Rural and nonprofit hospitals were more likely to have them
All 12 rural hospitals had a sepsis standing order in at least one setting, compared with 36 of 56 urban or suburban hospitals (64%). Rural hospitals were also more likely to have one in the ED (92% vs 50%).
ED sepsis orders were found in 39 of 61 nonprofit hospitals (64%) and in none of the 7 for-profit hospitals. Availability did not differ by hospital size, teaching status, or health system membership.
What it means for nurses
- Check whether your unit has a sepsis standing order, where it is kept, and exactly which tests and treatments it covers.
- If your protocol lets you draw lactate and blood cultures early, use it: the study suggests many such orders sit unused.
- Ask your sepsis committee whether IV fluid criteria could be added, especially for rapid response nurses, who already had the highest rate.
- Keep sharpening early recognition skills; resources such as our ABG interpretation guide help when lactate and acid-base results come back.
Limitations
- The survey covered one US state, so results may not apply elsewhere.
- Answers were self-reported by hospitals and may be inaccurate; use was unknown for 30 of 84 orders (36%).
- Several settings within the same hospital were analysed together, so observations were not fully independent.
- The study did not measure whether standing orders improved sepsis care or patient outcomes.
Frequently asked questions
Can nurses start sepsis treatment without a doctor’s order?
Only when a hospital has an approved protocol such as a nurse-initiated standing order. In this Michigan study, 71% of hospitals had a sepsis-specific order, but those orders mainly covered tests like lactate and blood cultures. About a third allowed IV fluids, and none permitted nurses to give antibiotics.
What tests are in a nurse-driven sepsis protocol?
In this study, the most common items were lactate (95.2% of orders), blood cultures (75.0%), a complete blood count (70.2%), and a comprehensive metabolic panel (58.3%). Exact contents vary by hospital, so nurses should always follow their own facility’s approved sepsis protocol and scope of practice.
Why are sepsis standing orders not used more often?
The study did not test reasons directly. The authors suggest possible explanations, including staff not knowing the order exists, poorly designed protocols, unsupportive hospital culture, or patients being assessed quickly by a physician anyway. They call for a core set of components and research into effects on outcomes.
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Sources
- Deshpande BR, Horowitz JK, Cahill M, et al. Nurse-Initiated Standing Orders for Sepsis Across Hospital Care Settings. JAMA Network Open, 29 October 2026.
This summary is for information only and does not replace official guidance or advice from a qualified professional.