Dear Colleague Letter: Sepsis Protocols Guidance Document to Assist Hospitals with Compliance with NYCRR Parts 405.2 and 405.4

June 2013

Dear Colleague,

I am pleased to share with you a guidance document to assist hospitals with compliance with NYCRR Parts 405.2 and 405.4, Sepsis Protocols. The guidance document is intended as a companion piece to the regulations to provide greater detail with respect to the required components of hospital protocols for severe sepsis and septic shock for adults and for children. Consistent with the regulation, all hospitals will be required to submit protocols on or before September 3, 2013 and once approved, to implement such protocols on or before December 31, 2013. IPRO will be assisting the New York State Department of Health (NYSDOH) with collection and review of protocols. A separate communication will be forwarded by IPRO with explicit instructions for how to submit the required information. In addition, IPRO will be hosting webinars on July 23rd ay 11 AM and again on August 7th at 1 PM. to provide information and guidance regarding protocol submission. (Additional information regarding these webinars will be sent by IPRO directly).

To assist with this process our colleagues at the Healthcare Association of New York State (HANYS) and the Greater New York Hospital Association (GNYHA) will host a series of webinars to provide additional education and guidance. Information for each of these organizations may be found by visiting the websites noted below.

In addition, the New York State Department of Health together with HANYS and GNYHA will be hosting a webinar to provide general guidance on both the regulations and the guidance document. Information on that webinar will be forthcoming and communicated through the HCS as well as the Association websites.

I thank you for your participation in this important initiative and look forward to working with you over the coming months to assure the best possible care for all New Yorkers.


Foster C. Gesten, M.D., FACP
Medical Director
Office of Quality and Patient Safety