IMPROVING EARLY SEPSIS MANAGEMENT THROUGH IMPLEMENTATION OF THE SEPSIS SIX BUNDLE: A CLINICAL AUDIT, QUALITY IMPROVEMENT INTERVENTION, AND RE-AUDIT

Abstract

Background: Sepsis is a time-critical clinical condition in which delays in recognition and initiation of appropriate treatment can contribute to adverse outcomes. The Sepsis Six bundle provides a simple framework for delivering key diagnostic and therapeutic interventions during the first hour of sepsis management. However, translating recommended sepsis care into consistent bedside practice remains challenging, particularly in busy and resource-constrained healthcare settings. This clinical audit and quality improvement project was undertaken to assess compliance with the Sepsis Six bundle in a tertiary-care medical unit and to determine whether a locally feasible quality improvement intervention could improve the timeliness and completeness of early sepsis management.

Methods: A two-cycle clinical audit and quality improvement project was conducted in the Medical B Unit of Ayub Teaching Hospital, Abbottabad, using a Plan–Do–Study–Act (PDSA) approach. The baseline audit was conducted from 1^st  September 2025 to 30^th  October 2025, followed by a multifaceted quality improvement intervention and a re-audit from 20^th  November 2025 to 20^th  January 2026. Adult patients aged ≥18 years with suspected or clinically documented sepsis and sufficient documentation for assessment of initial management were included. Compliance with the six components of the Sepsis Six bundle—serum lactate measurement, blood culture collection, appropriate intravenous antibiotics, intravenous fluids when clinically indicated, oxygen assessment/administration when indicated, and urine-output monitoring—was assessed within one hour of recognition of suspected sepsis. The predefined audit standard was ≥90% compliance with each applicable component and with the complete bundle. The intervention included staff education, introduction of a standardized Sepsis Six checklist, reinforcement during ward rounds and handovers, improved documentation of recognition and intervention times, and regular feedback to the clinical team.

Results: The baseline audit included 84 patients, while the re-audit included 88 patients. Overall compliance with completion of all applicable Sepsis Six components within one hour increased substantially from 21.4% at baseline to 64.8% after the intervention, representing an absolute improvement of 43.4 percentage points. Improvement was observed across all six individual components. Timely serum lactate measurement increased from 41.7% to 79.5%, appropriate blood culture collection from 38.1% to 77.3%, intravenous antibiotic administration within one hour from 57.1% to 86.4%, intravenous fluid administration when indicated from 65.7% to 82.7%, oxygen assessment/administration when indicated from 81.0% to 91.5%, and urine-output monitoring from 46.4% to 83.0%. Oxygen assessment and administration when clinically indicated was the only individual component to achieve the predefined ≥90% audit standard. The median time from recognition of suspected sepsis to lactate sampling decreased from 74 to 42 minutes, blood culture collection from 81 to 45 minutes, antibiotic administration from 68 to 39 minutes, intravenous fluid initiation from 54 to 37 minutes, oxygen administration from 31 to 24 minutes, and urine-output monitoring from 96 to 49 minutes. In-hospital mortality decreased from 19.0% to 14.8%, while median hospital stay decreased from 8 to 7 days; however, these clinical outcome changes were interpreted cautiously because the before-and-after audit design could not establish a causal relationship between improved bundle compliance and patient outcomes.

Conclusion: This clinical audit identified substantial gaps in the timely delivery of early sepsis care in the Medical B Unit of Ayub Teaching Hospital, Abbottabad. A locally adapted, low-cost and multidisciplinary PDSA-based intervention was associated with marked improvement in both the completeness and timeliness of Sepsis Six delivery. Although the predefined overall compliance target of ≥90% was not achieved, the improvement from 21.4% to 64.8% demonstrates that structured education, standardized documentation, bedside checklists, team reinforcement and audit feedback can meaningfully improve early sepsis management within existing hospital resources. Further PDSA cycles, continued audit and feedback, and improved coordination between medical, nursing and laboratory teams are required to sustain these gains and further close the remaining performance gap.