Improving Compliance With the Sepsis Six Care Bundle in the Surgical Emergency Department: A Closed-Loop Clinical...

Sepsis is one of the most important causes of morbidity and mortality and is a disease that affects more patients in low- and middle-income countries. Sepsis Six interventions are six time-critical interventions that can be delivered within an hour of sepsis recognition and have been shown to decrease mortality when reliably implemented, but adherence has been poor globally, especially in resource-challenged environments.

The aim of this study was to evaluate and enhance adherence to the Sepsis Six care bundle in adult patients presenting with sepsis in a tertiary care hospital in Pakistan through a closed-loop clinical audit approach.

The study method adopted was a prospective closed-loop clinical audit in Nishtar Hospital in Multan. Sixty consecutive adult patients with sepsis were evaluated for baseline compliance with the six elements of the Sepsis Six package in Cycle 1 (October 2, 2024, to January 3, 2025). After identification of an area of need, a structured intervention phase was put in place, which included educational sessions for medical and nursing staff, sepsis-awareness teaching, and the introduction of a standard sepsis proforma. A further 60 consecutive patients underwent re-audit of compliance, using the same criteria, in Cycle 2 (April 4, 2025, to July 5, 2025). Compliance rates, timing for individual interventions, and documentation quality were compared between cycles using the chi-square test (or Fisher's exact test where expected cell counts were <5) and the Mann-Whitney U test for non-normally distributed timing data.

There was no difference in baseline characteristics between the two audit cycles. There was a significant improvement after the intervention in all of the above, which stayed significant after Holm-Bonferroni correction for multiple comparisons (p ≤ 0.005). The key outcome of delivering the Sepsis Six bundle within one hour significantly increased from 15/60 (25.0%) to 42/60 (70.0%) (absolute difference 45.0%, 95% CI 27.5%-58.7%; χ² = 24.36, df = 1; OR 7.00, 95% CI 3.13-15.64; φ = 0.45). Median time to first antibiotic administration was reduced from 95 to 50 minutes (Mann-Whitney U ≈ 1174, Z ≈ -3.29, p < 0.001, r = 0.30), with documentation of sepsis increasing from 18/60 (30.0%) to 51/60 (85.0%) (p < 0.0001).

A low-cost educational package, combined with a structured sepsis proforma, was associated with significant and clinically meaningful improvements in compliance with the Sepsis Six bundle in a resource-limited tertiary hospital. The results confirm the value and feasibility of the closed-loop audit as a quality improvement tool applicable to other environments and the need for continued training and regular re-audits to sustain the benefits of the closed-loop audit.