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Volume 18 Supplement 2

Sepsis 2014

  • Poster presentation
  • Open Access

Clinical audit system in implementing Surviving Sepsis Campaign guidelines in patients with peritonitis

  • RC Valiveru1,
  • NK Maroju1,
  • K Srinivasan1 and
  • A Cherian2
Critical Care201418(Suppl 2):P30

Published: 3 December 2014


PeritonitisAudit SystemProspective Observational StudyProcess ImprovementSerum Lactate


Sepsis is the predominant cause of morbidity and mortality in patients with peritonitis [16]. The Surviving Sepsis Campaign (SSC) is an international effort in reducing mortality based on evidence-based guidelines [713]. This study aims to assess the impact of audit-based feedback in a Plan-Do-Study-Act (PDSA) format on improving implementation of the SSC guidelines in patients with generalised peritonitis at our centre.


This prospective observational study was conducted in four audit cycles in PDSA format. Multidepartmental inputs were taken to suggest modifications in practice. A questionnaire-based analysis of reasons for noncompliance was done to find out the opinions and reasons for noncompliance. Morbidity, mortality, the ICU and hospital stay among these patients were also analysed.


The baseline compliance with i.v. bolus administration, CVP-guided fluids and inotrope supports when indicated were 100%. Over the course of the three audit cycles, statistically significant improvement in compliance was noted for antibiotic administration within 3 hours of presentation (46% to 90%) (Table 1 Figure 1), obtaining blood cultures before antibiotics (13.8% to 72.5%) (Table 1 Figure 2) and serum lactate measurement (0% to 78.2%) (Figure 3). Overall bundle compliance improved from 9.2% to 64.7% (Table 2 Figure 4) by the end of Audit III. The mortality rate decreased from 32.3% to 20% (Table 2 Figure 5).
Table 1

Compliance with obtaining blood cultures before antibiotics and antibiotic administration within 3 hours.

Number of patients

Pre audit (n= 65)

Audit I (n= 55)

Audit II (n= 50)

Audit III (n= 51)

Blood cultures obtained before antibiotics

9 (13.6%)

18 (32.7%)a

30 (60%)b

37 (72.54%)b

Antibiotics given within 3 hours

30 (46.1%)

30 (67.2%)c

40 (80%)d

46 (90.1%)b

aP = 0.016. bP < 0.0001. cP = 0.463. dP = 0.0002.

Figure 1
Figure 1

Compliance with antibiotic administration within 3 hours of presentation.

Figure 2
Figure 2

Compliance with obtaining blood cultures before antibiotic administration.

Figure 3
Figure 3

Compliance with measurement of serum lactate.

Table 2

Total bundle compliance.

Total number of bundle components performed

Pre audit (n= 65)

Audit I (n= 55)

Audit II (n= 50)

Audit III (n= 51)





33a (64.7)


6 (9.2%)

13 (23.6%)

27 (54%)

3 (5.8%)


26 (40%)

29 (52.7%)

16 (32%)

11 (21.5%)


33 (50.7%)

13 (23.6%)

7 (14%)

4 (7.8%)











aSerum lactate was available in the hospital only during audit cycle III.

Figure 4
Figure 4

Overall bundle compliance.

Figure 5

Figure 5


This study demonstrates that audit-based feedback is a dependable means of improving compliance with SSC guidelines. It brings about improvement by educating users, by modifying their behaviour through feedback and also enhances process improvement by identifying and correcting systemic deficiencies in the organisation.
Table 3

Overall mortality.


Pre audit (n= 65)

Audit I (n= 55)

Audit II (n= 50)

Audit III (n= 51)

Overall mortality in percentage

21 (32.3%)

16 (29%)

12 (24%)

11 (20%)

P value (compared with the initial cycle)





Authors’ Affiliations

Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India


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© Valiveru et al.; licensee BioMed Central Ltd. 2014

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