Compliance with the 2021 surviving sepsis campaign Hour-1 Bundle and impact on patient outcomes in a resource-limited setting: A quality improvement initiative in a referral hospital in Rwanda
- 1University Teaching Hospital of Butare, Huye, Rwanda
- 2College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- 3Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
Abstract
Sepsis and septic shock are common life-threatening conditions associated with high mortality globally. Compliance with the Society of Critical Care Medicine’s Hour-1 Bundle for sepsis management has the potential to improve outcome, but the bundle is infrequently applied in resource-constrained settings. We assessed level of compliance with the Hour-1 bundle among patients diagnosed with sepsis and septic shock at the Accident and Emergency Department (AED) or Intensive Care Unit (ICU) of University Teaching Hospital of Butare, Rwanda. We conducted training for nurses and doctors in the AED and ICU, with the goal of improving compliance. We re-assessed bundle compliance one month after the training. We used univariate and multivariate analyses to evaluate the association of compliance and fluid resuscitation with hospital mortality while adjusting for severity of illness and other covariates. Our finding showed that seventy-eight patients were enrolled during the pre-intervention period, and 82 in post-intervention. The overall compliance with at least 4 elements of the Hour-1 bundle before the intervention was 14%, and 76% after the intervention (p < 0.001). Mortality was lower in the post-intervention period than in the pre-intervention period (51.2% vs 74.4%; p = 0.003). Non-survivors had a significantly lower bundle compliance than survivors (35% vs 80%; adjusted OR 0.18, 95% CI 0.05-0.57; p = 0.004). Administered 2 liters of IV fluids and beyond during the first hour was independently associated with higher mortality (adjusted OR 19.38, 95% CI 5.63-66.75; p < 0.001). Findings from this Quality Improvement project suggest that compliance with the Hour-1 sepsis bundle in a resource-constrained setting can be improved with training, can improve outcome.. Administration of ≥2 liters during the first hour in those was independently associated with a higher in-hospital mortality, although bundle-compliant resuscitation was not. More research is needed, both on the implementation of sepsis bundles in resource-constrained settings, to assess if all bundle elements are as effective in these settings as recommended in the international guidelines.
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BibTeX
@article{mahoro2026compliance,
title = {{Compliance with the 2021 surviving sepsis campaign Hour-1 Bundle and impact on patient outcomes in a resource-limited setting: A quality improvement initiative in a referral hospital in Rwanda}},
author = {Jean de Dieu Mahoro and Jean Paul Mvukiyehe and Elisabeth Riviello and Theogene Twagirumugabe},
journal = {PLOS Global Public Health},
year = {2026},
month = nov,
doi = {10.1371/journal.pgph.0005091},
url = {https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0005091},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Compliance with the 2021 surviving sepsis campaign Hour-1 Bundle and impact on patient outcomes in a resource-limited setting: A quality improvement initiative in a referral hospital in Rwanda
AU - Jean de Dieu Mahoro
AU - Jean Paul Mvukiyehe
AU - Elisabeth Riviello
AU - Theogene Twagirumugabe
PY - 2026
DA - 2026/11/05
JO - PLOS Global Public Health
DO - 10.1371/journal.pgph.0005091
UR - https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0005091
AB - Sepsis and septic shock are common life-threatening conditions associated with high mortality globally. Compliance with the Society of Critical Care Medicine’s Hour-1 Bundle for sepsis management has the potential to improve outcome, but the bundle is infrequently applied in resource-constrained settings. We assessed level of compliance with the Hour-1 bundle among patients diagnosed with sepsis and septic shock at the Accident and Emergency Department (AED) or Intensive Care Unit (ICU) of University Teaching Hospital of Butare, Rwanda. We conducted training for nurses and doctors in the AED and ICU, with the goal of improving compliance. We re-assessed bundle compliance one month after the training. We used univariate and multivariate analyses to evaluate the association of compliance and fluid resuscitation with hospital mortality while adjusting for severity of illness and other covariates. Our finding showed that seventy-eight patients were enrolled during the pre-intervention period, and 82 in post-intervention. The overall compliance with at least 4 elements of the Hour-1 bundle before the intervention was 14%, and 76% after the intervention (p < 0.001). Mortality was lower in the post-intervention period than in the pre-intervention period (51.2% vs 74.4%; p = 0.003). Non-survivors had a significantly lower bundle compliance than survivors (35% vs 80%; adjusted OR 0.18, 95% CI 0.05-0.57; p = 0.004). Administered 2 liters of IV fluids and beyond during the first hour was independently associated with higher mortality (adjusted OR 19.38, 95% CI 5.63-66.75; p < 0.001). Findings from this Quality Improvement project suggest that compliance with the Hour-1 sepsis bundle in a resource-constrained setting can be improved with training, can improve outcome.. Administration of ≥2 liters during the first hour in those was independently associated with a higher in-hospital mortality, although bundle-compliant resuscitation was not. More research is needed, both on the implementation of sepsis bundles in resource-constrained settings, to assess if all bundle elements are as effective in these settings as recommended in the international guidelines.
SN - 2767-3375
ER -