Sepsis Bundle SEP-1 Compliance Audit

Audit template for reviewing SEP-1 sepsis bundle compliance, including 3-hour and 6-hour bundle elements with required timestamps and documentation checks.

Case Identification and Sepsis Trigger

• Encounter and patient identifiers match audit record
• Documented time of sepsis recognition or SEP-1 clock start
• Evidence of suspected infection plus organ dysfunction documented
• Source documentation supports sepsis screening trigger

3-Hour Bundle Elements

• Blood cultures obtained before antibiotics
• Blood culture collection timestamp documented
• Serum lactate obtained within 3 hours of sepsis recognition
• Initial lactate result documented
• Broad-spectrum antibiotics administered within 3 hours
• Antibiotic administration timestamp documented

6-Hour Bundle Elements

• Crystalloid fluid resuscitation given for hypotension or lactate ≥ 4 mmol/L when indicated
• Fluid volume administered documented
• Repeat lactate obtained when initial lactate was elevated
• Repeat lactate timestamp documented
• Vasopressors initiated if hypotension persisted after fluids
• Hemodynamic reassessment documented within 6 hours

Documentation and Timeframe Validation

• All required timestamps are present and internally consistent
• Antibiotic, culture, lactate, and fluid documentation can be linked to the same encounter
• Provider note documents clinical rationale for sepsis management decisions
• Missing or conflicting documentation identified