Resource shortages hindered a sepsis protocol rollout in an Ethiopian emergency department

Researchers who developed a sepsis treatment protocol for the emergency department of Tikur Anbessa Specialized Hospital (TASH-ED) in Ethiopia have published a process evaluation explaining why the intervention did not translate into improved patient survival. The team, led by Lisa M. Puchalski Ritchie and colleagues, reported that after implementation they observed a decreased trend for survival at 72 hours and no change in 90-day mortality. The new analysis, published in BMC Health Services Research as a multi-component qualitative descriptive study, was designed to understand the factors that shaped how the protocol was actually delivered on the ground.

The study used a pragmatic multi-component qualitative design, combining interviews with a document review of staff and study team meeting notes, and analyzed the data through qualitative content analysis triangulated across multiple methods. Nineteen TASH-ED staff and trainees were interviewed. The most prominent finding was that shortages of both material and human resources were the primary barriers to implementation.

Human resource shortages affected implementation through two distinct pathways. First, they increased provider workload, leaving clinicians less capacity to absorb a new protocol into already stretched clinical routines. Second, they limited the implementation team’s own ability to support rollout activities, because competing demands pulled team members away from their implementation responsibilities. The evaluation also found that provider knowledge of the protocol’s content was high among physicians but varied among nursing staff. Some participants attributed this variability to staff shortages, suggesting that under pressure providers relied on prior practices rather than engaging with and internalizing the new protocol content.

Not all of the findings were negative. The vast majority of participants agreed with the protocol’s content, and they valued its format, including reminders posted in large format in clinical areas and pocket cards distributed to staff. However, because there was no back-up coverage for implementation team member absences, a number of participants reported never receiving the pocket card, and therefore lacked ready access to the protocol’s antibiotic recommendations. This detail illustrates how a seemingly minor logistical gap in the implementation strategy could undercut access to a key clinical component of the intervention.

The authors emphasized that despite tailoring both the sepsis protocol and its implementation strategy to the local context, the process evaluation identified important barriers that tailoring did not fully address. In addition to barriers recognized a priori, a number of previously unidentified barriers emerged during the study. The team argued that these findings highlight the importance of including process measures when monitoring and evaluating implementation activities, since outcome data alone would not have revealed why the intervention performed as it did. The pronounced impact of resource shortages, they concluded, underscores the need for health system strengthening if outcomes for sepsis patients in low- and middle-income countries are to improve. Sepsis remains an important cause of mortality globally, with low- and middle-income countries disproportionately affected. The study was registered on the Open Science Framework in June 2017, and the published version is an open-access article carrying a permanent DOI.

Subject of Research: A qualitative process evaluation of barriers and facilitators to implementing a sepsis treatment protocol in an Ethiopian emergency department.

Article Title: Implementing an evidence-based sepsis treatment protocol to improve patient outcomes in the Tikur Anbessa specialized hospital emergency department: a multi-component qualitative methods process evaluation

Article References: Puchalski Ritchie, L. M., Beza, L., Debebe, F., Gamble, K., Straus, S. E., Azazh, A., Zewdu, T., Hunchak, C., Landes, M., & Huluka, D. K. (2026). Implementing an evidence-based sepsis treatment protocol to improve patient outcomes in the Tikur Anbessa specialized hospital emergency department: a multi-component qualitative methods process evaluation. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15987-w

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15987-w

Keywords: sepsis, emergency department, Ethiopia, implementation science, process evaluation, qualitative research, low- and middle-income countries, health system strengthening, Tikur Anbessa Specialized Hospital, quality improvement, Implementing, evidence-based