Effects of external inspections on sepsis detection and treatment: a stepped-wedge study With cluster-level randomisation

Abstract

Objective: To evaluate the effects of external inspections on (1) hospital emergency departments’ clinical processes for detecting and treating sepsis and (2) length of hospital stay and 30-day mortality. Design: Incomplete cluster-randomised stepped-wedge design using data from patient records and patient registries. We compared care processes and patient outcomes before and after the intervention using regression analysis. Setting: Nationwide inspections of sepsis care in emergency departments in Norwegian hospitals. Participants: 7407 patients presenting to hospital emergency departments with sepsis. Intervention: External inspections of sepsis detection and treatment led by a public supervisory institution. Main outcome: measures Process measures for sepsis diagnostics and treatment, length of hospital stay and 30-day all-cause mortality. Results: After the inspections, there were significant improvements in the proportions of patients examined by a physician within the time frame set in triage (OR 1.28, 95% CI 1.07 to 1.53), undergoing a complete set of vital measurements within 1 hour (OR 1.78, 95% CI 1.10 to 2.87), having lactate measured within 1 hour (OR 2.75, 95% CI 1.83 to 4.15), having an adequate observation regimen (OR 2.20, 95% CI 1.51 to 3.20) and receiving antibiotics within 1 hour (OR 2.16, 95% CI 1.83 to 2.55). There was also significant reduction in mortality and length of stay, but these findings were no longer significant when controlling for time. Conclusions: External inspections were associated with improvement of sepsis detection and treatment. These findings suggest that policy-makers and regulatory agencies should prioritise assessing the effects of their inspections and pay attention to the mechanisms by which the inspections might contribute to improve care for patients.