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Health policy
Original research
Effects of external inspections on sepsis detection and treatment: a stepped-wedge study with cluster-level randomisation
  1. Gunnar Husabø1,2,
  2. Roy Miodini Nilsen3,
  3. Erik Solligård4,5,
  4. Hans Kristian Flaatten6,
  5. Kieran Walshe7,
  6. Jan C Frich8,
  7. Gunnar Tschudi Bondevik2,9,
  8. Geir Sverre Braut10,11,
  9. Jon Helgeland12,
  10. Stig Harthug13,14,
  11. Einar Hovlid1,2,11
  1. 1Department of Social Science, Western Norway University of Applied Sciences, Sogndal, Norway
  2. 2Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
  3. 3Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway
  4. 4Clinic of Anesthesia and Intensive Care, St. Olavs Hospital University Hospital in Trondheim, Trondheim, Norway
  5. 5Gemini Center for Sepsis Research, Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
  6. 6Department of Clinical Medicine, University of Bergen, Bergen, Norway
  7. 7Alliance Manchester Business School, The University of Manchester, Manchester, UK
  8. 8Institute of Health and Society, University of Oslo, Oslo, Norway
  9. 9National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Bergen, Norway
  10. 10Department of Research, Stavanger University Hospital, Stavanger, Norway
  11. 11Department 5, Norwegian Board of Health Supervision, Oslo, Norway
  12. 12Norwegian Institute of Public Health, Oslo, Norway
  13. 13Department of Research and Development, Haukeland University Hospital, Bergen, Norway
  14. 14Department of Clinical Science, University of Bergen, Bergen, Norway
  1. Correspondence to Dr Einar Hovlid; einar.hovlid{at}hvl.no

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.

Trial registration NCT02747121.

  • change management
  • health & safety
  • health policy
  • accident & emergency medicine
  • infectious diseases
  • audit
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2020-037715

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    Footnotes

    • Contributors GH: conception, data collection, data curation, statistical analyses, visualisation, project administration, writing – original draft, writing – critical revision, final approval. RMN: conception, statistical analyses, writing – critical revision, final approval. ES: conception, data collection, writing – critical revision, final approval. HKF: conception, writing – critical revision, final approval. KW: conception, writing – critical revision, final approval. JCF: conception, writing – critical revision, final approval. GTB: conception, writing – critical revision, final approval. GSB: conception, data collection, translation of supplemental material, writing – critical revision, final approval. JH: conception, writing – critical revision, final approval. SH: conception, writing – critical revision, final approval. EH: conception, statistical analyses, project administration, supervision, visualisation, writing – original draft, writing – critical revision, final approval.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Disclaimer Data from the Norwegian Patient Registry have been used in this publication. The interpretation and reporting of these data are the sole responsibility of the authors. No endorsement by the Norwegian Patient Registry is intended nor should be inferred.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval Ethics approval was obtained from the Regional Ethics Committee of Norway North (2015/2195/REK nord) and the Norwegian Data Protection Authority (15/01559). The Regional Ethics Committee of Norway Nord ruled that individual patient consent was not required for this study.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data may be obtained from a third party and are not publicly available. As this study used data from the Norwegian Patient Registry, there are legal restrictions on sharing the data set. The registry is regulated according to the Act relating to Personal Health Data Registries (2014) and specific regulation for the registry under the provision of this act. These laws do not permit us to share these data for secondary use. Third parties can apply to obtain data from the Norwegian Directorate of Health, which is the body granting access to the registry. The Directorate responds to inquiries regarding the Norwegian Patient Registry via email (helseregistre@helsedir.no). Data obtained from the Norwegian Patient Registry can be used to identify electronic health records at the hospitals, pending approval from ethics committee and hospitals.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.