Effects of External Inspection on Sepsis Detection and Treatment

Sepsis Clinical Trial

Official title:

Effects of External Inspection on Sepsis Detection and Treatment

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02747121
• Other study ID #: 2015/2195 REK number
• Status: Completed
• Phase: N/A
• Start date: April 2016
• Est. completion date: December 2020

Study information

• Verified date: January 2022
• Source: Norwegian Board of Health Supervision
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

External inspections are widely used as means to improve the quality of care. Despite their widespread use, there is limited knowledge about whether and how they affect the quality of care. This study uses inspection with detection and treatment of sepsis in hospitals as a case to evaluate the effect of inspections on the quality of care and to explore how inspections affect the hospitals.

Description:

The aim of this study is to assess what effect external inspections have on the quality of care provided to sepsis patients admitted to hospital and to explore how external inspections affect the involved organizations. External inspections are widely used as a means to improve the quality of care, and it is a core element of regulatory regimes and certification and accreditation processes. The activity of assessing a health care organization's performance according to an externally defined standard has been described by partly overlapping terms such as external inspection, external review, supervision, and audit. The project uses the term external inspection implying that the inspection is initiated and controlled by an organization external to the one being inspected; and define it as: "a system, process or arrangement in which some dimensions or characteristics of a healthcare provider organisation and its activities are assessed or analysed against a framework of ideas, knowledge, or measures derived or developed outside that organisation". In line with this definition the investigator intend to study how external inspection affect the quality of care provided on an organizational level. The project does not intend to study how external inspections can affect individuals in the organization nor individual professional development. The investigator takes the perspective that quality of care can be considered a system property, being dependent on how the organization providing care performs as a whole. Accordingly, improving the quality of care is dependent on changing the performance of the organization, which in turn implies change in organizational behavior and the way clinicians mutually interact and perform their clinical processes. Change in organizational behavior is a complex social process that involves a number of different practices on different organizational levels. If external inspection has the ability to contribute to improve the quality of care on an organizational level, it need to affect the practices involved in organizational change. The effect of external inspection systems on the quality of care remains unclear and the evidence is contradictory. Studies have demonstrated a positive association between accreditation and the ability to promote change, professional development, quality systems, and clinical leadership. There is evidence to support an association between inspections and different quality outcomes e.g. reduced incidence of pressure ulcer and suicide. There are however also studies reporting that inspections have no impact on the quality of care. Inspection systems are widely used and much resources are spent on such systems worldwide. More knowledge about how and whether external inspections can effect the quality of care is needed. The inspection process can be considered a complex intervention consisting of a set of activities that are introduced into varying organizational contexts. The inspection itself does not have a direct impact on the quality of care. If the inspection encounters non-compliant behavior, the inspected organization is responsible for implementing necessary changes. The way the inspection process affects the involved organization will thus influence how the inspected organizations pursue the following change process. The way external inspections affect the involved organization, is currently poorly understood. A better understanding of the underlying mechanisms for how inspection systems might contribute to improve the quality of care is needed. Such knowledge can improve the understanding of why effects of external inspections seem to vary, which in turn can facilitate the development of more effective ways of conducting inspections. The study uses external inspections of sepsis detection and treatment in hospitals as a case to explore how inspections affect the involved organizations and to evaluate their effect on the quality of care. Sepsis is a prevalent disease and one of the main causes of death among hospitalized patients internationally and in Norway. Former external inspections of Norwegian hospitals have showed that insufficient governance of clinical process in the emergency room could have severe consequences for patients admitted to hospital with undiagnosed sepsis. During recent years, the Norwegian Board of Health Supervision has investigated a number of cases in which the hospitals had not provided care in line with the recommended guidelines for sepsis treatment. On this background, the Norwegian Board of Health Supervision has decided to conduct a nationwide inspection campaign with sepsis detection and treatment in acute hospitals during 2016-2017. Early treatment with antibiotics along with compliance to treatment guidelines is associated with reduced mortality for sepsis patients. International studies have shown that compliance with treatment guidelines varies, and that improved compliance can improve patient outcomes. External inspection can identify sub-optimal compliance with treatment guidelines. Improved compliance with treatment guidelines is dependent on change in organizational practice. Such changes in organizational practice can be measured using process indicators that are indicative and sensitive for changes in the key areas identified during the inspection. The study uses process measures to assess how external inspections affect guideline adherence. Because improved guideline adherence has been demonstrated to improve the quality of care in terms of reduced mortality, it can be argued that this is an expedient case for evaluating how external inspections can affect the quality of care.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 7407
• Est. completion date: December 2020
• Est. primary completion date: December 2020
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Suspected infection and minimum 2 SIRS criteria. If high leucocytes are one of the two criteria, then 3 SIRS criteria are needed.

Exclusion Criteria:

• Patients below the age of 18 years.
• Patients who do not pass through the emergency room.

Related Conditions & MeSH terms

• Sepsis
• Toxemia

Intervention

Behavioral:
• External inspection of health services
The intervention is external inspections of acute hospitals addressing early detection and treatment of sepsis. The intervention is delivered on an organizational level. Individuals are not assigned to an intervention. The investigator use data from individuals to assess if the organizational intervention affects care. Therefore the investigator argues that that the study is observational. The inspection will have two components, a system revision and a follow up audit with verification of patient records 8 months later. The inspection can be considered a complex intervention. The study does not intend to evaluate the individual effects of the different components of the inspection, rather the effect of the inspection as a whole.

Locations

Country	Name	City	State
Norway	Haukeland hospital	Bergen	Hordaland

Sponsors (3)

Lead Sponsor	Collaborator
Norwegian Board of Health Supervision	Norwegian Institute of Public Health, University of Bergen

Country where clinical trial is conducted

Norway, 

References & Publications (19)

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Flodgren G, Pomey MP, Taber SA, Eccles MP. Effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD008992. doi: 10.1002/14651858.CD008992.pub2. Review. Update in: Cochrane Database Syst Rev. 2016 Dec 02;12 :CD008992. — View Citation

Gatewood MO, Wemple M, Greco S, Kritek PA, Durvasula R. A quality improvement project to improve early sepsis care in the emergency department. BMJ Qual Saf. 2015 Dec;24(12):787-95. doi: 10.1136/bmjqs-2014-003552. Epub 2015 Aug 6. Review. — View Citation

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Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, Schorr C, Artigas A, Ramsay G, Beale R, Parker MM, Gerlach H, Reinhart K, Silva E, Harvey M, Regan S, Angus DC; Surviving Sepsis Campaign. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med. 2010 Feb;38(2):367-74. doi: 10.1097/CCM.0b013e3181cb0cdc. — View Citation

Levy MM, Rhodes A, Phillips GS, Townsend SR, Schorr CA, Beale R, Osborn T, Lemeshow S, Chiche JD, Artigas A, Dellinger RP. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study. Crit Care Med. 2015 Jan;43(1):3-12. doi: 10.1097/CCM.0000000000000723. — View Citation

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* Note: There are 19 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Number of Sepsis Patients With 30 Days Mortality	We will still use 30-day mortality rate as our outcome measure. The new international sepsis definition will over time affect coding practice and we can therefore not use routine data from the National Patient Register to calculate the mortality rate. We will calculate the mortality rate based on the patient population we include in the study. We will compare mortality rates before and after the inspections.	30 days
Secondary	Hospital Length of Stay	Mean time for hospital length of stay before and after inspections	Exact number of days for the length of stay was collected from the National Patient Registry. Since the outcome measure is length of stay, the time frame varies between patients. Time frame for observation periode was at least 12 months for each patient.