Quality of care in sepsis management: development and testing of measures for improvement

Objectives: To develop and test a set of measures of quality of care in the process of sepsis management, to determine the inter-rater reliability of case-note review in assessment of these measures and to assess our current standard of care. Methods: Five measures of process of care and one of outcome were identified from the literature review and previous experience. Failure modes and effects analysis was used by a multidisciplinary team to validate these measures and prioritize them in terms of associated risk. Forty sets of case notes were reviewed by two independent teams and the inter-rater reliability was determined using observed percentage agreement and the kappa statistic. We used the data to calculate the proportion of patients in whom we are currently meeting targets for good quality of care. Results: The multidisciplinary team did not identify any additional areas of concern and assigned the highest risk priority to a delay of over 4 h from recognition of sepsis to antibiotic administration. The inter-rater agreement was > 80% for four of the measures, but was only 62.5% for appropriateness of antibiotic therapy. Room for improvement in practice exists, for example, antibiotic administration within 4 h was not achieved in 40% of patients. Conclusions: Four of our five measures of care are suitable for use in assessing the effect of interventions aimed at improving sepsis management, with at least moderate inter-rater reliability. Specific areas where increased clarity should improve agreement further have been identified.