Marwick Charis, Watts Emily, Evans Josie, Davey Peter
Department of Infectious Diseases, Medicine and Cardiovascular Group, Ninewells Hospital, Dundee DD1 9SY, Scotland, UK.
J Antimicrob Chemother. 2007 Sep;60(3):694-7. doi: 10.1093/jac/dkm234. Epub 2007 Jun 26.
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.
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.
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.
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.
制定并测试一套脓毒症管理过程中护理质量的衡量指标，确定病例记录审查在评估这些指标时的评分者间信度，并评估我们当前的护理标准。
通过文献综述和既往经验确定了五项护理过程指标和一项结局指标。一个多学科团队运用失效模式与效应分析来验证这些指标，并根据相关风险对其进行优先级排序。两个独立团队对40套病例记录进行了审查，并使用观察到的百分比一致性和kappa统计量来确定评分者间信度。我们利用这些数据计算了目前达到优质护理目标的患者比例。
多学科团队未发现任何其他需要关注的领域，并将从识别脓毒症到给予抗生素超过4小时的延迟列为最高风险优先级。四项指标的评分者间一致性>80%，但抗生素治疗的适当性指标仅为62.5%。实践中仍有改进空间，例如，40%的患者未在4小时内给予抗生素。
我们的五项护理指标中有四项适用于评估旨在改善脓毒症管理的干预措施的效果，评分者间信度至少为中等。已确定了一些特定领域，在这些领域进一步明确可进一步提高一致性。
