Sepsis Diagnostic Excellence: Development and Validation of a Theoretical Framework for Conceptualizing Accurate, Timely Sepsis Diagnosis

OBJECTIVES: Develop and empirically validate the Sepsis Diagnostic Excellence (SepsisDx) Theoretical Framework of multilevel factors influencing accurate, timely sepsis diagnosis. DESIGN: Observational qualitative semi-structured interviews. SETTING AND PARTICIPANTS: Twenty hospitals spanning four states and two health systems within the United States were purposively selected to maximize location, system structure, and patient population representation. ANALYSIS: We conducted 41 interviews with key informants from 13 hospitals, including top managers (e.g., system leaders), mid-level managers (e.g., emergency department (ED) heads; sepsis coordinators), and patient-facing clinicians and staff (e.g., unit nurses). We developed an interview guide by integrating three extant frameworks that collectively conceptualize sepsis diagnosis as a behavior among healthcare providers that is influenced by factors at micro-, meso-, and macroorganization levels. To develop SepsisDx, we used template analysis to identify constructs that influenced accurate, timely sepsis diagnosis and rapid analysis to identify relationships among the framework’s constructs. We refined preliminary findings based on feedback from a study advisory board and interview participants. RESULTS: Interviews validated the central premise of SepsisDx—that is, sepsis diagnosis is influenced by the interaction of factors at micro-, meso-, and macrolevels. The most salient individual-level factor influencing timely sepsis diagnosis was attention (i.e., noticing, encoding, interpreting, and focusing time and effort). Attention was reduced by ambiguous clinical presentations and environmental shocks (e.g., COVID-19). Various strategies increased organization-level attention while decreasing provider-level attention (e.g., audit and feedback). Strategies’ effectiveness was moderated by hospital characteristics such as staffing. CONCLUSIONS: The SepsisDx framework clarifies which factors influence sepsis diagnosis and how these factors operate through specific mechanisms. Accurate, timely sepsis diagnosis depends on organizational attention that aligns with individual provider attention to potential sepsis diagnoses. Leaders may improve sepsis diagnosis by pursuing health system- and organization-level strategies that reflect individual-, team-, and emergency-department-level experiences.