ATS 2017, WASHINGTON, DC -- According to a new study, patients with sepsis, a life-threatening complication of an infection, had delays approaching one hour in being given antibiotics when seen in emergency rooms that were overcrowded. The study was presented at the 2017 American Thoracic Society International Conference.
"Prompt initiation of appropriate antibiotics is the cornerstone of high-quality sepsis care, a fact emphasized in Medicare quality measures and international guidelines," said lead author Ithan Peltan, MD, MSc, from Intermountain Medical Center and the University of Utah School of Medicine, Salt Lake City, Utah. "I wanted to understand how strains on hospital resources influence timely antibiotics."
Dr. Peltan pointed out that each one-hour delay in antibiotics is associated with a 7-10 percent increase in the odds of dying from sepsis.
Dr. Peltan and colleagues looked back at the medical records of patients admitted to an intensive care unit after being seen in the emergency departments of two community hospitals and two tertiary referral centers in Utah between July 2013 and December 2015. Patients whose records were in the hospitals' joint sepsis registry were eligible for study inclusion if they exhibited sepsis on ER arrival. Emergency department workload was measured based on the ratio of registered patients to available beds. They identified overcrowding as the presence of more registered ER patients than available beds and conducted statistical analyses that examined the association between emergency dept. crowding and door-to-antibiotic time after adjusting for a number of variables including (but not limited to) nighttime ER arrival and indicators of illness severity.
The researchers found that, of 945 patients studied, 128 (14 percent) arrived when registered emergency department patients already exceeded the ERs' licensed beds. Patients received antibiotics within three hours in 83 percent of all cases in uncrowded ERs, but 72 percent of the time when the ER was crowded. In the adjusted analysis, patients who presented to a crowded ER rather than an empty ER waited an extra 47 minutes for antibiotics and were three times less likely to start antibiotics within three hours, the initiation window recommended by Medicare and international guidelines.
"Our findings suggest adequate staff and diagnostic resources are critical to effective sepsis care," said Dr. Peltan. "Hospitals should also consider sepsis care reorganization to bypass competing demands on clinicians and diagnostic resources."
He added: "In many emergency departments, protocols coupling pre-hospital notification and a multi-disciplinary rapid response team help ensure time-dependent therapies for stroke, heart attack and trauma patients. I suspect similar protocols could improve timely care for sepsis."
Media Contact for Dr. Peltan: Jess C. Gomez, Jess.Gomez@imail.org
Increasing ED Workload Is Associated with Delayed Antibiotic Initiation for Sepsis
Authors: I.D. Peltan1, J.R. Bledsoe2, T.A. Oniki2, A.R. Jephson2, T.L. Allen1, S.M. Brown1; 1Intermountain Medical Center and University of Utah School of Medicine - Salt Lake City, UT/US, 2Intermountain Medical Center - Salt Lake City, UT/US
Rationale: Prompt antibiotic initiation is associated with improved mortality in sepsis and septic shock, but determinants of door-to-antibiotic time are poorly understood. We investigated the influence of emergency department (ED) workload on door-to-antibiotic time for septic patients.
Methods: We conducted a retrospective cohort study of patients admitted to an intensive care unit after presenting to the EDs of two community hospitals and two tertiary referral centers in Utah between July 2013 and December 2015. Patients entered in the hospitals' joint sepsis registry were eligible for inclusion if they exhibited sepsis on admission, as defined by antibiotic initiation in the ED and an increase in the SOFA score ?2 compared to baseline. ED workload was quantified by the ED occupancy rate (the ratio of registered patients to available ED beds). Occupancy rate ?1 defined ED crowding. We employed multivariable regression to examine the association between ED workload and door-to-antibiotic time after adjustment for patient age, sex, comorbidities (Charlson score), nighttime ED arrival (10 pm-6:59 am), and indicators of illness severity (APACHE II score, arrival shock, and acuity score).
Results: Of 945 eligible patients with complete data for multivariable regression, 128 (14%) arrived when registered ED patients already exceeded licensed ED beds (occupancy rate ?1). Aside from a decreased median ED length of stay (222 [168-286] vs. 244 [188-312] minutes, p=0.016) and higher probability of nighttime admission (19% vs. 5%, p<0.001) when EDs were not crowded, demographic and clinical characteristics were similar in patients presenting to uncrowded versus crowded EDs. Overall median door-to-antibiotic time was 115 minutes (IQR 77-162) when occupancy rate was <1 and 139 (90-187) minutes when occupancy rate was ?1 (p=0.003). Patients received antibiotics within 3 hours in 83% of cases when the ED occupancy rate was <1 and 72% of cases when it was not (p=0.003). After multivariable adjustment, the ED occupancy rate remained a strong predictor of door-to-antibiotic time (β=47 minutes, 95% CI 32-63, p<0.001). Increasing ED occupancy rates were also associated with a decreased adjusted odds (OR 0.27, 95% CI 0.15-0.49, p<0.001) of receiving antibiotics within 3 hours as recommended by international guidelines (Figure 1).
Conclusion: As measured by the ED occupancy rate, ED crowding was associated with a nearly one-hour delay in antibiotic administration for septic patients. Crowded EDs may particularly benefit from interventions to speed antibiotic initiation.