Emergency Department Crowding Is Associated With Delayed Antibiotics for Sepsis - 21/03/19
, Joseph R. Bledsoe, MD d, Thomas A. Oniki, PhD a, Jeffrey Sorensen, MStat a, Al R. Jephson, BA a, Todd L. Allen, MD d, Matthew H. Samore, MD c, Catherine L. Hough, MD, MSc e, Samuel M. Brown, MD, MSc a, bAbstract |
Study objective |
Barriers to early antibiotic administration for sepsis remain poorly understood. We investigated the association between emergency department (ED) crowding and door-to-antibiotic time in ED sepsis.
Methods |
We conducted a retrospective cohort study of ED sepsis patients presenting to 2 community hospitals, a regional referral hospital, and a tertiary teaching hospital. The primary exposure was ED occupancy rate, defined as the ratio of registered ED patients to licensed ED beds. We defined ED overcrowding as an ED occupancy rate greater than or equal to 1. We used multivariable regression to measure the adjusted association between ED crowding and door-to-antibiotic time (elapsed time from ED arrival to first antibiotic initiation). Using Markov multistate models, we also investigated the association between ED crowding and pre-antibiotic care processes.
Results |
Among 3,572 eligible sepsis patients, 70% arrived when the ED occupancy rate was greater than or equal to 0.5 and 14% arrived to an overcrowded ED. Median door-to-antibiotic time was 158 minutes (interquartile range 109 to 216 minutes). When the ED was overcrowded, 46% of patients received antibiotics within 3 hours of ED arrival compared with 63% when it was not (difference 14.4%; 95% confidence interval 9.7% to 19.2%). After adjustment, each 10% increase in ED occupancy rate was associated with a 4.0-minute increase (95% confidence interval 2.8 to 5.2 minutes) in door-to-antibiotic time and a decrease in the odds of antibiotic initiation within 3 hours (odds ratio 0.90; 95% confidence interval 0.88 to 0.93). Increasing ED crowding was associated with slower initial patient assessment but not further delays after the initial assessment.
Conclusion |
ED crowding was associated with increased sepsis antibiotic delay. Hospitals must devise strategies to optimize sepsis antibiotic administration during periods of ED crowding.
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| Please see page 346 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Henry E. Wang, MD, MS |
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| Author contributions: IDP, JRB, JS, TLA, and SMB conceived and designed the study. IDP obtained research funding and wrote the article. IDP, TAO, and ARJ acquired the data. IDP, and JS analyzed the data. IDP, JRB, JS, TLA, MHS, CLH, and SMB interpreted the results. All authors contributed substantially to article revision. IDP takes responsibility for the paper as a whole. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The authors have stated that no such relationships exist. This work was supported by the Intermountain Research and Medical Foundation. |
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| The funding source had no role in the design, conduct, analysis, or reporting of this study. |
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Vol 73 - N° 4
P. 345-355 - avril 2019 Retour au numéro
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