Emergency Department Crowding Is Associated With Delayed Antibiotics for Sepsis

      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.


      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.


      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.


      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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      Linked Article

      • In reply:
        Annals of Emergency MedicineVol. 74Issue 4
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          We thank Drs. Li and Zhang for their interest in our study. The authors highlight how challenging it can be to choose from the numerous metrics of emergency department (ED) crowding used in previous research. We selected a range of validated measures of ED crowding, covering ED input, throughput, and output workload.1 The primary exposure of ED occupancy rate and the associated definition of ED crowding (ED occupancy rate ≥1) were selected according to past validation, generalizability, simplicity, expert recommendations, and broad use in the ED crowding literature generally and the ED sepsis care literature specifically.
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      • Emergency Department Crowding Delayed Antibiotics but Did Not Increased Mortality for Sepsis?
        Annals of Emergency MedicineVol. 74Issue 4
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          We congratulate Peltan et al1 on their recent article. Emergency department (ED) crowding is a difficult and persistent problem for many hospitals and for patients; it is also a topic of great interest to emergency physicians. The article explored the difference in the time of antibiotics administration in patients with sepsis and the state of ED crowding during administration, and concluded that patients received antibiotics earlier in uncrowded conditions. The conclusion facilitates improvement of awareness of early detection and diagnosis for patients with sepsis, and of early administration of antibiotics.
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