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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.

      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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      References

        • Wang H.E.
        • Jones A.R.
        • Donnelly J.P.
        Revised national estimates of emergency department visits for sepsis in the United States.
        Crit Care Med. 2017; 45: 1443-1449
        • Rhee C.
        • Dantes R.
        • Epstein L.
        • et al.
        Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009-2014.
        JAMA. 2017; 318: 1241-1249
        • Lewis A.J.
        • Griepentrog J.E.
        • Zhang X.
        • et al.
        Prompt administration of antibiotics and fluids in the treatment of sepsis: a murine trial.
        Crit Care Med. 2018; 46: e426-e434
        • Kumar A.
        • Haery C.
        • Paladugu B.
        • et al.
        The duration of hypotension before the initiation of antibiotic treatment is a critical determinant of survival in a murine model of Escherichia coli septic shock: association with serum lactate and inflammatory cytokine levels.
        J Infect Dis. 2006; 193: 251-258
        • Liu V.X.
        • Fielding-Singh V.
        • Greene J.D.
        • et al.
        The timing of early antibiotics and hospital mortality in sepsis.
        Am J Respir Crit Care Med. 2017; 196: 856-863
        • Seymour C.W.
        • Gesten F.
        • Prescott H.C.
        • et al.
        Time to treatment and mortality during mandated emergency care for sepsis.
        N Engl J Med. 2017; 376: 2235-2244
        • Ferrer R.
        • Martín-Loeches I.
        • Phillips G.
        • et al.
        Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program.
        Crit Care Med. 2014; 42: 1749-1755
        • Whiles B.B.
        • Deis A.S.
        • Simpson S.Q.
        Increased time to initial antimicrobial administration is associated with progression to septic shock in severe sepsis patients.
        Crit Care Med. 2017; 45: 623-629
        • Hershey T.B.
        • Kahn J.M.
        State sepsis mandates—a new era for regulation of hospital quality.
        N Engl J Med. 2017; 376: 2311-2313
        • Rhee C.
        • Gohil S.
        • Klompas M.
        Regulatory mandates for sepsis care—reasons for caution.
        N Engl J Med. 2014; 370: 1673-1676
        • Levy M.M.
        • Evans L.E.
        • Rhodes A.
        The Surviving Sepsis Campaign bundle: 2018 update.
        Intensive Care Med. 2018; 32 (858-854)
        • Amaral A.C.K.B.
        • Fowler R.A.
        • Pinto R.
        • et al.
        Patient and organizational factors associated with delays in antimicrobial therapy for septic shock.
        Crit Care Med. 2016; 44: 2145-2153
        • Peltan I.D.
        • Mitchell K.H.
        • Rudd K.E.
        • et al.
        Physician variation in time to antimicrobial treatment for septic patients presenting to the emergency department.
        Crit Care Med. 2017; 45: 1011-1018
        • Madsen T.E.
        • Napoli A.M.
        The DISPARITY-II study: delays to antibiotic administration in women with severe sepsis or septic shock.
        Acad Emerg Med. 2014; 21: 1499-1502
        • Schull M.J.
        • Vermeulen M.
        • Slaughter G.
        • et al.
        Emergency department crowding and thrombolysis delays in acute myocardial infarction.
        Ann Emerg Med. 2004; 44: 577-585
        • Wu D.
        • Zhou X.
        • Ye L.
        • et al.
        Emergency department crowding and the performance of damage control resuscitation in major trauma patients with hemorrhagic shock.
        Acad Emerg Med. 2015; 22: 915-921
        • Fee C.
        • Weber E.J.
        • Maak C.A.
        • et al.
        Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia.
        Ann Emerg Med. 2007; 50 (509.e1): 501-509
        • Gaieski D.F.
        • Agarwal A.K.
        • Mikkelsen M.E.
        • et al.
        The impact of ED crowding on early interventions and mortality in patients with severe sepsis.
        Am J Emerg Med. 2017; 35: 953-960
        • Dean N.C.
        • Jones B.E.
        • Jones J.P.
        • et al.
        Impact of an electronic clinical decision support tool for emergency department patients with pneumonia.
        Ann Emerg Med. 2015; 66: 511-520
        • Miller R.R.
        • Dong L.
        • Nelson N.C.
        • et al.
        Multicenter implementation of a severe sepsis and septic shock treatment bundle.
        Am J Respir Crit Care Med. 2013; 188: 77-82
        • Clayton P.D.
        • Narus S.P.
        • Huff S.M.
        • et al.
        Building a comprehensive clinical information system from components: the approach at Intermountain Health Care.
        Methods Inf Med. 2003; 42: 1-7
        • Harris P.A.
        • Taylor R.
        • Thielke R.
        • et al.
        Research Electronic Data Capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Singer M.
        • Deutschman C.S.
        • Seymour C.W.
        • et al.
        The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
        JAMA. 2016; 315: 801-810
        • Vincent J.-L.
        • Moreno R.
        • Takala J.
        • et al.
        The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure.
        Intensive Care Med. 1996; 22: 707-710
        • Seymour C.W.
        • Liu V.X.
        • Iwashyna T.J.
        • et al.
        Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
        JAMA. 2016; 315: 762-774
        • Angus D.C.
        • Linde-Zwirble W.T.
        • Lidicker J.
        • et al.
        Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care.
        Crit Care Med. 2001; 29: 1303-1310
        • Iwashyna T.J.
        • Odden A.
        • Rohde J.
        • et al.
        Identifying patients with severe sepsis using administrative claims: patient-level validation of the Angus implementation of the international consensus conference definition of severe sepsis.
        Med Care. 2014; 52: e39-e43
        • Asplin B.R.
        • Magid D.J.
        • Rhodes K.V.
        • et al.
        A conceptual model of emergency department crowding.
        Ann Emerg Med. 2003; 42: 173-180
        • Hwang U.
        • McCarthy M.L.
        • Aronsky D.
        • et al.
        Measures of crowding in the emergency department: a systematic review.
        Acad Emerg Med. 2011; 18: 527-538
        • McCarthy M.L.
        • Aronsky D.
        • Jones I.D.
        • et al.
        The emergency department occupancy rate: a simple measure of emergency department crowding?.
        Ann Emerg Med. 2008; 51 (24.e1-2): 15-24
        • Beniuk K.
        • Boyle A.A.
        • Clarkson P.J.
        Emergency department crowding: prioritising quantified crowding measures using a Delphi study.
        Emerg Med J. 2012; 29: 868-871
        • Bernstein S.L.
        • Verghese V.
        • Leung W.
        • et al.
        Development and validation of a new index to measure emergency department crowding.
        Acad Emerg Med. 2003; 10: 938-942
        • Jones S.S.
        • Allen T.L.
        • Flottemesch T.J.
        • et al.
        An independent evaluation of four quantitative emergency department crowding scales.
        Acad Emerg Med. 2006; 13: 1204-1211
        • Shapiro N.I.
        • Wolfe R.E.
        • Moore R.B.
        • et al.
        Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule.
        Crit Care Med. 2003; 31: 670-675
        • Shapiro N.I.
        • Howell M.D.
        • Talmor D.
        • et al.
        Mortality in Emergency Department Sepsis (MEDS) score predicts 1-year mortality.
        Crit Care Med. 2007; 35: 192-198
        • Quan H.
        • Sundararajan V.
        • Halfon P.
        • et al.
        Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.
        Med Care. 2005; 43: 1130-1139
        • van Walraven C.
        • Austin P.C.
        • Jennings A.
        • et al.
        A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data.
        Med Care. 2009; 47: 626-633
        • Bullard M.J.
        • Unger B.
        • Spence J.
        • et al.
        Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) adult guidelines.
        CJEM. 2008; 10: 136-151
        • Cox D.R.
        Regression models and life-tables.
        J R Stat Soc Series B Stat Methodol. 1972; 34: 187-220
        • Bellera C.A.
        • MacGrogan G.
        • Debled M.
        • et al.
        Variables with time-varying effects and the Cox model: some statistical concepts illustrated with a prognostic factor study in breast cancer.
        BMC Med Res Methodol. 2010; 10: 20
        • Sox H.C.
        • Higgins M.C.
        • Owens D.K.
        Medical Decision Making.
        2nd ed. John Wiley & Sons, Oxford, United Kingdom2013
        • Meira-Machado L.
        • de Uña-Álvarez J.
        • Cadarso-Suárez C.
        • et al.
        Multi-state models for the analysis of time-to-event data.
        Stat Methods Med Res. 2009; 18: 195-222
        • Lee J.
        • Bittner E.A.
        Improving the state of use and understanding of multistate models in critical care.
        Crit Care Med. 2018; 46: 1191-1192
        • Hubbard R.A.
        • Lange J.
        • Zhang Y.
        • et al.
        Using semi-Markov processes to study timeliness and tests used in the diagnostic evaluation of suspected breast cancer.
        Stat Med. 2016; 35: 4980-4993
        • Jackson C.H.
        Multi-state models for panel data: the msm package for R.
        J Stat Softw. 2011; 38: 1-28
        • Kumar A.
        • Roberts D.
        • Wood K.E.
        • et al.
        Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.
        Crit Care Med. 2006; 34: 1589-1596
        • Singer M.
        Antibiotics for sepsis: does each hour really count, or is it incestuous amplification?.
        Am J Respir Crit Care Med. 2017; 196: 800-802
        • Sun B.C.
        • Hsia R.Y.
        • Weiss R.E.
        • et al.
        Effect of emergency department crowding on outcomes of admitted patients.
        Ann Emerg Med. 2013; 61: 605-611.e606
        • Jo S.
        • Jeong T.
        • Jin Y.H.
        • et al.
        ED crowding is associated with inpatient mortality among critically ill patients admitted via the ED: post hoc analysis from a retrospective study.
        Am J Emerg Med. 2015; 33: 1725-1731
        • Chang A.M.
        • Lin A.
        • Fu R.
        • et al.
        Associations of emergency department length of stay with publicly reported quality-of-care measures.
        Acad Emerg Med. 2017; 24: 246-250
        • Tsai M.-T.
        • Yen Y.-L.
        • Su C.-M.
        • et al.
        The influence of emergency department crowding on the efficiency of care for acute stroke patients.
        Int J Qual Health Care. 2016; 28: 774-778
        • Chatterjee P.
        • Cucchiara B.L.
        • Lazarciuc N.
        • et al.
        Emergency department crowding and time to care in patients with acute stroke.
        Stroke. 2011; 42: 1074-1080
        • Shin T.G.
        • Jo I.J.
        • Choi D.J.
        • et al.
        The adverse effect of emergency department crowding on compliance with the resuscitation bundle in the management of severe sepsis and septic shock.
        Crit Care. 2013; 17: R224
        • Pines J.M.
        • Localio A.R.
        • Hollander J.E.
        • et al.
        The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia.
        Ann Emerg Med. 2007; 50: 510-516
        • Sikka R.
        • Mehta S.
        • Kaucky C.
        • et al.
        ED crowding is associated with an increased time to pneumonia treatment.
        Am J Emerg Med. 2010; 28: 809-812
        • Hwang U.
        • Graff L.
        • Radford M.J.
        • et al.
        The association between emergency department crowding and time to antibiotic administration.
        Ann Emerg Med. 2004; 44: S6-S7
        • Jo S.
        • Kim K.
        • Lee J.H.
        • et al.
        Emergency department crowding is associated with 28-day mortality in community-acquired pneumonia patients.
        J Infect. 2012; 64: 268-275
        • MacKenzie E.J.
        • Rivara F.P.
        • Jurkovich G.J.
        • et al.
        A national evaluation of the effect of trauma-center care on mortality.
        N Engl J Med. 2006; 354: 366-378
        • Bradley E.H.
        • Herrin J.
        • Wang Y.
        • et al.
        Strategies for reducing the door-to-balloon time in acute myocardial infarction.
        N Engl J Med. 2006; 355: 2308-2320

      Linked Article

      • In reply:
        Annals of Emergency MedicineVol. 74Issue 4
        • Preview
          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
        • Preview
          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.
        • Full-Text
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