More than one third of patients with septic shock presented to the emergency department with vague symptoms that were not specific to infection. These patients had delayed antibiotic administration and higher risk of mortality even after controlling for demographics, illness acuity, and time-to-antibiotics in multivariate analysis. These findings suggest that the nature of presenting symptoms is an important component of sepsis clinical phenotyping and may be an important confounder in sepsis epidemiologic studies.

Study objective: We identify factors associated with delayed emergency department (ED) antibiotics and determine feasibility of a 1-hour-from-triage antibiotic requirement in sepsis.Methods: We studied all ED adult septic patients in accordance with Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock National Quality Measures in 2 consecutive 12-month intervals. During the second interval, a quality improvement intervention was conducted: a sepsis screening protocol plus case-specific feedback to clinicians. Data were abstracted retrospectively through electronic query and chart review. Primary outcomes were antibiotic delay greater than 3 hours from documented onset of hypoperfusion (per Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock National Quality Measures) and antibiotic delay greater than 1 hour from triage (per 2018 Surviving Sepsis Campaign recommendations).Results: We identified 297 and 357 septic patients before and during the quality improvement intervention, respectively. Before and during quality improvement intervention, antibiotic delay in accordance with Centers for Medicare & Medicaid Services measures occurred in 30% and 21% of cases (-9% [95% confidence interval -16% to -2%]); and in accordance with 2018 Surviving Sepsis Campaign recommendations, 85% and 71% (-14% [95% confidence interval -20% to -8%]). Four factors were independently associated with both definitions of antibiotic delay: vague (ie, nonexplicitly infectious) presenting symptoms, triage location to nonacute areas, care before the quality improvement intervention, and lower Sequential [Sepsis-related] Organ Failure Assessment scores. Most patients did not receive antibiotics within 1 hour of triage, with the exception of a small subset postquality improvement intervention who presented with explicit infectious symptoms and triage hypotension. Conclusion:The quality improvement intervention significantly reduced antibiotic delays, yet most septic patients did not receive antibiotics within 1 hour of triage. Compliance with the 2018 Surviving Sepsis Campaign would require a wholesale alteration in the management of ED patients with either vague symptoms or absence of triage hypotension.

Objective To characterize the rate of monitoring alarms by alarm priority, signal type and developmental age in a Level-IIIB Neonatal Intensive Care Unit (NICU) population. Study Design Retrospective analysis of 2 294 687 alarm messages from Philips monitors in a convenience sample of 917 NICU patients, covering 12 001 patient-days. We stratified alarm rates by alarm priority, signal type, postmenstrual age (PMA), and birth weight (BW) and reviewed and adjudicated over 21 000 critical alarms. Results Of all alarms, 3.6% were critical alarms, 55.0% were advisory alarms, and 41.4% were device alerts. Over 60% of alarms related to oxygenation monitoring. The average alarm rate (±SEM) was 177.1±4.9 [median: 135.9; IQR: 89.2–213.3] alarms/patient-day; the medians varied significantly with PMA and BW (p<0.001) in U-shaped patterns, with higher rates at lower and higher PMA and BW. Based on waveform reviews, over 99% of critical arrhythmia alarms were deemed technically false. Conclusions The alarm burden in this NICU population is very significant; the average alarm rate significantly underrepresents alarm rates at low and high PMA and BW. Virtually all critical arrhythmia alarms were artifactual.

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