The adverse effect of emergency department crowding on compliance with the resuscitation bundle in the management of severe sepsis and septic shock

Abstract

IntroductionThe aim of this study is to evaluate the effects of emergency department (ED) crowding on the implementation of tasks in the early resuscitation bundle during acute care of patients with severe sepsis and septic shock, as recommended by the Surviving Sepsis Campaign guidelines.MethodsWe analyzed the sepsis registry from August 2008 to March 2012 for patients presenting to an ED of a tertiary urban hospital and meeting the criteria for severe sepsis or septic shock. The ED occupancy rate, which was defined as the total number of patients in the ED divided by the total number of ED beds, was used for measuring the degree of ED crowding. It was categorized into three groups (low; intermediate; high crowding). The primary endpoint was the overall compliance with the entire resuscitation bundle.ResultsA total of 770 patients were enrolled. Of the eligible patients, 276 patients were assigned to the low crowding group, 250 patients to the intermediate crowding group, and 244 patients to the high crowding group (ED occupancy rate: ≤ 115; 116–149; ≥ 150%). There was significant difference in compliance rates among the three groups (31.9% in the low crowding group, 24.4% in the intermediate crowding group, and 16.4% in the high crowding group, P < 0.001). In a multivariate model, the high crowding group had a significant association with lower compliance (adjusted odds ratio (OR), 0.44; 95% confidence interval (CI), 0.26 to 0.76; P = 0.003). When the ED occupancy rate was included as a continuous variable in the model, it had also a negative correlation with the overall compliance (OR of 10% increase of the ED occupancy rate, 0.90; 95% CI, 0.84 to 0.96, P = 0.002).ConclusionsED crowding was significantly associated with lower compliance with the entire resuscitation bundle and decreased likelihood of the timely implementation of the bundle elements.

The relationship between emergency department crowding and outcome of referred critical patients from other hospitals

“…10 In another study, the mean age was 65 and 56.8% were men. 11 In Pines et al study, 57.0% were men with the mean ± SD age of 44 ± 17 years. 12 In Nasr-Esfahani et al study, 484 patients were admitted to the ED with the mean ± SD age of 53.8 ± 20.3 which 55.8% were men.…”

Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002

“…Due to the importance of adherence to EGDT bundle, studies investigated factors associated with compliance (94,95). These studies showed that body temperature, experience of nurses and physicians, cryptic shock, serum lactate levels and ED crowding all affected adherence (94,96). An important distinction between RCTs exploring EGDT and observational studies applying the SSC bundle is that the latter included somewhat different components than recommended in EGDT.…”

The intensive care medicine research agenda on septic shock

“…Other factors that decrease compliance with resuscitation guidelines include low awareness among healthcare workers, healthcare workforce shortages, overcrowding of emergency departments [13], and unfavourable nurse-to-patient ratios [14]. Low availability of resources can also limit the application of some interventions.…”