Time to Treatment and Mortality during Mandated Emergency Care for Sepsis

Abstract

BACKGROUND In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients. METHODS We studied data from patients with sepsis and septic shock that were reported to the New York State Department of Health from April 1, 2014, to June 30, 2016. Patients had a sepsis protocol initiated within 6 hours after arrival in the emergency department and had all items in a 3-hour bundle of care for patients with sepsis (i.e., blood cultures, broad-spectrum antibiotic agents, and lactate measurement) completed within 12 hours. Multilevel models were used to assess the associations between the time until completion of the 3-hour bundle and risk-adjusted mortality. We also examined the times to the administration of antibiotics and to the completion of an initial bolus of intravenous fluid. RESULTS Among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3-hour bundle completed within 3 hours. The median time to completion of the 3-hour bundle was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the administration of antibiotics was 0.95 hours (interquartile range, 0.35 to 1.95), and the median time to completion of the fluid bolus was 2.56 hours (interquartile range, 1.33 to 4.20). Among patients who had the 3-hour bundle completed within 12 hours, a longer time to the completion of the bundle was associated with higher risk-adjusted inhospital mortality (odds ratio, 1.04 per hour; 95% confidence interval [CI], 1.02 to 1.05; P<0.001), as was a longer time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI, 1.03 to 1.06; P<0.001) but not a longer time to the completion of a bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02; P=0.21). CONCLUSIONS More rapid completion of a 3-hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality.

The SEP-1 quality mandate may be harmful: How to drown a patient with 30 mL per kg fluid!

“…Moreover, recent clinical trials suggest that protocolized resuscitation strategies, which are also mandated by Rory's Regulations, may paradoxically lead to increased lengths of stay in the ICU and in the hospital and higher costs [3,[28][29][30][31]. The regulations may also lead to antibiotic overuse, if hospitals, in an attempt to increase their adherence to guidelines, give antibiotics to patients who are not infected [32].…”

“…The regulations may also lead to antibiotic overuse, if hospitals, in an attempt to increase their adherence to guidelines, give antibiotics to patients who are not infected [32]. In a study among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3-hour bundle completed within 3 hours [31]. However, the results showed that more rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality [31].…”

“…In a study among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3-hour bundle completed within 3 hours [31]. However, the results showed that more rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality [31].…”

Bacterial sepsis

“…The fact that the measures in the sepsis bundles do not all have the same weight and the same priority was demonstrated by Seymour et al [46] in a recent retrospective study. In this investigation, it was rapid completion of the 3-hour bundle and earliest possible commencement of antibiotic therapy that were the decisive factors for reducing mortality.…”

What comes after the Early Goal Directed Therapy for sepsis era?

“…It would be more helpful if we had data for the percentage of patients who received antibiotics in the first 2-3 hours or for the mean time for the first administered antibiotics in each group. The New York State Department of Health reported results which included 49,331 patients with sepsis treated at 149 hospitals (10). A longer time to the administration of antibiotics was associated with increased mortality (odds ratio: 1.04 per hour, 95% CI: 1.03-1.06).…”