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Ann Emerg Med. 2019 Sep 24. pii: S0196-0644(19)30593-1. doi: 10.1016/j.annemergmed.2019.07.017. [Epub ahead of print]

Antibiotic Delays and Feasibility of a 1-Hour-From-Triage Antibiotic Requirement: Analysis of an Emergency Department Sepsis Quality Improvement Database.

Author information

1
Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA. Electronic address: mfilbin@mgh.harvard.edu.
2
Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
3
Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA.
4
Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA; Nihon Kohden Innovation Center, Cambridge, MA.
5
Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, CT.

Abstract

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 post-quality 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.

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