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Abstract

Introduction: Based on evidence that early antibiotics improve outcomes in severe sepsis, clinical guidelines are often implemented in the emergency department (ED) to expedite therapy. The role of guidelines targeted for children who develop nosocomial sepsis is not known. Hypothesis: For patients transferred to ICU, time from sepsis recognition to antibiotic administration is delayed in hospitalized inpatients compared to ED patients. Methods: We studied 75 consecutive patients with severe sepsis admitted to an academic pediatric ICU from Feb-July 2012 via the ED (n=25) or inpatient floor (n=50). A sepsis guideline was in place in the ED, but not inpatient floors or ICU. Age, chronic illness, and PRISM III-12 score were determined. Median (IQR) times from sepsis recognition to antibiotic order and administration were compared in ED vs hospitalized inpatients using Wilcoxon rank sum test. Achieving the benchmark of antibiotic administration within 60 minutes of sepsis recognition was compared in ED vs inpatient groups using binary logistic regression. Results: Septic patients admitted to ICU from ED and inpatient were similar in age (median, IQR 11.4, 5.2-14.0 vs 8.0, 2.4-18.0 years; p=0.18) and PRISM score (6, 5-12 vs 8, 3-12; p=0.76) but those admitted from ED had less chronic illness (ED 36%, inpatients 76%; p<0.01). Time to antibiotic order was 47 (7-126) for ED vs 87 (5-393) min for inpatients (p=0.18). Time to antibiotic administration was 73 (25-190) for ED vs 134 (58-443) min for inpatients (p<0.001). Delay from antibiotic order to administration was shorter for ED vs inpatients (14, 6-30 vs 62, 28-494 min; p=0.04). Inpatients were less likely to achieve antibiotic administration within 60 minutes (OR 0.29, 95% CI 0.11-0.81). After controlling for chronic illness, inpatients remained less likely to meet this metric, though this was not statistically significant (OR 0.41, 0.15-1.13). Conclusions: For patients transferred to ICU, time from sepsis recognition to antibiotic administration was delayed in hospitalized inpatients treated without a clinical sepsis guideline compared to ED patients treated with a clinical guideline. Guidelines that address barriers to therapy for inpatients who develop sepsis are needed.