Emergency Department Crowding Delayed Antibiotics but Did Not Increased Mortality for Sepsis?

Abstract

We congratulate Peltan et al1Peltan I.D. Bledsoe J.R. Oniki T.A. et al.Emergency department crowding is associated with delayed antibiotics for sepsis.Ann Emerg Med. 2019; 73: 345-355Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar on their recent article. Emergency department (ED) crowding is a difficult and persistent problem for many hospitals and for patients; it is also a topic of great interest to emergency physicians. The article explored the difference in the time of antibiotics administration in patients with sepsis and the state of ED crowding during administration, and concluded that patients received antibiotics earlier in uncrowded conditions. The conclusion facilitates improvement of awareness of early detection and diagnosis for patients with sepsis, and of early administration of antibiotics. However, we have several questions about this study. First, there is no recognized best definition for ED crowding. The most commonly used definitions have been numeric counts of patients and process times associated with patient care.2Hwang U. McCarthy M.L. Aronsky D. et al.Measures of crowding in the emergency department: a systematic review.Acad Emerg Med. 2011; 18: 527-538Crossref PubMed Scopus (157) Google Scholar Why did the authors choose the ratio of greater than or equal to 1 for registered ED patients to licensed ED beds? They did not describe the indication for admission to ED beds. Should all sepsis patients be admitted to ED beds before receiving antibiotics? Second, in the retrospective cohort study, patients were included from July 2013 to September 2015. According to the results of ED admission data, the mean pulse rate was 102 beats/min and the respiratory rate was 20.9 and 21.2 breaths/min, respectively. These results met the criteria of systemic inflammatory response syndrome. If according to previous sepsis guidelines3Levy M.M. Fink M.P. Marshall J.C. et al.2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions conference.Intensive Care Med. 2003; 29: 530-538Crossref PubMed Scopus (1909) Google Scholar this might be diagnosed as sepsis and antibiotic treatment might be started, as the authors showed in Figure 1, many patients should receive antibiotics after the clinician assessment and before laboratory test results are available; however, the authors did not show this in the results. Was there a difference in the proportion of patients between the 2 groups? Third, according to quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) criteria, the results of ED admission data might not have met at least 2 of the following clinical criteria: respiratory rate of 22 breaths/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.4Singer M. Deutschman C.S. Seymour C.W. et al.The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA. 2016; 315: 801-810Crossref PubMed Scopus (11822) Google Scholar However, the authors did not show data such as Pao2, Fio2, platelet level, and bilirubin level that are included in the qSOFA. Fourth, why was the overall hospital mortality rate of sepsis patients receiving earlier antibiotics administration higher (6.2%) than in the group receiving late antibiotics administration (5.3%)? The authors performed body fluid cultures but did not analyze the relevant results. Moreover, the proportion of patients with nighttime and weekend ED arrival was higher in the group with ED occupancy rate less than 1 than the group with ED occupancy rate greater than or equal to 1 (11.8% to 0.8% and 29.4% to 15.7%, respectively). According to our limited experience, patients who arrive during this time often have a serious condition, especially at night. Was the proportion of patients who arrived at nighttime and weekend with a higher qSOFA score and increased the hospital mortality in this study? In reply:Annals of Emergency MedicineVol. 74Issue 4PreviewWe thank Drs. Li and Zhang for their interest in our study. The authors highlight how challenging it can be to choose from the numerous metrics of emergency department (ED) crowding used in previous research. We selected a range of validated measures of ED crowding, covering ED input, throughput, and output workload.1 The primary exposure of ED occupancy rate and the associated definition of ED crowding (ED occupancy rate ≥1) were selected according to past validation, generalizability, simplicity, expert recommendations, and broad use in the ED crowding literature generally and the ED sepsis care literature specifically. Full-Text PDF Emergency Department Crowding Is Associated With Delayed Antibiotics for SepsisAnnals of Emergency MedicineVol. 73Issue 4PreviewBarriers to early antibiotic administration for sepsis remain poorly understood. We investigated the association between emergency department (ED) crowding and door-to-antibiotic time in ED sepsis. Full-Text PDF