The Effect of Emergency Department Crowding and Time of Day Upon the Adherence to Early Goal-Directed Therapy

Abstract

Emergency department (ED) crowding has been shown to impact the delivery of care for time-sensitive conditions (acute stroke, myocardial infarction). Aggressive and timely management of severe sepsis/septic shock through the protocolized care bundle, early goal directed therapy (EGDT), has been shown to improve mortality. We sought to analyze the effect of ED crowding and time of day upon the initiation of EGDT and time to critical interventions within the ED for patients with severe sepsis/septic shock. Retrospective chart review of EGDT-eligible (lactate >4 mmol/L or persistent hypotension) patients (≥2 SIRS criteria; a confirmed or suspected source of infection; presence of at ≥1 acute organ dysfunction), admitted to an urban, level I trauma center from the ED, 5/2008-2/2010. Four validated measures of ED crowding (occupancy, waiting patients, admitted patients, patient-hours) were assigned at the time of triage. Adjusted odds ratios (OR) were calculated for administration of intravenous fluids (IVF) and antibiotics (ABX), and implementation of EGDT. Odds ratios were adjusted for patient demographic data (age, sex, SOFA score, and comorbidities) and analyzed for differences in time of day and ED crowding measures. A total of 2,913 patients were identified; 1,033 patients met Rivers’ criteria; 652 were treated with EGDT. Mean age was 57.3 years; 46.1% African-American, in-hospital mortality was 26%. Compared to patients presenting from 7pm-12am, patients presenting from 7am-7pm were less likely to have IVF started within ≤1 hour (OR 0.73), whereas from 12am-7am patients were more likely (OR 1.52). As occupancy and patient-hours increased, patients were less likely to receive IVF ≤1 hour (OR 0.73, 0.64). Overnight, patients were more likely to receive ABX ≤1 and ≤3 hours (OR 1.37, 1.73). Increased ED occupancy, patient hours, and the number of boarding inpatient admissions negatively impacted administration of ABX ≤3 hours (OR 0.77, 0.77, 0.75). Initiation of EGDT for all patients meeting criteria was significantly more likely to occur as occupancy increased (OR 1.52) but less likely as the number of boarding inpatients increased (OR 0.39). The administration of critical interventions (IVF ≤1 hour and antibiotics ≤1 or ≤3 hours) was delayed during daytime and evening hours when adjusting for patient level factors. ED crowding, (occupancy rate, patient hours, and inpatient boarding) negatively impacts the delivery of time-sensitive interventions. Boarding admitted inpatients in the ED decreases the initiation rate of EGDT for patients meeting criteria. EDs must be mindful of crowding measures as they attempt to optimize delivery of time-sensitive therapies to critically ill patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)