Time of Emergency Department Arrival is an Inaccurate Measure of Time of Presentation of Patients With Severe Sepsis and Septic Shock

Abstract

Treatment bundles are associated with decreased mortality for severe sepsis/septic shock. In October 2012 the National Quality Forum endorsed Measure 500 (Severe Sepsis and Septic Shock: Management Bundle):A.Lactate measurementB.Blood cultures prior to antibioticsC.Broad spectrum antibioticsD.30ml/kg bolus of crystalloid for hypotension or lactate >=4 mmol/LE.Vasopressors for fluid resistant hypotensionF.CVP and ScvO2 measurement for persistent hypotension or initial lactate >=4mmol/L For compliance, A-C must be met <3 hrs of emergency department (ED) arrival (D-F <6hrs for shock only), independent of when patients meet diagnostic criteria. While antibiotic administration <1 hr of septic shock onset is associated with reduced mortality, little evidence validates defining time of presentation as ED arrival. If bundle is met <1hr after diagnostic criteria are met (appropriate care) but more than 3hrs from ED arrival (didn't initially meet criteria), providers will be non-compliant (“false negative”). To determine percentage of ED patients who did no meet diagnostic criteria <3 hrs from ED arrival and determine their impact on antibiotic administration <3 hrs from ED arrival (surrogate for bundle compliance). Design: retrospective descriptive analysis of a prospective cohort enrolled for quality assurance review. Setting: urban, tertiary, university ED with annual census of 39,000. Participants: all adult (age >= 18) ED patients with suspected severe sepsis/septic shock, September 5, 2012 - April 3, 2013. Severe sepsis / septic shock were defined in accordance with the 2012 Surviving Sepsis Campaign guidelines:•Known or suspected infection and•>=2 SIRS criteria and•End-organ dysfunction (severe sepsis) or refractory hypotension (shock). We report median time (IQR) from ED arrival to meeting diagnostic criteria. The primary outcome was percent (95% CI) of patients who did not meet diagnostic criteria <3 hrs of ED arrival. We also report compliance with antibiotic administration <3 hrs of ED arrival and <1 hr of severe sepsis/septic shock onset. Two hundred fifty-nine patients were suspected of having severe sepsis/septic shock during the study period. Median time from ED arrival until meeting diagnostic criteria was 71 min (35.5-130 min). 41 (15.8%, 95% CI 11.8-20.7) patients met diagnostic criteria >3hrs of ED arrival. Median time to antibiotics from ED arrival was 121 min (72 - 206 min). Overall, 67.6% (95% CI 61.7-73.1) received antibiotics <3 hrs after ED arrival. One hundred seventy patients (78%, 95% CI 72.6-82.7) met diagnostic criteria <3 hrs and received antibiotics <3hrs after ED arrival. One hundred sixty-six patients (64.1%, 95% CI 58.1-69.8) did so <1hr of meeting diagnostic criteria, regardless of ED arrival time. Notably, 29 patients (11.2%, 95% CI 7.6-15.7) received antibiotics <1hr of meeting diagnostic criteria, but not <3hrs after ED arrival (appropriate care but bundle non-compliant). ED arrival time inaccurately defines time of presentation for ED patients with suspected severe sepsis/septic shock. In this single center study, 15.8% of adult ED patients with suspected severe sepsis/septic shock did not meet diagnostic criteria < 3 hrs after ED arrival. If replicated more broadly, performance metrics need to account for this finding (ie, use time of meeting diagnostic criteria rather than ED arrival).