Objective To investigate the association between timing and volume of intravenous fluids administered to ED patients with suspected infection and all‐cause in‐hospital mortality. Methods Retrospective cohort study of ED presentations at four metropolitan hospitals in Sydney, Australia, between October 2018 and May 2019. Patients over 16 years of age with suspected infection who received intravenous fluids within 24 h of presentation were included. Results During the study period, 7533 patients with suspected infection received intravenous fluids. Of these, 1996 (26.5%) and 231 (3.1%) had suspected sepsis and septic shock, respectively. Each 1000 mL increase in intravenous fluids administered was associated with a reduction in risk of in‐hospital mortality (adjusted odds ratio [AOR] 0.87, 95% confidence interval [CI] 0.76–0.99). This association was stronger in patients with septic shock (AOR 0.66, 95% CI 0.49–0.89), and those admitted to intensive care unit (ICU) (AOR 0.74, 95% CI 0.56–0.96). Patients with suspected sepsis and septic shock who received a total volume of >3600 mL had lower in‐hospital mortality (AOR 0.44, 95% CI 0.22–0.91; AOR 0.16, 95% CI 0.05–0.57) compared to those administered <3600 mL within the first 24 h of presenting to the ED. There was no association between the time of initiation of fluids and in‐hospital mortality among survivors and non‐survivors (2.3 vs 2.5 h, P = 0.50). Conclusion We observed a reduction in risk of in‐hospital mortality for each 1000 mL increase in intravenous fluids administered in patients with septic shock or admitted to ICU suggesting illness severity to be a likely effect modifier.
Background Early intravenous fluids for patients with sepsis presenting with hypoperfusion or shock in the emergency department remains one of the key recommendations of the Surviving Sepsis Campaign guidelines to reduce mortality. However, compliance with the recommendation remains poor. While several interventions have been implemented to improve early fluid administration as part of sepsis protocols, the extent to which they have improved compliance with fluid resuscitation is unknown. The factors associated with the lack of compliance are also poorly understood. Methods We conducted a systematic review, meta-analysis and narrative review to investigate the effectiveness of interventions in emergency departments in improving compliance with early fluid administration and examine the non-interventional facilitators and barriers that may influence appropriate fluid administration in adults with sepsis. We searched MEDLINE Ovid/PubMed, Ovid EMBASE, CINAHL, and SCOPUS databases for studies of any design to April 2021. We synthesised results from the studies reporting effectiveness of interventions in a meta-analysis and conducted a narrative synthesis of studies reporting non-interventional factors. Results We included 31 studies out of the 825 unique articles identified in the systematic review of which 21 were included in the meta-analysis and 11 in the narrative synthesis. In meta-analysis, interventions were associated with a 47% improvement in the rate of compliance [(Random Effects (RE) Relative Risk (RR) = 1.47, 95% Confidence Interval (CI), 1.25–1.74, p-value < 0.01)]; an average 24 min reduction in the time to fluids [RE mean difference = − 24.11(95% CI − 14.09 to − 34.14 min, p value < 0.01)], and patients receiving an additional 575 mL fluids [RE mean difference = 575.40 (95% CI 202.28–1353.08, p value < 0.01)]. The compliance rate of early fluid administration reported in the studies included in the narrative synthesis is 48% [RR = 0.48 (95% CI 0.24–0.72)]. Conclusion Performance improvement interventions improve compliance and time and volume of fluids administered to patients with sepsis in the emergency department. While patient-related factors such as advanced age, co-morbidities, cryptic shock were associated with poor compliance, important organisational factors such as inexperience of clinicians, overcrowding and inter-hospital transfers were also identified. A comprehensive understanding of the facilitators and barriers to early fluid administration is essential to design quality improvement projects. PROSPERO Registration ID CRD42021225417.
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