Antibiotic Delays and Feasibility of a 1-Hour-From-Triage Antibiotic Requirement: Analysis of an Emergency Department Sepsis Quality Improvement Database

Abstract

Study objective: We identify factors associated with delayed emergency department (ED) antibiotics and determine feasibility of a 1-hour-from-triage antibiotic requirement in sepsis.Methods: We studied all ED adult septic patients in accordance with Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock National Quality Measures in 2 consecutive 12-month intervals. During the second interval, a quality improvement intervention was conducted: a sepsis screening protocol plus case-specific feedback to clinicians. Data were abstracted retrospectively through electronic query and chart review. Primary outcomes were antibiotic delay greater than 3 hours from documented onset of hypoperfusion (per Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock National Quality Measures) and antibiotic delay greater than 1 hour from triage (per 2018 Surviving Sepsis Campaign recommendations).Results: We identified 297 and 357 septic patients before and during the quality improvement intervention, respectively. Before and during quality improvement intervention, antibiotic delay in accordance with Centers for Medicare & Medicaid Services measures occurred in 30% and 21% of cases (-9% [95% confidence interval -16% to -2%]); and in accordance with 2018 Surviving Sepsis Campaign recommendations, 85% and 71% (-14% [95% confidence interval -20% to -8%]). Four factors were independently associated with both definitions of antibiotic delay: vague (ie, nonexplicitly infectious) presenting symptoms, triage location to nonacute areas, care before the quality improvement intervention, and lower Sequential [Sepsis-related] Organ Failure Assessment scores. Most patients did not receive antibiotics within 1 hour of triage, with the exception of a small subset postquality improvement intervention who presented with explicit infectious symptoms and triage hypotension. Conclusion:The quality improvement intervention significantly reduced antibiotic delays, yet most septic patients did not receive antibiotics within 1 hour of triage. Compliance with the 2018 Surviving Sepsis Campaign would require a wholesale alteration in the management of ED patients with either vague symptoms or absence of triage hypotension.

Predictors for delayed antibiotic administration among bacteraemic patients in the Emergency Department: Differences between medical and surgical interns

“…4 While the vast majority of patients had a secondary bacteraemia (90.9%), it has been shown in previous studies that patients with primary BSIs received antibiotics later than those with secondary ones, probably due to the absence of an obvious site of infection. 16 This delay in antibiotic administration may explain the worst outcome of patients with bacteraemia with unidentified source of infection. 2,3 As previously shown in septic patients, 17 low respiratory tract infection was independently associated with mortality.…”

Sepsis, a 2020 review for the internist

“…Moreover, its feasibility in the real life is doubted because of expectedly unsurmountable systematic delays [20]. Overall, the arbitrary "1-hour" bundle is probably not yet primed for real life use, but early active resuscitation interventions and protocolized follow-up are highly recommended.…”

Antiinfektive Therapie

“…Intensivaufenthaltsdauer [16,21]. Die praktische Durchführbarkeit der Antibiotikagabe innerhalb der ersten Stunde ist immer wieder infrage gestellt worden und bedarf großer Anstrengungen, unter anderem in der Logistik der Notaufnahmen [11,14], andererseits dürfte sich nur über ambitionierte Ziele eine relevante Verbesserung in der medianen Zeit bis zur ersten Antibiotikagabe erreichen lassen. Selbst in gut trainierten zentralen Notaufnahmen großer Krankenhäuser liegen die zurzeit erreichten Zeiten ("door-to-antibiotic") im Schnitt eher im Bereich von 2 bis 3 h [21].…”