May - 2017
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Time to Treatment and Mortality during Mandated Emergency Care for Sepsis
New Eng J Med, 2017, online first May
In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. Although protocols could be tailored by each hospital, all
the protocols were required to include a;
What effect did this mandated care have?
This retrospective study examined patient level data from the NYSDOH database of patients with sepsis and septic shock, for 185 hospitals from 1st April 14 to 30th June 16. They looked at patients with community acquired sepsis, and 3-hour bundle initiated within 6 hours of arrival in ED. They excluded outliers who did not have 3-hr protocol completed by 12-hours. They report:
Overall this large database study reports high levels of compliance with the mandated sepsis bundle in NYC, and an association between earlier 3-hour bundle delivery and survival. The authors believe the lack of association between timing of fluid administration and survival should be interpreted with caution, as this is most open to confounding, clinicians will give sicker patients fluid quicker. They conclude that if the relationship between timing of delivery of the bundle and survival is causal, then prompt recognition and faster treatment of sepsis may save lives. This seems reasonable.
It would have been a fascinating addition to this analysis if data preceding the 2013 bundle was obtained. If a baseline audit period had been conducted, we would have seen if mandated care results in changes in recognition of sepsis, delivery of the components, and outcome.
In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients.
We studied data from patients with sepsis and septic shock that were reported to the New York State Department of Health from April 1, 2014, to June 30, 2016. Patients had a sepsis protocol initiated within 6 hours after arrival in the emergency department and had all items in a 3-hour bundle of care for patients with sepsis (i.e., blood cultures, broad-spectrum antibiotic agents, and lactate measurement) completed within 12 hours. Multilevel models were used to assess the associations between the time until completion of the 3-hour bundle and risk-adjusted mortality. We also examined the times to the administration of antibiotics and to the completion of an initial bolus of intravenous fluid.
Among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3-hour bundle completed within 3 hours. The median time to completion of the 3-hour bundle was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the administration of antibiotics was 0.95 hours (interquartile range, 0.35 to 1.95), and the median time to completion of the fluid bolus was 2.56 hours (interquartile range, 1.33 to 4.20). Among patients who had the 3-hour bundle completed within 12 hours, a longer time to the completion of the bundle was associated with higher risk-adjusted in hospital mortality (odds ratio, 1.04 per hour; 95% confidence interval [CI], 1.02 to 1.05; P<0.001), as was a longer time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI, 1.03 to 1.06; P<0.001) but not a longer time to the completion of a bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02; P = 0.21).
More rapid completion of a 3-hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality.
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