Time to Treatment and Mortality during Mandated Emergency Care for Sepsis
- PMID: 28528569
- PMCID: PMC5538258
- DOI: 10.1056/NEJMoa1703058
Time to Treatment and Mortality during Mandated Emergency Care for Sepsis
Abstract
Background: 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.
Methods: 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.
Results: 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).
Conclusions: 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. (Funded by the National Institutes of Health and others.).
Figures
![Figure 1](https://cdn.statically.io/img/www.ncbi.nlm.nih.gov/pmc/articles/instance/5538258/bin/nihms882574f1.gif)
![Figure 2](https://cdn.statically.io/img/www.ncbi.nlm.nih.gov/pmc/articles/instance/5538258/bin/nihms882574f2.gif)
![Figure 3](https://cdn.statically.io/img/www.ncbi.nlm.nih.gov/pmc/articles/instance/5538258/bin/nihms882574f3.gif)
![Figure 4](https://cdn.statically.io/img/www.ncbi.nlm.nih.gov/pmc/articles/instance/5538258/bin/nihms882574f4.gif)
Comment in
-
In sepsis, beyond adherence, timeliness matters.J Thorac Dis. 2017 Sep;9(9):2808-2811. doi: 10.21037/jtd.2017.08.65. J Thorac Dis. 2017. PMID: 29221245 Free PMC article. No abstract available.
-
From Barcelona to New York: 15 years of transition of sepsis performance improvement.J Thorac Dis. 2017 Oct;9(10):3453-3455. doi: 10.21037/jtd.2017.08.144. J Thorac Dis. 2017. PMID: 29268313 Free PMC article. No abstract available.
-
Sepsis Therapies: Insights from Population Health to Cellular Therapies and Genomic Medicine.Am J Respir Crit Care Med. 2018 Dec 15;198(12):1570-1572. doi: 10.1164/rccm.201804-0782RR. Am J Respir Crit Care Med. 2018. PMID: 30277812 Free PMC article. No abstract available.
Similar articles
-
Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis.JAMA. 2018 Jul 24;320(4):358-367. doi: 10.1001/jama.2018.9071. JAMA. 2018. PMID: 30043064 Free PMC article.
-
Relationship Between a Sepsis Intervention Bundle and In-Hospital Mortality Among Hospitalized Patients: A Retrospective Analysis of Real-World Data.Anesth Analg. 2017 Aug;125(2):507-513. doi: 10.1213/ANE.0000000000002085. Anesth Analg. 2017. PMID: 28514322
-
Arriving by emergency medical services improves time to treatment endpoints for patients with severe sepsis or septic shock.Acad Emerg Med. 2011 Sep;18(9):934-40. doi: 10.1111/j.1553-2712.2011.01145.x. Epub 2011 Aug 30. Acad Emerg Med. 2011. PMID: 21883637
-
The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis.Crit Care Med. 2015 Sep;43(9):1907-15. doi: 10.1097/CCM.0000000000001142. Crit Care Med. 2015. PMID: 26121073 Free PMC article. Review.
-
A quality improvement project to improve early sepsis care in the emergency department.BMJ Qual Saf. 2015 Dec;24(12):787-95. doi: 10.1136/bmjqs-2014-003552. Epub 2015 Aug 6. BMJ Qual Saf. 2015. PMID: 26251506 Review.
Cited by
-
Trajectories of State-Level Sepsis-Related Mortality by Race and Ethnicity Group in the United States.J Clin Med. 2024 May 12;13(10):2848. doi: 10.3390/jcm13102848. J Clin Med. 2024. PMID: 38792390 Free PMC article.
-
Suppression PCR-Based Selective Enrichment Sequencing for Pathogen and Antimicrobial Resistance Detection on Cell-Free DNA in Sepsis-A Targeted, Blood Culture-Independent Approach for Rapid Pathogen and Resistance Diagnostics in Septic Patients.Int J Mol Sci. 2024 May 17;25(10):5463. doi: 10.3390/ijms25105463. Int J Mol Sci. 2024. PMID: 38791501 Free PMC article.
-
Clinical outcomes and risk factors for mortality in recipients with carbapenem-resistant gram-negative bacilli infections after kidney transplantation treated with ceftazidime-avibactam: a retrospective study.Front Cell Infect Microbiol. 2024 May 8;14:1404404. doi: 10.3389/fcimb.2024.1404404. eCollection 2024. Front Cell Infect Microbiol. 2024. PMID: 38779560 Free PMC article.
-
Impact of Gram-Negative Bacilli Resistance Rates on Risk of Death in Septic Shock and Pneumonia.Open Forum Infect Dis. 2024 Apr 26;11(5):ofae219. doi: 10.1093/ofid/ofae219. eCollection 2024 May. Open Forum Infect Dis. 2024. PMID: 38770211 Free PMC article.
-
Blood calprotectin as a biomarker for infection and sepsis - the prospective CASCADE trial.BMC Infect Dis. 2024 May 16;24(1):496. doi: 10.1186/s12879-024-09394-x. BMC Infect Dis. 2024. PMID: 38755564 Free PMC article.
References
-
- Gaieski DF, Edwards JM, Kallan MJ, Carr BG. Benchmarking the incidence and mortality of severe sepsis in the United States. Crit Care Med. 2013;41:1167–74. - PubMed
-
- Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43:304–77. - PubMed
-
- Kumar A, Haery C, Paladugu B, et al. The duration of hypotension before the initiation of antibiotic treatment is a critical determinant of survival in a murine model of Escherichia coli septic shock: association with serum lactate and inflammatory cytokine levels. J Infect Dis. 2006;193:251–8. - PubMed
-
- Ferrer R, Martin-Loeches I, Phillips G, et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med. 2014;42:1749–55. - PubMed
MeSH terms
Substances
Grants and funding
LinkOut - more resources
Full Text Sources
Other Literature Sources
Medical
Miscellaneous