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@NEJM Ask the Authors & Experts: Time to Treatment and Mortality during Mandated Emergency Care for Sepsis

Original Article

Time to Treatment and Mortality during Mandated Emergency Care for Sepsis

Christopher W. Seymour, MD, MSc, Foster Gesten, MD, Hallie C. Prescott, MD, MSc, Marcus E. Friedrich, MD, Theodore J. Iwashyna, MD, PhD, Gary S. Phillips, MAS, Stanley Lemeshow, PhD, Tiffany Osborn, MD, MPH, Kathy M. Terry, PhD, Mitchell M. Levy, MD


May 21, 2017.

BACKGROUND
There is controversy whether more rapid treatment of sepsis improves patient outcomes.

METHODS
In 2013 New York State required hospitals to follow protocols for early identification and treatment of sepsis. We studied patients with sepsis and septic shock reported to the New York State Department of Health from April 1, 2014 to June 30, 2016 who had a sepsis protocol initiated within 6 hours of arrival to the emergency department, and who within 12 hours had completed all items in a 3-hour sepsis bundle (i.e. blood cultures, broad-spectrum antibiotics, and lactate measurement). Multilevel models were used to assess the associations between time until completion of the 3- hour bundle and risk adjusted mortality. We also examined time to administration of antibiotics and completion of an intravenous (IV) fluid bolus.

RESULTS
Among 49,331 patients at 149 hospitals, 40,696 (83%) completed the 3-hour bundle within 3 hours. The median time to bundle completion was 1.30 hours [IQR:0.65,2.35 hours], time to antibiotics was 0.95 hours [IQR:0.35,1.95 hours], and time to fluid bolus was 2.56 hours [IQR:1.33,4.20 hours]. Among those who completed the bundle within 12 hours, longer time to 3-hour bundle completion was associated with greater risk-adjusted in-hospital mortality (odds ratio:1.04 [95%CI:1.02,1.05] per hour, p<0.01), as was time to antibiotics (odds ratio:1.04 [95%CI:1.03,1.06] per hour, p<0.01) but not completion of IV fluid bolus (odds ratio:1.01 [95%CI:0.99,1.02] per hour, p=0.22).

CONCLUSIONS
More rapid completion of a 3-hour sepsis bundle and administration of antibiotics, but not completion of an initial IV fluid bolus, were associated with lower risk- adjusted in-hospital mortality.

 Originally Appeared in The New England Journal of Medicine on May 21, 2017.