Prioritize sepsis assessments in your overcrowded emergency department

Hospital Safety Insider, May 2, 2019

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By Christopher Cheney, HealthLeaders Media

Emergency department crowding leads to a significant increase in door-to-antibiotic time for septic patients, recent research shows.

On an annual basis, sepsis affects about 1.7 million American adults and the infection is linked to more than 250,000 deaths. Prompt administration of antibiotics is the standard of care for patients who have been identified with sepsis.

The recent research found only 46% of emergency department sepsis patients received antibiotics within 3 hours of ED arrival when the emergency room was crowded compared to 63% receiving timely antibiotics when the ER was not crowded.

The researchers examined data collected from more than 3,500 sepsis patients.

"We observed a consistent association between increased ED crowding and decreased antibiotic timeliness. When ED occupancy rate was in the highest quartile, the adjusted probability of starting antibiotics within 3 hours was more than 50% lower than when ED occupancy rate was at or below the 25th percentile," the researchers wrote.

Achieving standard of care under crowded ER conditions

Even in a crowded ED and with the diagnostic challenges of sepsis, meeting the 3-hour standard of care for administration of antibiotics to sepsis patients is a reasonable expectation, the lead author of the research told HealthLeaders.

"Myocardial infarction treatment and stroke treatment also require a team evaluation and multiple aspects of clinical evaluation?there is intensive resource mobilization. However, for MI or for stroke, we don't say, 'The ED was overcrowded, so it's OK that we didn't achieve our one-hour time to treatment goals,'" said Ithan Peltan, MD, MSc, an attending physician in the Department of Medicine at Intermountain Medical Center, Murray, Utah.

EDs should have a similar approach to sepsis treatment as MI and stroke treatment, with the acknowledgement that sepsis diagnosis is definitely not as clear cut, he said. "We should determine how we can achieve our treatment goals for sepsis without increasing harm to patients?without increasing overtreatment or giving antibiotics unnecessarily to patients."

Accelerating sepsis assessment

Peltan's research team found that delayed administration of antibiotics results mainly from challenges in the early stage of patient care.

"Crowding-associated antibiotic delays resulted from delays in initial patient assessment (patient triage, evaluation by a clinician, and diagnostic data collection) rather than delay occurring between initial assessment completion and antibiotic initiation," the researchers wrote.

There are methods to improve early-stage care of sepsis patients in crowded EDs, Peltan told HealthLeaders.

"One factor is that the earliest stages of sepsis treatment are critical. You need to recognize the patients who might have sepsis. That is not to say we are going to diagnose sepsis right away, immediately start treatment, and give antibiotics indiscriminately. That is clearly not the right thing to do," he said.

In the early stage of patient care, identifying patients who are at high risk of sepsis is pivotal, Peltan said. "Identifying patients who are at increased risk for sepsis can be based on clinician suspicion with increasing education of our frontline providers and more advanced sepsis prediction models."

Once an ED patient has been identified as high risk for sepsis, the assessment process should be accelerated, Peltan said.

"The next step is to do what we have done for stroke and MI, which is to take measures that expedite the assessment that is necessary before the treatment decision can be made for patients. We should bring all of the resources into the room, we should get the blood tests done quickly, we should conduct point-of-care tests, we should have the nurses getting IV access, we should get a basic chest X-ray done, and we should collect a urinalysis sample."

Although speeding up the assessment process is challenging in a crowded ED, it is an essential step to reach an initial decision on whether sepsis is present or more assessment is necessary, he said. "This approach is helpful when there is ED crowding. One of the big challenges that ED crowding poses is for the physician at the bedside to have all of the data needed to make decisions."

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