Time to Treatment and Mortality during Mandated Emergency Care for Sepsis

By C. Seymour, F. Gesten, H. Prescott, M. Friedrich, Theodore J. Iwashyna, G. Phillips, S. Lemeshow, T. Osborn, Kathleen M. Terry, Mitchell M. Levy. New England Journal of Medicine, 2017

1,816 citations recorded by the source corpus.

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.)

Subfields: Clinical Biochemistry, Critical Care and Intensive Care Medicine, Epidemiology

View Paper: https://www.semanticscholar.org/paper/62b9aa37782c55c987f30172befdf1a32ae2a027

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Citations in the corpus

"The human body is a black box": supporting clinical decision-making with deep learning (2019, background): “very quarter, healthcare systems manually comb through randomly selected charts to document compliance with the SEP-1 sepsis treatment guidelines that have been documented to improve patient outcomes [37, 38]. While some health systems have improved performance and patient outcomes through quality i”
The Surviving Sepsis Campaign Bundle: 2018 update (2018, background): “The important relationship between the bundles and survival was confirmed in a publication from this NYS initiative [16].”
Improving Sepsis Treatment Strategies by Combining Deep and Kernel-Based Reinforcement Learning (2018, positive): “Then we define the reward r(o, a, o′) as r(o, a, o′) = − log f(o ′) 1− f(o′) f(o′) + log f(o) 1− f(o) (1)”
An Improved Multi-Output Gaussian Process RNN with Real-Time Validation for Early Sepsis Detection (2017, background): “m septic shock by 7.6% (Kumar et al. (2006)). Additionally, recent work found timely administration of a 3-hour care bundle was associated with lower in-hospital mortality across all septic patients (Seymour et al. (2017)), further emphasizing the need for fast and aggressive treatment. With the wid”
Learning to Detect Sepsis with a Multitask Gaussian Process RNN Classifier (2017, background): “blood culture, broadspectrum antibiotics, and a lactate measurement) was associated with lower in-hospital mortality (Seymour et al., 2017), further emphasizing the need for fast and aggressive treatment.”
Sepsis and septic shock. (2018, background): “65 Regarding patients with hypotension, a widely cited observational study showed an association between delayed antibiotic initiation and death, with a 7% increase in risk of death for every hour of delay.”
An Interpretable Machine Learning Model for Accurate Prediction of Sepsis in the ICU (2017, background): “[5] Identifying those at risk for sepsis and initiating appropriate treatment, prior to any clinical manifestations, would have a significant impact on the overall mortality and cost burden of sepsis.”
Early prediction of circulatory failure in the intensive care unit using machine learning (2020, result): “This finding is consistent with other clinical trials that indicate that repeated or prolonged episodes of hypotension and high dose vasopressors 11,53 , as well as delays in shock treatment 9,54–58 , are associated with higher mortality.”