Blank Jessica A, King Jessie E, Grant Julieann F, Tian Shuo, Shrestha Sachita, England Peter, Paje David, Taylor Stephanie P
Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
Department of Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA.
J Hosp Med. 2025 Apr;20(4):368-373. doi: 10.1002/jhm.13536. Epub 2024 Oct 27.
Patients who first meet clinical criteria for sepsis while boarding in the emergency department (ED) may not receive optimal sepsis care.
Assess the association between ED boarding status and sepsis quality of care and outcomes.
We conducted a retrospective cohort study of adult patients admitted to a large academic hospital from July 2021 to October 2023 who had clinical features consistent with sepsis present while physically in the ED. We compared outcomes for patients who experienced time zero (T-0; the time clinical features of sepsis were first present) while boarding in the ED (physically in the ED but admitted to a different service) to those experiencing T-0 while still under the care of the ED provider team. We used logistic regression to estimate the association between ED boarding status at T-0 and compliance with the US Centers for Medicare & Medicaid Services (CMS) Severe Sepsis and Septic Shock: Management Bundle (SEP-1) core measure, individual bundle element compliance, and hospital mortality adjusting for prespecified covariates. In a subgroup analysis among patients who had not already received antibiotics before T-0, we conducted a Cox proportional hazards model to estimate the association between boarding status on time-to-antibiotics.
Among 4795 patients meeting a clinical definition of sepsis in the ED, 422 (8.8%) experienced T-0 as ED boarders. These patients were similar in age, sex, and comorbidities compared with patients experiencing T-0 while still under ED care. Fewer patients with T-0 as an ED boarder received SEP-1 compliant care (25% vs. 38%, p < .001), including a lower proportion of fluid resuscitation (15% vs. 26%, p = .004) and lactate assessment (62% vs. 94%, p < .001). Overall, more patients in the ED boarder group received antibiotics within 3 hours, but one-third of patients had already received antibiotics prior to T-0. Among patients who had not already received antibiotics prior to T-0, experiencing T-0 as an ED boarder was associated with a decreased likelihood of receiving antibiotics (hazard ratio [HR]: 0.67 [95% confidence interval [CI], 0.54-0.84]) and longer time to antibiotics from T-0 (142 min vs. 100 min, p = .007).
Sepsis patients experiencing T-0 as a boarder in the ED have a lower likelihood of receiving SEP-1 compliant care compared to patients who experience T-0 while still under ED care.
在急诊科（ED）候诊时首次符合脓毒症临床标准的患者可能无法获得最佳的脓毒症治疗。
评估急诊科候诊状态与脓毒症护理质量及预后之间的关联。
我们对2021年7月至2023年10月入住一家大型学术医院的成年患者进行了一项回顾性队列研究，这些患者在身处急诊科时具有与脓毒症一致的临床特征。我们比较了在急诊科候诊（身处急诊科但被收治到不同科室）时经历零时（T-0；脓毒症临床特征首次出现的时间）的患者与仍在急诊科医护团队照料下经历T-0的患者的预后情况。我们使用逻辑回归来估计T-0时的急诊科候诊状态与美国医疗保险和医疗补助服务中心（CMS）严重脓毒症和脓毒性休克：管理集束方案（SEP-1）核心指标的依从性、各个集束要素的依从性以及根据预先指定的协变量调整后的医院死亡率之间的关联。在T-0之前尚未接受抗生素治疗的患者亚组分析中，我们进行了Cox比例风险模型分析，以估计候诊状态与使用抗生素时间之间的关联。
在急诊科符合脓毒症临床定义的4795例患者中，422例（8.8%）在急诊科候诊时经历了T-0。与仍在急诊科照料下经历T-0的患者相比，这些患者在年龄、性别和合并症方面相似。作为急诊科候诊患者经历T-0的患者接受符合SEP-1标准护理的比例较低（25%对38%，p<0.001），包括液体复苏比例较低（15%对26%，p=0.004）和乳酸评估比例较低（62%对94%，p<0.001）。总体而言，急诊科候诊组中更多患者在3小时内接受了抗生素治疗，但三分之一的患者在T-0之前已经接受了抗生素治疗。在T-0之前尚未接受抗生素治疗的患者中，作为急诊科候诊患者经历T-0与接受抗生素治疗的可能性降低相关（风险比[HR]：0.67[95%置信区间[CI]，0.54-0.84]），并且从T-0到使用抗生素的时间更长（142分钟对100分钟，p=0.007）。
与仍在急诊科照料下经历T-0的患者相比，在急诊科候诊时经历T-0的脓毒症患者接受符合SEP-1标准护理的可能性较低。
