Clinical question: Does early identification and treatment of sepsis using protocols improve outcomes?
Background: International clinical guidelines recommend early detection and treatment of sepsis with broad spectrum antibiotics and intravenous fluids which are supported by preclinical and observation studies that show a reduction in avoidable deaths. However, controversy remains in the timing of these treatments on how it relates to patient outcomes such as risk-adjusted mortality.
Study design: Retrospective cohort study using data reported to the New York State Department of Health from April 1, 2014, to June 30, 2016.
Setting: New York hospitals.
Synopsis: For patients with sepsis and septic shock, a sepsis protocol was initiated within 6 hours after arrival in the emergency department and had all items in a 3-hour bundle of care (that is, blood cultures, broad-spectrum antibiotic, and lactate measurement) completed within 12 hours. Among 49,331 patients at 149 hospitals, higher risk-adjusted in-hospital mortality was associated with longer time to the completion of the bundle (P less than .001), administration of antibiotics (P less than .001), but not completion of a bolus of intravenous fluids (P = .21).
Study limitations include being nonrandomized, hospitals all from one state possibly introducing epidemiologic distinct features of sepsis inherent to the region, and accuracy of the data collection (that is, start time).
No association was found between time to completion of the initial bolus of fluids and improved outcomes in risk-adjusted mortality; however, the analysis of time of the initial fluid bolus was most vulnerable to confounding; a causal relationship will need further study.
Bottom line: A lower risk-adjusted in-hospital mortality was associated with rapid administration of antibiotics and a faster completion of a 3-hour bundle of sepsis care, but there was no discernable association with the rapid administration of initial bolus of intravenous fluids.
Citation: Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017; 376:2235-44.
Dr. Choe is a hospitalist at Ochsner Health System, New Orleans.