“… our results provide a worrisome view of the quality of care of septic patients in U.S. EDs.”
Crikey.
This is serious business. Tell me more.
“Our data suggest that many emergency department patients (31%) with sepsis do not receive antibiotics until they arrive on the inpatient unit.”
This is somewhat concerning data. Of course, some patients can have sepsis from viremia, and would not warrant antibiotics – but, I think most admitted patients with SIRS and a suspected infectious source ought to receive treatment.
But, unfortunately, for this study, the question is less the quality of ED care, and more the quality of the data source. The National Hospital Ambulatory Medical Care Survey is a lovely data set, whose quality is only increasing as coding and structured data become more prevalent – but a retrospective analysis of these data is not appropriate substrate to make sweeping generalizations regarding the care in the Emergency Department.
From the ~400 Emergency Departments providing yearly data to NHAMCS, 0.32% of patients met their definition of sepsis. That meant these data reflect a sample of 1,141 patients, and the admitted limitation of “studies relying on NHAMCS data are vulnerable to errors of omission in data collection.” These authors lack information regarding previously administered antibiotics from transferred patients, and admit some patients – those spending <1 hour in the ED – may simply have left the ED before antibiotic administration could be completed.
Quite simply, it’s (mostly) garbage in and (mostly) garbage out.
The authors also attempt an assessment of antibiotic appropriateness from this retrospective chart abstraction. It is so egregiously flawed it doesn’t even warrant comment.
“Sepsis Visits and Antibiotic Utilization in U.S. Emergency Departments”
http://www.ncbi.nlm.nih.gov/pubmed/24201179
Thanks for the review Rick. In response, I'd say, "Ouch!" Careful about throwing the baby out with the bathwater. NHMACS data can be dangerous when used wrongly, but when used right can provide some pretty useful information. Our paper did assess the concern about patients who received antibiotics pre-transfer, and we found that only 3.1% of the patients in the database were transferred — so this wouldn't explain our results. Also, it's not just that we "admit" that patients with short lengths of stay would be less likely to receive antibiotics — we reported an analysis that separated such patients out and provided data to show that even patients who spent lots of time in the ED didn't get antibiotics. Finally, we compare our results to those from rigorous prospective studies (including Manny Rivers' classic) and find that our observations are in the same ballpark — only somewhat worse than what was observed in "sepsis clinical labs." So we think the findings are actually pretty robust. We agree that they're not perfect but we'd like to think they're somewhere above the food chain than garbage. (o: -Danny (senior author)
Hi Dan – thanks for the feedback!
I agree, if you look at the numbers in context of some of the earlier studies, then the reported statistics don't seem that out of whack. But, I'm still a little apprehensive regarding standing behind a conclusion that 31% of patients manifesting sepsis in the ED are not receiving antibiotics. Some of these patients, as you note, are being transported before antibiotics are completed. Furthermore, the sepsis diagnoses are all discharge diagnoses – meaning there's no guarantee the patient manifested sepsis in the Emergency Department, rather than at some point during their hospitalization. This number is being trumpeted about as indicative of poor care in the Emergency Department – and I'm not certain it's as extraordinarily concerning as this data set supports.