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. 2022 Sep;19(9):1525-1533.
doi: 10.1513/AnnalsATS.202112-1360OC.

Association of Unit Census with Delays in Antimicrobial Initiation among Ward Patients with Hospital-acquired Sepsis

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Association of Unit Census with Delays in Antimicrobial Initiation among Ward Patients with Hospital-acquired Sepsis

Jennifer C Ginestra et al. Ann Am Thorac Soc. 2022 Sep.

Abstract

Rationale: Patients with hospital-acquired sepsis (HAS) experience higher mortality and delayed care compared with those with community-acquired sepsis. Capacity strain, the extent to which demand for hospital resources exceeds availability, thus impacting patient care, is a possible mechanism underlying antimicrobial delays for HAS but has not been studied. Objectives: Assess the association of ward census with the timing of antimicrobial initiation among ward patients with HAS. Methods: This retrospective cohort study included adult patients hospitalized at five acute care hospitals between July 2017 and December 2019 who developed ward-onset HAS, distinguished from community-acquired sepsis by onset after 48 hours of hospitalization. The primary exposure was ward census, measured as the number of patients present in each ward at each hour, standardized by quarter and year. The primary outcome was time from sepsis onset to antimicrobial initiation. We used quantile regression to assess the association between ward census at sepsis onset and time to antimicrobial initiation among patients with HAS defined by Centers for Disease Control and Prevention Adult Sepsis Event criteria. We adjusted for hospital, year, quarter, age, sex, race, ethnicity, severity of illness, admission diagnosis, and service type. Results: A total of 1,672 hospitalizations included at least one ward-onset HAS episode. Median time to antimicrobial initiation after HAS onset was 4.1 hours (interquartile range, 0.4-22.3). Marginal adjusted time to antimicrobial initiation ranged from 3.6 hours (95% confidence interval [CI], 2.4-4.8 h) to 6.8 hours (95% CI, 5.3-8.4 h) at census levels 2 standard deviations (SDs) below and above the ward-specific mean, respectively. Each 1-SD increase in ward census at sepsis onset, representing a median of 2.4 patients, was associated with an increase in time to antimicrobial initiation of 0.80 hours (95% CI, 0.32-1.29 h). In sensitivity analyses, results were consistent across severity of illness and electronic health record-based sepsis definitions. Conclusions: Time to antimicrobial initiation increased with increasing census among ward patients with HAS. These findings suggest that delays in care for HAS may be related to ward capacity strain as measured by census. Additional work is needed to validate these findings and identify potential mechanisms operating through clinician behavior and care delivery processes.

Keywords: bed occupancy; clinical decision-making; critical care; risk factors; time-to-treatment.

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Figures

Figure 1.
Figure 1.
Adjusted time to antimicrobial initiation after sepsis onset by standardized census among ward patients with hospital-acquired sepsis identified by the Centers for Disease Control and Prevention Adult Sepsis Event (CDC ASE) and Third International Consensus Definition for Sepsis (Sepsis-3) criteria. Shaded areas denote 95% confidence intervals; census standardized for each unit by quarter and year; analyses included hospital, admission-year, and episode-quarter fixed effects and were adjusted for age, sex, race, ethnicity, severity of illness (as measured by Sequential Organ Failure Assessment score at sepsis onset), admission diagnosis category (from International Classification of Diseases-Tenth codes), and service type (i.e., medicine vs. surgery). SD = standard deviation.
Figure 2.
Figure 2.
Adjusted probability of antimicrobial initiation within 1 hour of sepsis onset by standardized census among ward patients with hospital-acquired sepsis identified by the Centers for Disease Control and Prevention Adult Sepsis Event (CDC ASE) and Third International Consensus Definition for Sepsis (Sepsis-3) criteria. Shaded areas denote 95% confidence intervals; census standardized for each unit by quarter and year; analyses included hospital, admission-year, and episode-quarter fixed effects and were adjusted for age, sex, race, ethnicity, severity of illness (as measured by Sequential Organ Failure Assessment score at sepsis onset), admission diagnosis category (from International Classification of Diseases-Tenth codes), and service type (i.e., medicine vs. surgery). SD = standard deviation.
Figure 3.
Figure 3.
Adjusted probability of antimicrobial initiation at any hour after sepsis onset by standardized census among ward patients with hospital-acquired sepsis identified by the Centers for Disease Control and Prevention Adult Sepsis Event (CDC ASE) and Third International Consensus Definition for Sepsis (Sepsis-3) criteria. Shaded areas denote 95% confidence intervals; census standardized for each unit by quarter and year; analyses included hospital, admission-year, and episode-quarter fixed effects and hours from sepsis onset as the time axis and were adjusted for age, sex, race, ethnicity, severity of illness (as measured by Sequential Organ Failure Assessment score at sepsis onset), admission diagnosis category (from International Classification of Diseases-Tenth codes), and service type (i.e., medicine vs. surgery). SD = standard deviation.
Figure 4.
Figure 4.
Cumulative probability of antimicrobial initiation by standardized census at sepsis onset among ward patients with hospital-acquired sepsis using Centers for Disease Control and Prevention Adult Sepsis Event criteria. Shaded areas denote 95% confidence intervals; census standardized for each unit by quarter and year; analyses included hospital, admission-year, and episode-quarter fixed effects and were adjusted for age, sex, race, ethnicity, severity of illness (as measured by Sequential Organ Failure Assessment score at sepsis onset), admission diagnosis category (from International Classification of Diseases-Tenth codes), and service type (i.e., medicine vs. surgery). SD = standard deviation.

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