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Is the 1-Hour Sepsis Mandate Doable?

November 8, 2019

Written by Clay Smith

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Despite a QI initiative for an ED-wide sepsis screening protocol and individual clinician feedback, this center was not able to meet the new Surviving Sepsis 1-hour antibiotic metric most of the time.

Why does this matter?
A new metric was promulgated by the Surviving Sepsis Campaign in 2018 that recommended several actions be initiated in 1 hour for sepsis patients, including administration of broad spectrum antibiotics. Among the problems with this, it was written by doctors who don’t work in the ED. There has been significant backlash.

1-hour mandate madness
This was a before and after study following a QI initiative at a single center after starting a sepsis-screening protocol and individual, case-specific clinician feedback. Outcomes of interest were delay of antibiotics >3 hours from onset of hypoperfusion (the CMS metric) and delay >1 hour from triage (the 2018 Surviving Sepsis metric). Comparing before and after, there were antibiotic delays according to the CMS metric in 30% and 21% of cases, respectively; -9% (95%CI -16% to -2%]). Antibiotic delays occurred before and after with the 2018 Surviving Sepsis 1-hour metric in 85% and 71%, respectively; difference -14% (95%CI -20% to -8%). They found four factors were independently associated with delay in antibiotics: vague presenting infectious symptoms, triage to a low-acuity part of the ED, time before the QI intervention, and lower SOFA score. Even with the QI, most patients didn’t meet the 1-hour metric. The only ones who did had obvious infectious symptoms and were hypotensive in triage. What this means is that the new 1-hour Surviving Sepsis metric to give antibiotics is not feasible in real life, even with a sepsis screening protocol and tailored clinician feedback. It’s just a bad idea.

Antibiotic Delays and Feasibility of a 1-Hour-From-Triage Antibiotic Requirement: Analysis of an Emergency Department Sepsis Quality Improvement Database. Ann Emerg Med. 2019 Sep 24. pii: S0196-0644(19)30593-1. doi: 10.1016/j.annemergmed.2019.07.017. [Epub ahead of print]

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