Time to Treatment and Mortality during Mandated Emergency Care for Sepsis
Background
In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients.
自2013年開始，紐約要求所有醫院遵循有關流程對膿毒症進行早期識別和治療。但是，這種更快的對膿毒症患者進行治療是否能夠改善病人預後，仍存有爭議。
Methods
We studied data from patients with sepsis and septic shock that were reported to the New York State Department of Health from April 1, 2014, to June 30, 2016. Patients had a sepsis protocol initiated within 6 hours after arrival in the emergency department and had all items in a 3-hour bundle of care for patients with sepsis (i.e., blood cultures, broad-spectrum antibiotic agents, and lactate measurement) completed within 12 hours. Multilevel models were used to assess the associations between the time until completion of the 3-hour bundle and risk-adjusted mortality. We also examined the times to the administration of antibiotics and to the completion of an initial bolus of intravenous fluid.
該研究是對紐約州衛生部2014年4月1日——2016年6月30日膿毒症和膿毒性休克的患者收集信息。對膿毒症患者到達急診科後6小時內啟動膿毒症處理流程，在12小時內對其在進行一個3小時診療流程(如血培養、廣譜抗生素使用和乳酸水平測量)。用多層次模型評估3小時診療流程的完成時間和風險調整後的死亡率之間的關係。同時，該試驗也評估抗生素使用時間和初始液體複蘇時間與死亡率的關係。
Results
Among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3-hour bundle completed within 3 hours. The median time to completion of the 3-hour bundle was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the administration of antibiotics was 0.95 hours (interquartile range, 0.35 to 1.95), and the median time to completion of the fluid bolus was 2.56 hours (interquartile range, 1.33 to 4.20). Among patients who had the 3-hour bundle completed within 12 hours, a longer time to the completion of the bundle was associated with higher risk-adjusted in-hospital mortality (odds ratio, 1.04 per hour; 95% confidence interval [CI], 1.02 to 1.05; P<0.001), as was a longer time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI, 1.03 to 1.06; P<0.001) but not a longer time to the completion of a bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02; P=0.21).
該試驗共收集了149家醫院的49331名患者，其中40696(82.5%）完成了3個小時診療流程。3小時診療流程完成時間的中位值為1.30小時(四分位範圍,0.65到2.35)；抗生素應用的平均時間為0.95小時(四分位範圍,0.35 - 1.95)；液體複蘇完成時間中位值為2.56小時(四分位範圍,1.33到4.20)。在12小時內完成3小時診療流程的患者中，更長的完成時間與更高的風險調整後的院內死亡率相關(OR 1.04/h;95%CI1.02—1.05;P < 0.001)；抗生素使用時間延長也與更高的風險調整後的院內死亡率相關(OR 1.04/h，95%CI 1.03—1.06;P < 0.001)；但是液體複蘇時間與死亡率無明顯關係。（OR 1.01/h，95%CI,0.99—1.02;P = 0.21)。
Conclusions
More rapid completion of a 3-hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality.
患者接受更快完成3小時診療流程的膿毒症和快速抗生素使用，與較低的風險調整後的住院死亡率相關，但是快速完成初始液體複蘇並無明顯優勢。
