title: Many emergency department patients with severe sepsis and septic shock do not meet diagnostic criteria within 3 hours of arrival.
abstract: OBJECTIVE
  Proposed national performance measures for severe sepsis or septic shock include interventions within 3 hours of emergency department (ED) arrival rather than from time of first meeting diagnostic criteria. We aim to determine the percentage of ED patients who first meet criteria greater than 3 hours after arrival.
  
  
  METHODS
  We conducted a retrospective analysis of adult patients with severe sepsis or septic shock in 2 EDs (university hospital [September 2012 to June 2013] and public trauma center [December 2012 to May 2013]). Times of ED arrival and first meeting clinical criteria were collected for quality assurance programs, which differed between institutions. At the university hospital, patients with admission diagnoses consistent with infection were included. Clinical presentation was defined as time meeting 2 or more systemic inflammatory response syndrome criteria and evidence of end-organ dysfunction. At the trauma center, only patients with hospital discharge diagnoses consistent with infection were included. Clinical presentation was defined by time of end-organ dysfunction.
  
  
  RESULTS
  Three hundred seventy-two patients met inclusion criteria at the university hospital and 133 at the trauma center. Median times from ED arrival to first meeting criteria were 68 minutes (interquartile range 34 to 130 minutes) and 31 minutes (interquartile range 8 to 73 minutes), respectively; 15.3% (95% confidence interval 11.9% to 19.3%) and 9.8% (95% confidence interval 5.5% to 15.7%) first met criteria greater than 3 hours from ED arrival, respectively.
  
  
  CONCLUSIONS
  Compliance with a performance metric for severe sepsis and septic shock within 3 hours of ED arrival would require application of this measure to patients who do not meet diagnostic criteria, potentially resulting in unnecessary interventions. Measure developers should consider these findings.
authors.affiliation: Department of Emergency Medicine, University of California San Francisco, San Francisco, CA; San Francisco General Hospital, San Francisco, CA. Electronic address: julian.villar@ucsf.edu.
authors.forename: Julian
authors.initials: J
authors.lastname: Villar
authors.affiliation: San Francisco General Hospital, San Francisco, CA.
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Clement
authors.affiliation: Patient Safety and Quality Services, University of California San Francisco, San Francisco, CA.
authors.forename: Jim
authors.initials: J
authors.lastname: Stotts
authors.affiliation: Division of BioInformatics, National IT, Kaiser Permanente, Oakland, CA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Linnen
authors.affiliation: San Francisco General Hospital, San Francisco, CA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Rubin
authors.affiliation: Department of Emergency Medicine, University of California San Francisco, San Francisco, CA.
authors.forename: David
authors.initials: D
authors.lastname: Thompson
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of California San Francisco, San Francisco, CA; San Francisco General Hospital, San Francisco, CA.
authors.forename: Antonio
authors.initials: A
authors.lastname: Gomez
authors.affiliation: Department of Emergency Medicine, University of California San Francisco, San Francisco, CA. Electronic address: christopher.fee@ucsf.edu.
authors.forename: Christopher
authors.initials: C
authors.lastname: Fee
mesh_terms: D000328:Adult; D002140:California; D057286:Electronic Health Records; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D006785:Hospitals, University; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D018805:Sepsis / Q000175:diagnosis* / Q000628:therapy; D012720:Severity of Illness Index; D012772:Shock, Septic / Q000175:diagnosis / Q000628:therapy; D013997:Time Factors; D014193:Trauma Centers