Interhospital Transfer Delays Appropriate Treatment for Patients With Severe Sepsis and Septic Shock: A Retrospective Cohort Study.
OBJECTIVE
To test the hypothesis that interhospital transfer causes significant delays in the administration of appropriate antibiotics and compliance with the completion of Surviving Sepsis Bundle elements.


METHODS
Single-center retrospective cohort study.


METHODS
A comprehensive 60,000-visit emergency department at a 711-bed Midwestern academic medical center.


METHODS
Patients with severe sepsis and septic shock treated between 2009 and 2014 were identified by International Classification of Diseases,9th Revision, Clinical Modification, codes, then divided into two cohorts: 1) transfer patients who arrived at the tertiary academic center after receiving care in a local community hospital and 2) control patients who presented directly to the tertiary academic center emergency department.


METHODS
None.


RESULTS
One hundred ninety-three patients were included. Transfer patients were more likely to require surgery in the hospital (p < 0.001) and require ICU care (p = 0.001) but had similar illness severity based on (Acute Physiology and Chronic Health Evaluation II, 17.7 vs 17.5; p = 0.662). Antibiotic administration at 1 and 3 hours was comparable between the two cohorts, but initial antibiotic appropriateness was lower in transfer patients (34% vs 79%; p < 0.001). Transfer patients were less likely to have fluid resuscitation started by 3 hours (54% vs 89%; p < 0.001), but they were not less likely to receive an adequate fluid bolus (30 mL/kg) by the time of hospital admission (p = 0.056). There were no differences in ICU length of stay or mortality.


CONCLUSIONS
Interhospital transfer significantly delays administration of appropriate initial antibiotics and resuscitation therapy. Future studies are needed to identify strategies of providing regional sepsis care prior to transfer to tertiary centers and to continue care pathways during the interhospital transfer process.
1Department of Emergency Medicine, Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA. 2Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA. 3Division of Emergency Medicine, Department of Anesthesiology, Division of Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO. 4Department of Emergency Medicine, Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA.
Brett A
BA
Faine
Joseph M
JM
Noack
Terrance
T
Wong
Jeffrey T
JT
Messerly
Azeemuddin
A
Ahmed
Brian M
BM
Fuller
Nicholas M
NM
Mohr
D018806:APACHE; D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D005440:Fluid Therapy / Q000379:methods; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D018805:Sepsis / Q000188:drug therapy* / Q000401:mortality / Q000628:therapy; D012772:Shock, Septic / Q000401:mortality / Q000628:therapy; D013997:Time Factors
D000900:Anti-Bacterial Agents