title: Patient and Organizational Factors Associated With Delays in Antimicrobial Therapy for Septic Shock.
abstract: OBJECTIVE
  To identify clinical and organizational factors associated with delays in antimicrobial therapy for septic shock.
  
  
  METHODS
  In a retrospective cohort of critically ill patients with septic shock.
  
  
  METHODS
  Twenty-four ICUs.
  
  
  METHODS
  A total of 6,720 patients with septic shock.
  
  
  METHODS
  None.
  
  
  RESULTS
  Higher Acute Physiology Score (+24 min per 5 Acute Physiology Score points; p < 0.0001); older age (+16 min per 10 yr; p < 0.0001); presence of comorbidities (+35 min; p < 0.0001); hospital length of stay before hypotension: less than 3 days (+50 min; p < 0.0001), between 3 and 7 days (+121 min; p < 0.0001), and longer than 7 days (+130 min; p < 0.0001); and a diagnosis of pneumonia (+45 min; p < 0.01) were associated with longer times to antimicrobial therapy. Two variables were associated with shorter times to antimicrobial therapy: community-acquired infections (-53 min; p < 0.001) and higher temperature (-15 min per 1°C; p < 0.0001). After adjusting for confounders, admissions to academic hospitals (+52 min; p< 0.05), and transfers from medical wards (medical vs surgical ward admission; +39 min; p < 0.05) had longer times to antimicrobial therapy. Admissions from the emergency department (emergency department vs surgical ward admission, -47 min; p< 0.001) had shorter times to antimicrobial therapy.
  
  
  CONCLUSIONS
  We identified clinical and organizational factors that can serve as evidence-based targets for future quality-improvement initiatives on antimicrobial timing. The observation that academic hospitals are more likely to delay antimicrobials should be further explored in future trials.
authors.affiliation: 1Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.2Department of Emergency Medicine, University Health Network, University of Toronto, Toronto, ON, Canada.3Critical Care Medicine, Prairie Mountain Health, Brandon, MB, Canada.4Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.5Critical Care Medicine, Richmond General Hospital, Richmond, BC, Canada.6Critical Care Medicine, Royal Columbian Hospital, New Westminster, BC, Canada.7Critical Care Medicine, Jewish General Hospital, Montreal, QC, Canada.8Critical Care Medicine and Department of Medicine, Winnipeg Regional Health Authority, Winnipeg, MB, Canada.
authors.forename: Andre C K B
authors.initials: AC
authors.lastname: Amaral
authors.forename: Robert A
authors.initials: RA
authors.lastname: Fowler
authors.forename: Ruxandra
authors.initials: R
authors.lastname: Pinto
authors.forename: Gordon D
authors.initials: GD
authors.lastname: Rubenfeld
authors.forename: Paul
authors.initials: P
authors.lastname: Ellis
authors.forename: Brian
authors.initials: B
authors.lastname: Bookatz
authors.forename: John C
authors.initials: JC
authors.lastname: Marshall
authors.forename: Greg
authors.initials: G
authors.lastname: Martinka
authors.forename: Sean
authors.initials: S
authors.lastname: Keenan
authors.forename: Denny
authors.initials: D
authors.lastname: Laporta
authors.forename: Daniel
authors.initials: D
authors.lastname: Roberts
authors.forename: Anand
authors.initials: A
authors.lastname: Kumar
mesh_terms: D000890:Anti-Infective Agents / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D058996:Quality Improvement / Q000458:organization & administration; D012189:Retrospective Studies; D012307:Risk Factors; D012772:Shock, Septic / Q000188:drug therapy*; D013997:Time Factors
chemical_list: D000890:Anti-Infective Agents