title: The impact of ED crowding on early interventions and mortality in patients with severe sepsis.
abstract: OBJECTIVE
  Critically ill patients require significant time and care coordination in the emergency department (ED). We hypothesized that ED crowding would delay time to intravenous fluids and antibiotics, decrease utilization of protocolized care, and increase mortality for patients with severe sepsis or septic shock.
  
  
  METHODS
  This was a retrospective cohort study of severe sepsis patients admitted to the hospital from the ED between January 2005 and February 2010. Associations between four validated measures of ED crowding (occupancy, waiting patients, admitted patients, and patient-hours) assigned at triage, and time of day, time to antibiotics and fluids, and mortality were tested by analyzing trends across crowding quartiles.
  
  
  RESULTS
  During the study period, 2913 severe sepsis patients were admitted to the hospital and 1127 (38.7%) qualified for protocolized care. In-hospital mortality was 14.3% overall and 26% for patients qualifying for protocolized care. Time to IV fluids was delayed as ED occupancy rate increased and as patient hours increased. Time to antibiotics increased as occupancy rates, patient hours, and the number of boarding inpatients increased. Implementation rates of protocolized care decreased from 71.3% to 50.5% (p<0.0001, OR 0.39) as the number of ED inpatient boarders increased; initiation of protocolized care was significantly higher as occupancy increased (OR 1.52). Mortality was unaffected by crowding parameters in all analyses.
  
  
  CONCLUSIONS
  With increased ED crowding, time to critical severe sepsis therapies significantly increased and protocolized care initiation decreased. As crowding increases, EDs must implement systems that optimize delivery of time-sensitive therapies to critically ill patients.
authors.affiliation: Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States. Electronic address: David.gaieski@jefferson.edu.
authors.forename: David F
authors.initials: DF
authors.lastname: Gaieski
authors.affiliation: Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Anish K
authors.initials: AK
authors.lastname: Agarwal
authors.affiliation: Department of Internal Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Mark E
authors.initials: ME
authors.lastname: Mikkelsen
authors.affiliation: Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Byron
authors.initials: B
authors.lastname: Drumheller
authors.affiliation: Commonwealth Medical School, Graduate Medical Education, Scranton, PA, United States.
authors.forename: S
authors.initials: S
authors.lastname: Cham Sante
authors.affiliation: Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Frances S
authors.initials: FS
authors.lastname: Shofer
authors.affiliation: Department of Emergency Medicine, Georgetown University School of Medicine, Washington, D.C, United States.
authors.forename: Munish
authors.initials: M
authors.lastname: Goyal
authors.affiliation: Department of Emergency Medicine and Health Policy, George Washington University School of Medicine and Health Sciences, Washington, D.C., United States.
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Pines
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016638:Critical Illness / Q000401:mortality / Q000628:therapy*; D003441:Crowding; D004636:Emergency Service, Hospital; D005260:Female; D005440:Fluid Therapy; D019983:Guideline Adherence; D006302:Health Services Research; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D012151:Resuscitation; D012189:Retrospective Studies; D018805:Sepsis / Q000401:mortality / Q000628:therapy*; D061665:Time-to-Treatment / Q000706:statistics & numerical data*; D014218:Triage / Q000379:methods; D014481:United States / Q000453:epidemiology
chemical_list: D000900:Anti-Bacterial Agents
keywords: Administration; Crowding; Resuscitation; Severe sepsis