• Ithan D Peltan, Joseph R Bledsoe, Thomas A Oniki, Jeffrey Sorensen, Al R Jephson, Todd L Allen, Matthew H Samore, Catherine L Hough, and Samuel M Brown.
• Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT. Electronic address: ithan.peltan@utah.edu.
• Ann Emerg Med. 2019 Apr 1; 73 (4): 345-355.

Study ObjectiveBarriers to early antibiotic administration for sepsis remain poorly understood. We investigated the association between emergency department (ED) crowding and door-to-antibiotic time in ED sepsis.MethodsWe conducted a retrospective cohort study of ED sepsis patients presenting to 2 community hospitals, a regional referral hospital, and a tertiary teaching hospital. The primary exposure was ED occupancy rate, defined as the ratio of registered ED patients to licensed ED beds. We defined ED overcrowding as an ED occupancy rate greater than or equal to 1. We used multivariable regression to measure the adjusted association between ED crowding and door-to-antibiotic time (elapsed time from ED arrival to first antibiotic initiation). Using Markov multistate models, we also investigated the association between ED crowding and pre-antibiotic care processes.ResultsAmong 3,572 eligible sepsis patients, 70% arrived when the ED occupancy rate was greater than or equal to 0.5 and 14% arrived to an overcrowded ED. Median door-to-antibiotic time was 158 minutes (interquartile range 109 to 216 minutes). When the ED was overcrowded, 46% of patients received antibiotics within 3 hours of ED arrival compared with 63% when it was not (difference 14.4%; 95% confidence interval 9.7% to 19.2%). After adjustment, each 10% increase in ED occupancy rate was associated with a 4.0-minute increase (95% confidence interval 2.8 to 5.2 minutes) in door-to-antibiotic time and a decrease in the odds of antibiotic initiation within 3 hours (odds ratio 0.90; 95% confidence interval 0.88 to 0.93). Increasing ED crowding was associated with slower initial patient assessment but not further delays after the initial assessment.ConclusionED crowding was associated with increased sepsis antibiotic delay. Hospitals must devise strategies to optimize sepsis antibiotic administration during periods of ED crowding.Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

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