Introduction
Methods
Patient inclusion criteria
Definition
Resuscitation protocol and bundle
Emergency department crowding measurement
Outcome measurement
Data collection
Statistical analysis
Results
Baseline characteristics
Overall group | Low crowding group | Intermediate crowding group | High crowding group |
P
| |
---|---|---|---|---|---|
(number = 770) | (number = 276) | (number = 250) | (number = 244) | ||
Age (years) | 65 (55 to 73) | 64 (53 to 72) | 67 (56 to 73) | 65 (54 to 74) | 0.081 |
Gender (male) | 437 (56.8) | 161 (58.3) | 131 (52.4) | 145 (59.4) | 0.232 |
Comorbidities | |||||
Hypertension | 244 (31.7) | 76 (27.5) | 82 (32.8) | 86 (35.2) | 0.152 |
Diabetes | 165 (21.4) | 52 (18.8) | 56 (22.4) | 57 (23.4) | 0.411 |
Cardiovascular disease | 79 (10.7) | 26 (9.4) | 27 (10.8) | 26 (10.7) | 0.847 |
Chronic lung disease | 48 (6.2) | 17 (6.2) | 18 (7.2) | 13 (5.3) | 0.690 |
Chronic renal disease | 35 (4.5) | 4 (1.4) | 22 (8.8)a | 9 (3.7) | <0.001 |
Chronic hepatic disease | 67 (8.7) | 19 (6.9) | 21 (8.4) | 27 (11.1) | 0.235 |
Metastatic solid cancer | 194 (25.2) | 65 (23.6) | 58 (23.3) | 71 (29.1) | 0.241 |
Hematologic malignancy | 99 (12.9) | 36 (13.1) | 29 (11.6) | 34 (13.9) | 0.734 |
Organ transplantation | 14 (1.8) | 6 (2.2) | 3 (1.2) | 5 (2.1) | 0.667 |
Neutropenia (ANC <500 mm3) | 131 (17.0) | 48 (17.4) | 42 (16.8) | 41 (16.8) | 0.978 |
Nursing home resident | 29 (3.8) | 9 (3.7) | 9 (3.6) | 11 (4.5) | 0.741 |
Poor performance status | 35 (4.6) | 11(4.0) | 12 (4.8) | 12 (4.9) | 0.854 |
Suspected infection focus | 0.259 | ||||
Intra-abdominal infection | 288 (37.4) | 112 (40.6) | 92 (36.8) | 84 (34.4) | |
Pneumonia | 218 (28.3) | 77 (27.9) | 71 (28.4) | 70 (28.7) | |
Urinary tract infection | 115 (14.9) | 40 (14.5) | 44 (17.6) | 31 (12.7) | |
Others | 149 (19.3) | 47 (17.0) | 43 (17.2) | 59 (24.2) | |
Initial vital signs | |||||
Mean arterial pressure (mmHg) | 66 (58 to 80) | 66 (58 to 81) | 65 (57 to 78) | 67 (59 to 81) | 0.185 |
Heart rate (per minute) | 112 (95 to 130) | 115 (96 to 135) | 109 (94 to 126) | 112 (95 to 130) | 0.065 |
Respiratory rate (per minute) | 20 (20 to 24) | 20 (20 to 24) | 20 (20 to 24) | 20 (19 to 24) | 0.271 |
Body temperature (°C) | 38.0 (36.8 to 38.9) | 38.3 (37.0 to 38.9) | 37.9 (36.7 to 38.8) | 37.9 (36.8 to 38.9) | 0.165 |
Initial presentation of cryptic shock | 288 (37.4) | 103 (37.2) | 95 (38.0) | 90 (36.9) | 0.967 |
Initial serum lactate (mmol/L) | 4.3 (2.5 to 5.7) | 4.4 (2.8 to 5.8) | 4.4 (2.4 to 5.7) | 4.2 (2.5 to 5.4) | 0.531 |
SOFA score | 7 (4 to 9) | 7(4 to 10) | 7(4 to 9) | 7(4 to 9) | 0.458 |
Mechanical ventilation | 87 (11.3) | 32 (11.6) | 28 (11.2) | 27 (11.1) | 0.980 |
Time period of initial presentation | |||||
Night (10 PM to 7 AM) | 191 (24.8) | 122 (44.2) | 60 (24.0)a | 9 (3.7)ab | < 0.001 |
Weekend | 227 (29.5) | 162 (58.7) | 58 (23.2)a | 7 (2.9)ab | < 0.001 |
Physician’s experience | 0.217 | ||||
≤ 2nd year residents | 602 (78.2) | 212 (76.8) | 190 (76.0) | 200 (82.0) | |
≥ 3rd year residents or | 168 (21.8) | 64 (23.2) | 60 (24.0) | 44 (18.0) | |
board-certified physicians | |||||
Physician’s gender (male) | 381 (49.5) | 135 (48.9) | 114 (45.6) | 132 (54.1) | 0.163 |
Nurse’s experience | 0.115 | ||||
0 to about 2 years | 397 (51.6) | 152 (55.3) | 136 (54.4) | 109 (44.7) | |
3 to about 5 years | 215 (28.0) | 73 (26.6) | 67 (26.8) | 75 (30.7) | |
More than 5 years | 157 (20.4) | 50 (18.2) | 47 (18.8) | 60 (24.6) | |
Use of EMS | 247 (32.2) | 88 (32.1) | 81 (32.4) | 78 (32.1) | 0.997 |
Study period | 0.221 | ||||
2008 to about 2009 | 291 (37.8) | 104 (37.7) | 104 (41.6) | 83 (34.0) | |
2010 to about 2012 | 479 (62.2) | 172 (62.3) | 146 (58.4) | 161 (66.0) | |
Critical care zone at full capacity | 55 (7.1) | 9 (3.3) | 10 (4.0) | 36 (14.6) | < 0.001 |
ED occupancy rate (%) | 132 (110 to 162) | 100 (92 to 111) | 136 (126 to 142) | 172 (163 to 187) |
Resuscitation bundle compliance
Overall group | Low crowding group | Intermediate crowding group | High crowding group |
P
| |
---|---|---|---|---|---|
(number = 770) | (number = 276) | (number = 250) | (number = 244) | ||
Number of interventions of the bundle accomplishedc | 5 (4 to 6) | 6 (5 to 7) | 6 (5 to 6) | 5 (4 to 6)ab | <0.001 |
Time to the implementationd (hours) | |||||
Serum lactate measurementc | 1.3 (0.8) | 1.2 (0.8 to 2.5) | 1.3 (0.9 to 3.0) | 1.4 (0.9 to 3.6) | 0.023 |
Blood culturesc | 1.2 (0.8 to 2.1) | 1.2 (0.8 to 1.9) | 1.2 (0.8 to 2.3) | 1.3 (0.9 to 2.2) | 0.109 |
Broad-spectrum antibioticsc | 2.5 (1.7 to 3.8) | 2.4 (1.5 to 3.5) | 2.6 (1.7 to 3.9) | 2.8 (1.8 to 4.2) | 0.018 |
Intravenous fluid challengec (n = 649) | 0.6 (0.1 to 1.5) | 0.6 (0.1 to 1.5) | 0.6 (0.1 to 1.6) | 0.8 (0.2 to 1.6) | 0.109 |
CVP ≥8 mmHg achievedc (n = 546) | 2.9 (1.7 to 5.5) | 2.5 (1.5 to 5.0) | 2.7 (1.5 to 4.9) | 3.5 (2.0 to 6.8)ab | 0.005 |
Use of vasopressorsc (n = 473) | 2.1 (1.1 to 3.4) | 1.8 (1.0 to 3.1) | 1.9 (1.1 to 3.1) | 2.4 (1.4 to 4.2)ab | 0.003 |
Scvo2 ≥70% achievedc (n = 573) | 3.5 (1.9 to 6.6) | 3.3 (1.7 to 5.7) | 3.5 (2.0 to 5.8) | 4.2 (1.9 to 6.5) | 0.051 |
Logistic regression analysis
Variable | Univariate | Multivariate | ||
---|---|---|---|---|
Unadjusted OR (95% CI) |
P
| Adjusted OR (95% CI) |
P
| |
Tertile groups of crowding | ||||
Low | Reference | Reference | ||
Intermediate | 0.69 (0.46 to 1.01) | 0.058 | 0.70 (0.45 to 1.09) | 0.116 |
High | 0.41 (0.27 to 0.64) | <0.001 | 0.44 (0.26 to 0.76) | 0.003 |
Age >65 years | 1.15 (0.83 to 1.61) | 0.382 | 1.16 (0.82 to 1.66) | 0.391 |
Female gender | 1.02 (0.73 to 1.42) | 0.901 | 1.15 (0.82 to 1.67) | 0.429 |
Comorbidities | ||||
Hypertension | 1.14 (0.80 to 1.62) | 0.460 | ||
Diabetes | 0.86 (0.57 to 1.30) | 0.475 | ||
Cardiovascular disease | 0.90 (0.52 to 1.56) | 0.701 | ||
Chronic lung disease | 0.60 (0.27 to 1.30) | 0.193 | ||
Chronic renal disease | 1.07 (0.49 to 2.32) | 0.869 | ||
Chronic hepatic disease | 0.64 (0.34 to 1.24) | 0.190 | ||
Metastatic solid cancer | 0.81 (0.55 to 1.20) | 0.295 | ||
Hematologic malignancy | 1.05 (0.65 to 1.71) | 0.842 | ||
Organ transplantation | 0.51 (0.11 to 2.30) | 0.381 | ||
Neutropenia (ANC <500 mm3) | 0.90 (0.57 to 1.40) | 0.631 | ||
Nursing home resident | 0.79 (0.32 to 1.98) | 0.621 | ||
Poor performance status | 0.62 (0.26 to 1.53) | 0.302 | ||
Suspected infection focus | ||||
Others | Reference | |||
Intra-abdominal infection | 0.98 (0.62 to 1.57) | 0.962 | ||
Pneumonia | 0.86 (0.53 to 1.42) | 0.559 | ||
Urinary tract infection | 1.48 (0.86 to 2.56) | 0.150 | ||
Heart rate >100 per minute | 0.90 (0.63 to 1.27) | 0.545 | ||
Respiratory rate >24 per minute | 1.03 (0.68 to 1.56) | 0.886 | ||
Body temperature >38.0°C | 1.50 (1.07 to 2.09) | 0.016 | 1.68 (1.17 to 2.40) | 0.005 |
Initial presentation of cryptic shock | 0.35 (0.24 to 0.52) | <0.001 | 0.39 (0.24 to 0.65) | <0.001 |
Lactate >4 mmol/L | 0.55 (0.40 to 0.78) | 0.001 | 0.80 (0.53 to 1.22) | 0.311 |
SOFA score ≥8 | 1.93 (1.38 to 2.69) | <0.001 | 1.46 (1.00 to 2.13) | 0.051 |
Mechanical ventilation | 0.72 (0.41 to 1.25) | 0.251 | ||
Time period, night (10 PM to 7 AM) | 1.34 (0.92 to 1.94) | 0.116 | 0.93 (0.60 to 1.42) | 0.725 |
Time period, weekend | 1.47 (1.03 to 2.10) | 0.032 | 1.24 (0.81 to 1.92) | 0.313 |
Physician’s experience | ||||
≤ 2nd year residents | Reference | Reference | ||
≥ 3rd year residents or | 2.51 (1.74 to 3.63) | <0.001 | 2.85 (1.90 to 4.28) | <0.001 |
Board-certified physicians | ||||
Physician’s gender (male) | 0.93 (0.67 to 1.29) | 0.673 | 0.83 (0.58 to 1.19) | 0.318 |
Nurse’s experience | ||||
0 to about 2 years | Reference | Reference | ||
3 to about5 years | 1.38 (0.94 to 2.01) | 0.093 | 1.56 (1.04 to 2.36) | 0.030 |
More than 5 years | 1.01 (0.65 to 1.58) | 0.948 | 1.16 (0.73 to 1.88) | 0.604 |
Use of EMS | 1.12 (0.79-1.60) | 0.496 | ||
Study period | ||||
2008 to about 2009 | Reference | Reference | ||
2010 to about 2012 | 0.98 (0.70 to 1.37) | 0.921 | 1.19 (0.82 to 1.73) | 0.369 |
Critical care zone at full capacity | 0.66 (0.33 to 1.35) | 0.258 |
Variables | Adjusted OR (95% CI) |
P
|
---|---|---|
Serum lactate measurement | ||
Intermediate crowding groupa | 0.91 (0.51 to 1.63) | 0.747 |
High crowding groupa | 0.73 (0.38 to 1.41) | 0.346 |
ED occupancy rate (+10%)b | 0.95 (0.88 to 1.03) | 0.206 |
Blood cultures before antibiotics | ||
Intermediate crowding groupa | 1.31 (0.52 to 3.30) | 0.561 |
High crowding groupa | 0.80 (0.30 to 2.16) | 0.659 |
ED occupancy rate (+10%)b | 0.98 (0.86 to 1.10) | 0.711 |
Early broad-spectrum antibiotics | ||
Intermediate crowding groupa | 0.76 (0.50 to 1.15) | 0.193 |
High crowding groupa | 0.57 (0.35 to 0.91) | 0.019 |
ED occupancy rate (+10%)b | 0.93 (0.88 to 0.98) | 0.018 |
Intravenous fluid challenge | ||
Intermediate crowding groupa | 1.20 (0.60 to 2.39) | 0.603 |
High crowding groupa | 0.86 (0.40 to 1.84) | 0.697 |
ED occupancy rate (+10%)b | 0.99 (0.91 to 1.10) | 0.974 |
CVP ≥8 mmHg achieved | ||
Intermediate crowding groupa | 1.07 (0.69 to 1.65) | 0.772 |
High crowding groupa | 0.83 (0.50 to 1.37) | 0.462 |
ED occupancy rate (+10%)b | 0.95 (0.89 to 1.01) | 0.095 |
MAP ≥65 mmHg achievedc | ||
Intermediate crowding groupa | 0.29 (0.06 to 1.45) | 0.133 |
High crowding groupa | 0.34 (0.07 to 1.79) | 0.203 |
ED occupancy rate (+10%)b | 0.93 (0.80 to 1.10) | 0.442 |
Scvo2 ≥70% achieved | ||
Intermediate crowding group
a
| 0.83 (0.53 to 1.29) | 0.408 |
High crowding groupa | 0.42 (0.25 to 0.7) | 0.001 |
ED occupancy rate (+10%)b | 0.90 (0.85 to 0.96) | 0.001 |
Length of stay and in-hospital mortality
Overall group | Low crowding group | Intermediate crowding group | High crowding group |
P
| |
---|---|---|---|---|---|
(number = 770) | (number = 276) | (number = 250) | (number = 244) | ||
ED LOS, hoursa | 20 (8 to 34) | 16 (9 to 31) | 20 (8 to 36) | 24 (9 to 46)b | 0.009 |
ICU LOS, days | 3 (2 to 6) | 3 (2 to 9) | 3 (2 to 6) | 3 (2 to 6) | 0.379 |
In-hospital LOS, days | |||||
All patients | 12 (7 to 22) | 11 (7 to 20) | 13 (8 to 23) | 12 (8 to 22) | 0.051 |
Survivors | 12 (8 to 22) | 11 (7 to 20) | 13 (9 to 22) | 13 (8 to 22) | 0.048 |
In-hospital mortality | 126 (16.4) | 45 (16.3) | 36 (14.4) | 45 (18.4) | 0.478 |
Discussion
Conclusions
Key messages
-
ED crowding was significantly associated with lower compliance with the entire resuscitation bundle in the management of severe sepsis or septic shock.
-
ED crowding was also associated with a decreased likelihood of the timely implementation of the bundle elements.