Institution of an emergency department "swarming" care model and sepsis door-to-antibiotic time: A quasi-experimental retrospective analysis

Abstract

Background: Prompt sepsis treatment is associated with improved outcomes but requires a complex series of actions by multiple clinicians. We investigated whether simply reorganizing emergency department (ED) care to expedite patients' initial evaluation was associated with shorter sepsis door-to-antibiotic times.

Methods: Patients eligible for this retrospective study received IV antibiotics and demonstrated acute organ failure after presenting to one of three EDs in Utah. On May 1, 2016, the intervention ED instituted "swarming" as the default model for initial evaluation of all mid- and low-acuity patients. Swarming involved simultaneous patient evaluation by the ED physician, nurse, and technician followed by a team discussion of the initial care plan. Care was unchanged at the two control EDs. A 30-day wash-in period separated the baseline (May 16, 2015 to April 15, 2016) and post-intervention (May 16, 2016 to November 15, 2016) analysis periods. We conducted a quasi-experimental analysis comparing door-to-antibiotic time for sepsis patients at the intervention ED after versus before care reorganization, applying difference-in-differences methods to control for trends in door-to-antibiotic time unrelated to the studied intervention and multivariable regression to adjust for patient characteristics.

Results: The analysis included 3,230 ED sepsis patients, including 1,406 from the intervention ED. Adjusted analyses using difference-in-differences methods to control for temporal trends unrelated to the studied intervention revealed no significant change in door-to-antibiotic time after care reorganization (-7 minutes, 95% CI -20 to 6 minutes, p = 0.29). Multivariable pre/post analyses using data only from the intervention ED overestimated the magnitude and statistical significance of outcome changes associated with ED care reorganization.

Conclusions: Implementation of an ED care model involving parallel multidisciplinary assessment and early team discussion of the care plan was not associated with improvements in mid- and low-acuity sepsis patients' door-to-antibiotic time after accounting for changes in the outcome unrelated to the studied intervention.

Conflict of interest statement

We have read the journal's policy and the authors of this manuscript have the following competing interests: IDP and SMB have received research funding to their institution from Janssen Pharmaceuticals, and IDP has received research funding to his institution from Immunexpress Inc. Faron Pharmaceuticals and Sedana Medical paid SMB’s institution for his service on trial steering committees. Asahi Kasei Pharma provided research funding to the institution of IDP, SMB, JRB and DB for subject enrollment in a clinical trial. AMAG Pharmaceuticals paid JRB consultation fees. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The authors otherwise have declared that no competing interests exist.

Figures

Fig 1. Schematic diagram of difference-in-differences analysis.

Solid lines represent hypothetical observed data for each emergency department (ED); dotted lines represent the data expected without intervention. The point estimates of analysis period means are indicated by solid circles.

Fig 2. CONSORT-style diagram.