Characteristics, clinical care, and outcomes of sepsis among patients boarding in the emergency department

Abstract

Background: Patients who first meet clinical criteria for sepsis while boarding in the emergency department (ED) may not receive optimal sepsis care.

Objective: Assess the association between ED boarding status and sepsis quality of care and outcomes.

Methods: We conducted a retrospective cohort study of adult patients admitted to a large academic hospital from July 2021 to October 2023 who had clinical features consistent with sepsis present while physically in the ED. We compared outcomes for patients who experienced time zero (T-0; the time clinical features of sepsis were first present) while boarding in the ED (physically in the ED but admitted to a different service) to those experiencing T-0 while still under the care of the ED provider team. We used logistic regression to estimate the association between ED boarding status at T-0 and compliance with the US Centers for Medicare & Medicaid Services (CMS) Severe Sepsis and Septic Shock: Management Bundle (SEP-1) core measure, individual bundle element compliance, and hospital mortality adjusting for prespecified covariates. In a subgroup analysis among patients who had not already received antibiotics before T-0, we conducted a Cox proportional hazards model to estimate the association between boarding status on time-to-antibiotics.

Results: Among 4795 patients meeting a clinical definition of sepsis in the ED, 422 (8.8%) experienced T-0 as ED boarders. These patients were similar in age, sex, and comorbidities compared with patients experiencing T-0 while still under ED care. Fewer patients with T-0 as an ED boarder received SEP-1 compliant care (25% vs. 38%, p < .001), including a lower proportion of fluid resuscitation (15% vs. 26%, p = .004) and lactate assessment (62% vs. 94%, p < .001). Overall, more patients in the ED boarder group received antibiotics within 3 hours, but one-third of patients had already received antibiotics prior to T-0. Among patients who had not already received antibiotics prior to T-0, experiencing T-0 as an ED boarder was associated with a decreased likelihood of receiving antibiotics (hazard ratio [HR]: 0.67 [95% confidence interval [CI], 0.54-0.84]) and longer time to antibiotics from T-0 (142 min vs. 100 min, p = .007).

Conclusions: Sepsis patients experiencing T-0 as a boarder in the ED have a lower likelihood of receiving SEP-1 compliant care compared to patients who experience T-0 while still under ED care.