• Ithan D Peltan, Kristina H Mitchell, Kristina E Rudd, Blake A Mann, David J Carlbom, Catherine L Hough, Thomas D Rea, and Samuel M Brown.
• 1Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Salt Lake City, UT. 2Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT. 3Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA. 4Department of Medicine, University of Washington School of Medicine, Seattle, WA.
• Crit. Care Med. 2017 Jun 1; 45 (6): 1011-1018.

ObjectivesDelayed initiation of appropriate antimicrobials is linked to higher sepsis mortality. We investigated interphysician variation in septic patients' door-to-antimicrobial time.DesignRetrospective cohort study.SettingEmergency department of an academic medical center.SubjectsAdult patients treated with antimicrobials in the emergency department between 2009 and 2015 for fluid-refractory severe sepsis or septic shock. Patients who were transferred, received antimicrobials prior to emergency department arrival, or were treated by an attending physician who cared for less than five study patients were excluded.InterventionsNone.Measurements And Main ResultsWe employed multivariable linear regression to evaluate the association between treating attending physician and door-to-antimicrobial time after adjustment for illness severity (Acute Physiology and Chronic Health Evaluation II score), patient age, prehospital or arrival hypotension, admission from a long-term care facility, mode of arrival, weekend or nighttime admission, source of infection, and trainee involvement in care. Among 421 eligible patients, 74% received antimicrobials within 3 hours of emergency department arrival. After covariate adjustment, attending physicians' (n = 40) median door-to-antimicrobial times varied significantly, ranging from 71 to 359 minutes (p = 0.002). The percentage of each physician's patients whose antimicrobials began within 3 hours of emergency department arrival ranged from 0% to 100%. Overall, 12% of variability in antimicrobial timing was explained by the attending physician compared with 4% attributable to illness severity as measured by the Acute Physiology and Chronic Health Evaluation II score (p < 0.001). Some but not all physicians started antimicrobials later for patients who were normotensive on presentation (p = 0.017) or who had a source of infection other than pneumonia (p = 0.006). The adjusted odds of in-hospital mortality increased by 20% for each 1 hour increase in door-to-antimicrobial time (p = 0.046).ConclusionsAmong patients with severe sepsis or septic shock receiving antimicrobials in the emergency department, door-to-antimicrobial times varied five-fold among treating physicians. Given the association between antimicrobial delay and mortality, interventions to reduce physician variation in antimicrobial initiation are likely indicated.

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