The Relationship between Quality of Care in the Emergency Department and Timeliness of Interventions for Patients with Severe Sepsi

A comprehensive review of relevant literature was conducted using CINHAL, Medline, and Proquest to include the following search words: ED crowding, ED LOS, ED boarding, critical care, timeliness of care, early goal-directed therapy, sepsis bundle, mortality, nursing experience, expertise and competency. Emergency Department (ED) crowding and a delay in transferring critically-ill patients out of the department may adversely influence the delivery of timely treatment and adherence to established sepsis protocols. In addition, crowding can increase ED LOS and may increase HLOS and/or mortality for severe sepsis patients. In a landmark study by Rivers et al. (2001), a significant decrease in mortality was observed in patients with severe sepsis who were treated with early goal-directed therapy in the ED. Donabedian's structure, process, and outcome (SPO) model was utilized as a framework to evaluate the quality of care in the ED. A retrospective, exploratory research design was used with a non-probability, purposive sample of critically-ill patients seen in the ED and admitted to the intensive care unit.;In general, the effect of the predictor variables on the timeliness of care and sepsis bundle compliance was found to be small. ED volume had very little influence on the outcome variables when using sepsis bundle interventions as a surrogate for quality of care. ED volume had minimal influence (3-5%) on timeliness of lactate draw, collection of blood cultures, and administration of antibiotics. Overall, sepsis bundle compliance was not directly influenced by ED volume. Instead, the importance of hospital characteristics, positive sepsis screens, and hypotension were identified as key factors influencing compliance. A delay in the identification of severe sepsis can be an important factor in determining compliance and timeliness of bundle interventions. In this study, a positive sepsis screen increased the odds of obtaining a serum lactate level by 76% and antibiotic administration within three hours by 72%. ED LOS only explained 1% of the variance in hospital length of stay (HLOS) and did not increase the occurrence of mortality prior to hospital discharge. In conclusion, ED volume by itself is not as significant of an influence in this health system as other factors. The goal of this study was to explore the effects of ED volume and other predictors variables on the quality of care delivered to severe sepsis patients. While the quality of care is impacted by several organizational and process factors it was not directly influenced by ED volume. Therefore, improvement efforts should focus on the removal of organizational barriers, building a more effective screening process and developing the role of the ED nurse in the management of sepsis patients.