Physician Variation in Early Sepsis Management

Prompt antimicrobial therapy is essential in sepsis, but accelerating antimicrobial administration may increase overtreatment.

To examine the extent of and factors associated with physician variation in time from emergency department (ED) presentation to antimicrobial administration (hereinafter termed door-to-antimicrobial time) for sepsis and to assess whether faster practice patterns are associated with overtreatment.

This explanatory mixed-methods study linked a quantitative retrospective cohort (July 1, 2013, to January 31, 2017) involving 30-day patient follow-up with prospective qualitative physician interview data (May 17, 2022, to June 28, 2023) at 4 Utah EDs. Participants included ED attending physicians and their patients meeting sepsis criteria (including intravenous antimicrobial administration) before ED departure. Data analysis occurred from 2021 to 2025.

Assessment for physician door-to-antimicrobial time variation used a likelihood ratio test comparing a linear mixed-effects model incorporating physician-level random intercepts and patient-level covariates with a model without physician random effects. Empirical best linear unbiased predictions of the physician random intercepts (termed physician-predicted mean door-to-antimicrobial times) quantified variation. The primary analysis used a joint mixed-effects shared parameter model to evaluate the association of physicians' door-to-antimicrobial practice patterns with their overtreatment rate (infection ruled out on final retrospective adjudication). Qualitative analysis of semistructured cognitive task analysis interviews compared ED physicians in the fastest and slowest door-to-antimicrobial time quartiles.

Quantitative analyses included 88 ED physicians (71 [80.7%] male; median age, 39 [IQR, 35-49] years) and 9810 patients with sepsis (median age, 63 [IQR, 48-75] years), of whom 4635 (50.5%) were female and 3540 (38.6%) received antimicrobials more than 3 hours after ED arrival. The median number of patient encounters per physician was 105 (IQR, 75-129). Physicians' door-to-antimicrobial time varied significantly (likehood ratio test P < .001), with average physician-level estimated mean door-to-antimicrobial time of 184 (95% estimation interval, 146-222) minutes for a typical patient, but was not associated with overtreatment (adjusted odds ratio, 0.98 [95% CI 0.94-1.02] per 10-minute increase in physician estimated mean door-to-antimicrobial time; P = .37). Among 18 physicians interviewed, physicians with faster door-to-antimicrobial times emphasized proactive, parallel task execution and care team coordination, while physicians with slower times described a more reactive and stepwise sepsis evaluation and treatment process.

In this mixed-methods study, ED physicians' antimicrobial administration time for sepsis varied significantly, but faster antimicrobial initiation practice patterns were not associated with overtreatment. Physicians with shorter door-to-antimicrobial times described a proactive, parallel processing approach to sepsis care.