Authors’ Reply to Letters to Editor re: “Physician variation in time to antimicrobial treatment for septic patients presenting to the emergency department”

The authors respond

Drs. Peabody and Hauck provide a thoughtful discussion of our findings from the perspective of unwarranted care variation. We agree that interventions to explore and modify physician variation in sepsis care are important and indicated on the basis of our work. Standardized simulations, serious games (1), and other techniques appropriate to adult learners can simultaneously identify variation, motivate behavior change, improve practice styles, and fine tune new behavior patterns to avoid unintended consequences (such as excessive antibiotic prescribing). Significant costs in time and money are the major downside to the intensive simulation Drs. Peabody and Hauck describe.

We agree wholeheartedly with Drs. Jouffroy, Carli, and Vivien that the time has come to test aggressive prehospital sepsis treatment, and look forward to results from their trial. Prehospital antibiotics for sepsis would bypass ED physician variation in door-to-antibiotic time and hopefully will provide benefits analogous to prehospital treatment of other time-dependent critical illnesses, including stroke and myocardial infarction (2, 3). We note, however, that the SAMU Save Sepsis trial may have limited generalizability for prehospital care in many settings — including the United States — where physicians are rarely or never present on scene (4). Although telemedicine offers one option to overcome this barrier (3), data from in-progress sepsis trials employing nurses (5) or paramedics (6) to initiate prehospital antibiotics on the basis of history and physical examination alone may be more informative for such systems. We also believe it will be important to carefully measure the unintended effects of prehospital diagnosis and treatment. Overtreatment of patients without sepsis, anchoring bias for patients with sepsis mimics, and/or missed diagnosis of patients with sepsis could result in patient-level or system-level harms which would need to be balanced against any observed patient-level benefits from early intervention protocols. Overall, however, we are optimistic that by demonstrating prehospital antibiotics to be feasible, safe, and effective for sepsis treatment across a spectrum of prehospital care systems, these trials will usher in a new era of more integrated, faster, and less variable early sepsis care.