Sepsis identification and bundle delivery in US emergency departments, 2012-2022: A nationally representative analysis.

BACKGROUND: Sepsis is a leading cause of mortality; the emergency department (ED) is the entry point for approximately 80% of affected US patients. National trends in ED sepsis identification and bundle delivery across regulatory and definitional changes are unknown. METHODS: Serial cross-sectional analyses of the National Hospital Ambulatory Medical Care Survey (NHAMCS), a representative sample of US ED visits, were conducted (2012-2022). Adult sepsis visits were identified as explicit (sepsis-specific code) or implicit+ (infection plus organ-dysfunction codes, any position); the composite was analyzed. The primary aim was to describe trends in sepsis identification and documented four-component bundle delivery (intravenous fluids, antibiotics, blood cultures, lactate); secondary aims addressed individual components and factors associated with delivery. Survey-weighted logistic and segmented regression estimated trends. RESULTS: Of a cumulative weighted 820.1 million adult ED visits (2012-2022), 18.3 million (2.2%) met the sepsis definition. Sepsis identification rose from 0.9% to 2.5% (odds ratio [OR] per year 1.14; 99% CI 1.10-1.17). Bundle delivery rose from 2.4% to a peak of 20% (OR 1.15 per year; 99% CI 1.07-1.23), with a 2016 level shift (OR 4.38). Lactate rose most steeply yet remained the least delivered. The strongest associations were severe presentation at triage (OR 2.84; 1.73-4.65) and abdominal infection source (OR 0.30; 0.12-0.72). CONCLUSIONS: Four-component bundle delivery increased modestly but remained incomplete, even among explicitly recognized sepsis patients. Because the all-or-nothing composite may not fully capture partially delivered care and its benefit is contested, individual evidence-based components and measures of personalized resuscitation may be useful quality indicators.