Early Goal-Directed Therapy (EGDT) for Severe Sepsis/Septic Shock

Which Components of Treatment Are More Difficult to Implement in a Community-Based Emergency Department?

Rory O'Neill, DO; Javier Morales, DO; Michael Jule, DO

Disclosures

J Emerg Med. 2012;42(5):503-510. 

In This Article

Abstract and Introduction

Abstract

Background Early goal-directed therapy (EGDT) has been shown to reduce mortality in patients with severe sepsis/septic shock, however, implementation of this protocol in the emergency department (ED) is sometimes difficult.
Objectives We evaluated our sepsis protocol to determine which EGDT elements were more difficult to implement in our community-based ED.
Methods This was a non-concurrent cohort study of adult patients entered into a sepsis protocol at a single community hospital from July 2008 to March 2009. Charts were reviewed for the following process measures: a predefined crystalloid bolus, antibiotic administration, central venous catheter insertion, central venous pressure measurement, arterial line insertion, vasopressor utilization, central venous oxygen saturation measurement, and use of a standardized order set. We also compared the individual component adherence with survival to hospital discharge.
Results A total of 98 patients presented over a 9-month period. Measures with the highest adherence were vasopressor administration (79%; 95% confidence interval [CI] 69–89%) and antibiotic use (78%; 95% CI 68–85%). Measures with the lowest adherence included arterial line placement (42%; 95% CI 32–52%), central venous pressure measurement (27%; 95% CI 18–36%), and central venous oxygen saturation measurement (15%; 95% CI 7–23%). Fifty-seven patients survived to hospital discharge (Mortality: 33%). The only element of EDGT to demonstrate a statistical significance in patients surviving to hospital discharge was the crystalloid bolus (79% vs. 46%) (respiratory rate [RR] = 1.76, 95% CI 1.11–2.58).
Conclusion In our community hospital, arterial line placement, central venous pressure measurement, and central venous oxygen saturation measurement were the most difficult elements of EGDT to implement. Patients who survived to hospital discharge were more likely to receive the crystalloid bolus.

Introduction

At least 750,000 patients per year develop severe sepsis, with > 210,000 of them dying from the disease.[1] Emergency department (ED)-initiated early goal-directed therapy (EGDT) has been shown to significantly reduce the mortality of patients with severe sepsis/septic shock.[2–6] Nonetheless, integration of this landmark research from larger, research-oriented centers into clinical practice has been slow.[7] In one study as few as 7% of emergency physicians, even in academic tertiary hospitals, reported using EGDT.[8] Barriers to implementation include: lack of adequate time and staff, inserting central venous catheters, monitoring central venous pressures, physical space in the ED, communication with medical specialties, and identifying appropriate patients.[9,10] Moreover, the treatment of sepsis has often been viewed as an intensive care unit responsibility.[11]

Some clinicians and researchers have raised questions regarding which individual components of EGDT have the greatest impact on mortality and if, indeed, all elements, especially the invasive procedures, are required for adequate treatment.[8,12,13] Debate over central venous catheters/central venous pressures, central venous oxygenation saturation, fluid administration, vasopressors, red blood cell transfusions, and antibiotics have filled the literature in the years since the original publication by Rivers et al.[2,14–25] The ability to implement these complex protocols into smaller, non-tertiary, community hospitals where resources are already thin has also been called into question.[1,26] Furthermore, it is unclear which specific elements of EGDT may be more difficult to implement in community EDs.

Previous studies have demonstrated the benefits of EGDT as well as the documented difficulties with implementation.[2–10] As EGDT has become more accepted, community hospitals of various capacities and resources have began to develop programs. Therefore, it would be important to know which specific parts of these protocols are more arduous to implement. This information has significant implications for community hospitals that currently have sepsis protocols as well as community hospitals starting up EGDT programs, as it provides areas of focus to improve adherence.

In this study, we evaluated the severe sepsis/septic shock protocol at our institution to determine which specific treatment elements were more difficult to implement in a community-based ED. We also compared adherence of each specific process measure with survival to hospital discharge.

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