Chest
Volume 129, Issue 2, February 2006, Pages 225-232
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Original Research
Translating Research to Clinical Practice: A 1-Year Experience With Implementing Early Goal-Directed Therapy for Septic Shock in the Emergency Department

https://doi.org/10.1378/chest.129.2.225Get rights and content

Objective

Early goal-directed therapy (EGDT) has been shown to decrease mortality in patients with severe sepsis and septic shock. Consensus guidelines now advocate EGDT for the first 6 h of sepsis resuscitation. However, EGDT has not yet been widely adopted in practice. A need for effective collaboration between emergency medicine and critical care medicine services has been identified as an obstacle for implementation. We aimed to determine if EGDT end points could reliably be achieved in real-world clinical practice.

Methods

EGDT was implemented as a collaborative emergency medicine/critical care quality improvement initiative. EGDT included the following: IV fluids (IVF) targeting central venous pressure ≥ 8 mm Hg, vasopressors targeting mean arterial pressure ≥ 65 mm Hg, and (if necessary) packed RBCs (PRBCs) and/or dobutamine targeting central venous oxygen saturation ≥ 70%. A retrospective analysis was performed of emergency department (ED) patients with persistent sepsis-induced hypotension (systolic BP < 90 mm Hg despite 1.5 L of IVF) treated with EGDT during the first year of the initiative. Primary outcome measures included successful achievement of EGDT end points and time to achievement. A secondary analysis was performed comparing EGDT cases to historical control cases (nonprotocolized control subjects without invasive monitoring).

Results

All end points were achieved in 20 of 22 cases (91%). The median time to reach each end point was ≤ 6 h. In the secondary analysis, patients (n = 38; EGDT, n = 22; pre-EGDT, n = 16) had similar age, do-not-resuscitate status, severity scores, hypotension duration, and vasopressor requirement (p = not significant). In the ED, EGDT used more IVF and included PRBC/dobutamine utilization, without any impact on the overall use of these therapies through the first 24 h in the ICU. EGDT was associated with decreased ICU pulmonary artery catheter (PAC) utilization (9.1% vs 43.7%, p = 0.01).

Conclusions

With effective emergency medicine/critical care collaboration, we demonstrate that EGDT end points can reliably be achieved in real-world sepsis resuscitation. ED-based EGDT appears to decrease ICU PAC utilization.

Section snippets

Study Design and Setting

This was a retrospective cohort study at an urban academic medical center (Cooper University Hospital, Camden, NJ), with an ED volume of 48,000 annual patient visits. The institution has an emergency medicine residency program and a multispecialty critical care medicine fellowship program.

Cooper University Hospital adopted EGDT as a best practice model for sepsis resuscitation on January 1, 2004. The EGDT program at Cooper University Hospital is a collaborative effort in which the emergency

Primary Analysis

Of 45 records identified from the EGDT registry in 2004, 23 records did not meet the criteria for hypotension in the ED (normotensive with lactate elevation), leaving 22 EGDT subjects in the primary analysis. All 22 subjects were admitted from the ED to the ICU service. Patient characteristics for the EGDT group are displayed in the right column of Table 2.

All end points of EGDT were successfully achieved for 20 of 22 EGDT cases. In the remaining two cases, CVP and MAP targets were achieved,

Discussion

The transfer of research innovations to clinical practice has historically been a slow and complex process.789 This is an issue of high priority because research transfer is one of the major mechanisms by which medical advances can lead to health-care improvement. Early hemodynamic optimization with an EGDT protocol is a research innovation that has been shown to reduce mortality in severe sepsis and septic shock1 and is now recommended for use by international consensus.2 The relatively early

ACKNOWLEDGMENT

The authors thank the nurses in the ED and ICU at Cooper University Hospital for their dedication in implementing state-of-the-art care for our critically ill patients with sepsis.

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Dr. Trzeciak is a consultant and member of the Speakers Bureau for Edwards Lifesciences and Eli Lilly. Dr. Dellinger is a consultant for GlaxoSmithKline and a member of the Speakers Bureau for Edwards Lifesciences and Eli Lilly. Dr. Zanotti is a member of the Speakers Bureau for Eli Lilly. Dr. Parrillo is a consultant for Edwards Lifesciences, GlaxoSmithKline, and Ortho-Biotech, and has research grants from GlaxoSmithKline.

There was no source of external funding for this study. The authors' institution received an unrestricted educational grant from Edwards Lifesciences for an education program prior to protocol implementation.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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