Early goal-directed therapy: improving mortality and morbidity of sepsis in the emergency department.

BACKGROUND: The growing number of patients with severe sepsis or septic shock and the resulting mortality rate (30%) require changes in the current protocols used to treat these conditions. Through adaptation of early goal-directed therapy (EGDT), Carolinas Medical Center developed a process improvement strategy for decreasing mortality associated with severe sepsis and septic shock. Before implementing the EDGT protocol, the ED did not follow a written management protocol for septic patients. METHODS: Following establishment of an interdisciplinary team, several process improvement activities were conducted, including the development of a standardized algorithm and treatment protocol, a physician order sheet, a nursing flow sheet, and a code sepsis response team. RESULTS: A total of 381 patients were enrolled: 79 in the pre-intervention phase and 302 in the postintervention phase. Mortality rates decreased from 27% pre-intervention to 19% postintervention (-8% absolute mortality; 95% confidence interval [C.I.], 7-9; p = .2138). There were significant differences between the pre- and postintervention groups for endotracheal intubation (17%, p = .0012), crystalloid infusion (1.4 L, p < .0001), vasopressor administration (33%, p < .0001), and packed red blood cells (34%, p < .0001). Both groups were generally similar in their demographics, comorbidities, and vital signs. DISCUSSION: As a result of this process improvement initiative, patients who might have received delayed and/or inadequate treatment for severe sepsis or septic shock are now receiving effective, life-saving treatment. Because of the emphasis on training, consistency in applying the protocol, relatively few changes in current ED practice, and low direct expenditures for equipment, the protocol can be easily integrated into existing ED environments to allow hospitals to quickly implement this successful, best-practice program.

Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock.

OBJECTIVE: To determine the clinical effectiveness of implementing early goal-directed therapy (EGDT) as a routine protocol in the emergency department (ED). METHODS: Prospective interventional study conducted over 2 years at an urban ED. Inclusion criteria included suspected infection, criteria for systemic inflammation, and either systolic BP < 90 mm Hg after a fluid bolus or lactate concentration >/= 4 mol/L. Exclusion criteria were age < 18 years, contraindication to a chest central venous catheter, and need for immediate surgery. We prospectively recorded preintervention clinical and mortality data on consecutive, eligible patients for 1 year when treatment was at the discretion of board-certified emergency physicians. We then implemented an EGDT protocol (the intervention) and recorded clinical data and mortality rates for 1 year. Prior to the first year, we defined a 33% relative reduction in mortality (relative mortality reduction that was found in the original EGDT trial) to indicate clinical effectiveness of the intervention. RESULTS: We enrolled 79 patients in the preintervention year and 77 patients in the postintervention year. Compared with the preintervention year, patients in the postintervention year received significantly greater crystalloid volume (2.54 L vs 4.66 L, p < 0.001) and frequency of vasopressor infusion (34% vs 69%, p < 0.001) during the initial resuscitation. In-hospital mortality was 21 of 79 patients (27%) before intervention, compared with 14 of 77 patients (18%) after intervention (absolute difference, - 9%; 95% confidence interval, + 5 to - 21%). CONCLUSIONS: Implementation of EGDT in our ED was associated with a 9% absolute (33% relative) mortality reduction. Our data provide external validation of the clinical effectiveness of EGDT to treat sepsis and septic shock in the ED.