The Utility of a Quality Improvement Bundle in Bridging the Gap between Research and Standard Care in the Management of Severe Sepsis and Septic Shock in the Emergency Department (original) (raw)
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Early Goal-Directed Therapy: Improving Mortality and Morbidity of Sepsis in the Emergency Department
The Joint Commission Journal on Quality and Patient Safety, 2009
C arolinas Medical Center (CMC), located in Charlotte, North Carolina, is the flagship hospital of Carolinas HealthCare System (CHS), the third-largest health care system in the United States. With more than 800 beds, this public, not-for-profit, tertiary and Level 1 trauma center supports various residency programs, as well as numerous large multispecialty private medical groups. CMC is the only indigent-care hospital in Charlotte, providing care for more than 1 million patients annually. The emergency department (ED) evaluates more than 100,000 patients each year. The high acuity of illness of those presenting in the ED results in an annual admission rate of approximately 14% of all visits. Of these admissions, approximately 1% are due to septicemia, the incidence of which, following national estimates, is projected to increase by 1.5% each year. 1 The implementation of early goal-directed therapy (EGDT) on November 15, 2005, for the treatment of severe sepsis/septic shock in the ED was a priority to potentially reduce morbidity and mortality in our patients with sepsis. Before we implemented the EGDT protocol, our in-hospital mortality rate for those patients presenting in the ED was approximately 27%, in contrast with the 30% mortality rate reported in national studies. 1,2 Because approximately 50% of our hospital sepsis cases originated in the ED, a significant number of lives could be saved by initiating an effective intervention. Methods CODE SEPSIS TASK FORCE Following Institutional Review Board approval, CMC's ED physicians began identifying and tracking patients who presented with symptoms of severe sepsis or septic shock in August 2004. A code sepsis task force composed of ED, ICU, internal medicine, and infectious disease physicians; ED and ICU nurses; and a pharmacist was formed to address the following objectives: 1. Critically evaluate the evidence supporting EGDT 2. If evidence supports this therapy, develop an acceptable Article-at-a-Glance 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.
The Ochsner journal, 2013
Sepsis, an inflammatory response to an infection that may lead to severe organ dysfunction and death, is the leading cause of death in medical intensive care units. The Society of Critical Care Medicine has issued guidelines and promoted protocols to improve the management of patients with severe sepsis and septic shock. Generally, the medical community has been slow to adopt these guidelines because of the system challenges associated with protocol implementation. We describe an interdisciplinary team approach to the development and implementation of management protocols for treating patients with severe sepsis and septic shock. To determine the effectiveness of the bundled emergency department and critical care order sets developed by the Sepsis Steering Committee, we performed a case review of 1,105 sequential patients admitted to a large academic tertiary referral hospital with a diagnosis of severe sepsis or septic shock between July 2008 and January 2012. Implementation of the...
PeerJ, 2015
Despite knowledge that EGDT improves outcomes in septic patients, staff education on EGDT and compliance with the CPOE order set has been variable. Based on results of a resident survey to identify barriers to decrease severe sepsis/septic shock mortality in the medical intensive care unit (MICU), multifaceted interventions such as educational interventions to improve awareness to the importance of early goal-directed therapy (EGDT), and the use of the Computerized Physician Order Entry (CPOE) order set, were implemented in July 2013. CPOE order set was established to improve compliance with the EGDT resuscitation bundle elements. Orders were reviewed and compared for patients admitted to the MICU with severe sepsis/septic shock in July and August 2013 (controls) and 2014 (following the intervention). Similarly, educational slide sets were used as interventions for residents before the start of their ICU rotations in July and August 2013. While CPOE order set compliance did not sign...
Critical Care Medicine, 2007
P atients suffering from severe sepsis or septic shock have a mortality rate of 20 -54% (1-3). Among the 751,000 annual cases of severe sepsis in the United States, approximately 458,200 cases (or 61%) are first encountered in the emergency department (ED) (1, 4). Early appropriate antibiotics (5-7), early goal-directed therapy Objective: The purpose of this study was to examine the outcome implications of implementing a severe sepsis bundle in an emergency department as a quality indicator set with feedback to modify physician behavior related to the early management of severe sepsis and septic shock.
Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.
Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002
Journal of thoracic disease, 2017
Severe sepsis and septic shock are major causes of morbidity and mortality in patients entering the emergency department (ED) or intensive care unit (ICU). Despite substantial efforts to improve patient outcome, treatment of sepsis remains challenging to clinicians. In this context, early goal directed therapy (EGDT) represents an important concept emphasizing both early recognition of sepsis and prompt initiation of a structured treatment algorithm. As part of the AME evidence series on sepsis, we conducted a systematic review of all randomized controlled EGDT trials. Focus was laid on the setting (emergency department versus ICU) where EGDT was carried out. Early recognition of sepsis, through clinical or automated systems for early alert, together with well-timed initiation of the recommended therapy bundles may improve patients' outcome. However, the original "EGDT" protocol by Rivers and coworkers has been largely modified in subsequent trials. Currently, many inv...
Open Access Emergency Medicine, 2016
Since early goal-directed therapy (EGDT) became standard care in severe sepsis and septic shock patients in intensive care units many years ago, we suppose that the survival rate of severe sepsis and septic shock patients improves if the resuscitative procedure is quickly implemented and is initiated in the emergency room. Objective: We aimed at recording emergency department time to improve our patient care system as well as determine the rate at which EGDT goals can be achieved. The second analysis is to find out how much we can improve the survival rate. Methods: This was a prospective observational study in an emergency room setting at a tertiary care facility where EGDT was applied for resuscitation of severe sepsis and septic shock patients. The data recorded were the initial vital signs, APACHE II (Acute Physiology and Chronic Health Evaluation II) score, SAP II (Simplified Acute Physiology II) score, SOFA (Sequential Organ Failure Assessment) score, time at which EGDT goals were achieved (central venous oxygen saturation [Scvo 2 ] .70%), initial and final diagnosis, and outcome of treatment. The t-test and Mann-Whitney U-test were used to compare between the achieved goal and nonachieved goal groups. Results: There were 63 cases of severe sepsis in the study period. Only 55 patients submitted a signed consent form and had central line insertion. Twenty-eight (50.9%) cases were male. Thirty-nine (70.9%) patients achieved the goal, and the mean SAP II score was 8. There were no statistically significant differences between the two groups (P-value =0.097). Thirty of the 39 patients (70.9%) survived in the achieved goal group, which was a statistically significant improvement of the survival rate when compared with only one of 16 patients (6.3%) surviving in the nonachieved goal group (P,0.001).