BACKGROUND: Protocol-driven early goal-directed therapy (EGDT) has been shown to reduce mortality in patients with severe sepsis and septic shock in the ED. EGDT appears to be underused, even in centers with formalized protocols. The aim of our study was to identify factors associated with not initiating EGDT in the ED. METHODS: This was a cohort study of 340 EGDT-eligible patients presenting to a single center ED from 2005 to 2007. EGDT eligibility was defined as a serum lactate >or= 4 mmol/L or systolic BP< 90 mm Hg after volume resuscitation. EGDT initiation was defined as the measurement of central venous oxygen saturation via central venous catheter. Multivariable logistic regression was used to adjust for potential confounding. RESULTS: EGDT was not initiated in 142 eligible patients (42%). EGDT was not completed in 43% of patients in whom EGDT was initiated. Compliance with the protocol varied significantly at the physician level, ranging from 0% to 100%. Four risk factors were found to be associated independently with decreased odds of initiating EGDT: female sex of the patient (P = .001), female sex of the clinician (P = .041), serum lactate (rather than hemodynamic) criterion for EGDT (P = .018), and nonconsultation to the Severe Sepsis Service (P < .001). CONCLUSIONS: Despite a formalized protocol, we found that EGDT was underused. We identified potential barriers to the effective implementation of EGDT at the patient, clinician, and organizational level. The use of a consultation service to facilitate the implementation of EGDT may be an effective strategy to improve protocol adherence.
BACKGROUND: Protocol-driven early goal-directed therapy (EGDT) has been shown to reduce mortality in patients with severe sepsis and septic shock in the ED. EGDT appears to be underused, even in centers with formalized protocols. The aim of our study was to identify factors associated with not initiating EGDT in the ED. METHODS: This was a cohort study of 340 EGDT-eligible patients presenting to a single center ED from 2005 to 2007. EGDT eligibility was defined as a serum lactate >or= 4 mmol/L or systolic BP< 90 mm Hg after volume resuscitation. EGDT initiation was defined as the measurement of central venous oxygen saturation via central venous catheter. Multivariable logistic regression was used to adjust for potential confounding. RESULTS: EGDT was not initiated in 142 eligible patients (42%). EGDT was not completed in 43% of patients in whom EGDT was initiated. Compliance with the protocol varied significantly at the physician level, ranging from 0% to 100%. Four risk factors were found to be associated independently with decreased odds of initiating EGDT: female sex of the patient (P = .001), female sex of the clinician (P = .041), serum lactate (rather than hemodynamic) criterion for EGDT (P = .018), and nonconsultation to the Severe Sepsis Service (P < .001). CONCLUSIONS: Despite a formalized protocol, we found that EGDT was underused. We identified potential barriers to the effective implementation of EGDT at the patient, clinician, and organizational level. The use of a consultation service to facilitate the implementation of EGDT may be an effective strategy to improve protocol adherence.
Authors: Scott T Micek; Nareg Roubinian; Tim Heuring; Meghan Bode; Jennifer Williams; Courtney Harrison; Theresa Murphy; Donna Prentice; Brent E Ruoff; Marin H Kollef Journal: Crit Care Med Date: 2006-11 Impact factor: 7.598
Authors: Ravi Kalhan; Mark Mikkelsen; Pali Dedhiya; Jason Christie; Christine Gaughan; Paul N Lanken; Barbara Finkel; Robert Gallop; Barry D Fuchs Journal: Crit Care Med Date: 2006-02 Impact factor: 7.598
Authors: H Bryant Nguyen; Stephen W Corbett; Robert Steele; Jim Banta; Robin T Clark; Sean R Hayes; Jeremy Edwards; Thomas W Cho; William A Wittlake Journal: Crit Care Med Date: 2007-04 Impact factor: 7.598
Authors: Nathan I Shapiro; Michael D Howell; Daniel Talmor; Dermot Lahey; Long Ngo; Jon Buras; Richard E Wolfe; J Woodrow Weiss; Alan Lisbon Journal: Crit Care Med Date: 2006-04 Impact factor: 7.598
Authors: Alexandra Ortego; David F Gaieski; Barry D Fuchs; Tiffanie Jones; Scott D Halpern; Dylan S Small; S Cham Sante; Byron Drumheller; Jason D Christie; Mark E Mikkelsen Journal: Crit Care Med Date: 2015-04 Impact factor: 7.598
Authors: Michael J Ward; Jeremy S Boyd; Nicole J Harger; John M Deledda; Carol L Smith; Susan M Walker; Jeffrey D Hice; Kimberly W Hart; Christopher J Lindsell; Stewart W Wright Journal: World J Emerg Med Date: 2012-06-12
Authors: Ithan D Peltan; Kristina H Mitchell; Kristina E Rudd; Blake A Mann; David J Carlbom; Catherine L Hough; Thomas D Rea; Samuel M Brown Journal: Crit Care Med Date: 2017-06 Impact factor: 7.598
Authors: Katy M Hanzelka; Sai-Ching J Yeung; Gary Chisholm; Kelly Willis Merriman; Susan Gaeta; Imrana Malik; Terry W Rice Journal: Support Care Cancer Date: 2012-09-07 Impact factor: 3.603
Authors: Zhongheng Zhang; Yucai Hong; Nathan J Smischney; Han-Pin Kuo; Panagiotis Tsirigotis; Jordi Rello; Win Sen Kuan; Christian Jung; Chiara Robba; Fabio Silvio Taccone; Marc Leone; Herbert Spapen; David Grimaldi; Sven Van Poucke; Steven Q Simpson; Patrick M Honore; Stefan Hofer; Pietro Caironi Journal: J Thorac Dis Date: 2017-02 Impact factor: 2.895
Authors: William Dale; Joshua Hemmerich; Elizabeth Moliski; Margaret L Schwarze; Avery Tung Journal: J Am Geriatr Soc Date: 2012-09-27 Impact factor: 5.562
Authors: Brian Casserly; Michael Baram; Patricia Walsh; Andrew Sucov; Nicholas S Ward; Mitchell M Levy Journal: Lung Date: 2010-11-16 Impact factor: 2.584
Authors: John P Haran; Gregory Wu; Vanni Bucci; Andrew Fischer; Edward W Boyer; Patricia L Hibberd Journal: Am J Emerg Med Date: 2015-08-21 Impact factor: 2.469