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

Alan E. Jones, Anne Focht, James M. Horton, Jeffrey Kline

Research output: Contribution to journalArticle

188 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)425-432
Number of pages8
JournalChest
Volume132
Issue number2
DOIs
StatePublished - Aug 2007
Externally publishedYes

Fingerprint

Septic Shock
Hospital Emergency Service
Sepsis
Mortality
Therapeutics
Central Venous Catheters
Hospital Mortality
Resuscitation
Lactic Acid
Emergencies
Thorax
Prospective Studies
Confidence Intervals
Inflammation
Physicians
Infection

Keywords

  • Early goal-directed therapy
  • Emergency department
  • Resuscitation
  • Sepsis
  • Septic shock

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine

Cite this

Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock. / Jones, Alan E.; Focht, Anne; Horton, James M.; Kline, Jeffrey.

In: Chest, Vol. 132, No. 2, 08.2007, p. 425-432.

Research output: Contribution to journalArticle

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abstract = "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.",
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AB - 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.

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