Key Point

Early goal-directed therapy is a highly effective measure for beginning treatment of sepsis in the emergency department that depends on close collaboration between the emergency department and the ICU.

CAMDEN, NJ—Early goal-directed therapy can reduce mortality in patients with severe sepsis and septic shock. In fact, consensus guidelines now recommend early goal-directed therapy for the first six hours of sepsis resuscitation. Despite this, however, early goal-directed therapy is still not widely used in clinical practice. Researchers from Cooper University Hospital in Camden, New Jersey, postulated that early goal-directed therapy could be successfully implemented using collaboration between emergency department and critical care services.¹

The study hospital implemented early goal-directed therapy in 2004; prior to that, the emergency department did not use any protocolized resuscitation or invasive hemodynamic monitoring. The present study was undertaken to see if early goal-directed therapy end points could be achieved in real-world clinical practice. A secondary objective was to determine the effect of protocolized therapy on the use of hospital resources compared to a group of historical controls who did not receive early goal-directed therapy in the emergency department.

The early goal-directed therapy protocol is triggered when there is a clinical suspicion of sepsis accompanied by one or more of the following: systolic blood pressure less than 90 mm Hg or mean arterial pressure less than 65 mm Hg, or a lactate level of 4 mmol/L or greater. The monitoring of end points was continued into the ICU phase of therapy and stopped only at the discretion of the ICU physician. No time frame was mandated for the achievement of each end point, and neither the emergency department nor ICU physicians were aware that the time to successful achievement of end points would be tracked.

Early goal-directed therapy cases were initiated in existing emergency department patient care areas with conventional monitors that were brought to the bedside when needed. "Implementing [early goal-directed therapy] required no modifications of the [emergency department] physical plant," the authors pointed out.

Study patients included those presenting to the emergency department with confirmed or suspected sepsis and persistent hypotension that was treated using early goal-directed therapy. These patients were identified using a prospective emergency department–based quality assurance registry for early goal-directed therapy that was compiled during the first year of protocol implementation.

Four independent reviewers abstracted data that included physiologic parameters, resource utilization, timing of therapies, and outcomes from the emergency department and ICU. Time to achievement of each early goal-directed therapy end point was then determined.

GOAL-DIRECTED THERAPY TARGETS ACHIEVED WITHIN SIX HOURS

Of 45 patient records identified from the 2004 early goal-directed therapy registry, 22 met the criteria for hypotension in the emergency department. All of the end points were achieved in 20 patients. The median time required to achieve end points was 1.5 hours for central line insertion, six hours for central venous pressure goal, four hours for mean arterial pressure goal, and five hours for central venous oxygen saturation goal. In the remaining two patients, central venous pressure and mean arterial pressure were achieved but the end point for central venous oxygen saturation was not.

LOWER CATHETERIZATION RATES, COSTS, AND MORTALITY

When the early goal-directed therapy group and the control group were compared, the overall rates of central venous catheterization (either in the emergency department or in the ICU) were similar. However, the rate of pulmonary artery catheterization was significantly lower in the group receiving early goal-directed therapy than it was in the control group (9.1% vs 43.8%, respectively). Interestingly, when data from 2004 were examined, patients diagnosed with sepsis who were admitted to the ICU from locations other than the emergency department during the early goal-directed therapy implementation period were given a pulmonary artery catheter in 42% of cases.

The in-hospital mortality rate in the group that received early goal-directed therapy was 18.2% compared to 43.8% in the control group. Likewise, median facilities charges were $82,233 for the early goal-directed therapy group compared to $135,199 for the control group.

COLLABORATION KEY FOR SUCCESSFUL EARLY GOAL-DIRECTED THERAPY

The authors pointed out that no extra clinical staffing in the emergency departmen or the ICU was allocated for the implementation of early goal-directed therapy. Additionally, the study’s emergency department had no special critical care equipment beyond that found in any conventional emergency department. The most important factor, however, was the close collaboration between clinicians in the emergency department and the critical care unit.

"Early goal-directed therapy has to do with reorganizing how it is that we interface emergency department and critical care services," said Stephen Trzeciak, MD, Assistant Professor in the Section of Critical Care Medicine and the Department of Emergency Medicine at UMDNJ–Robert Wood Johnson Medical School and Cooper University Hospital, both in Camden. "We aimed to create a seamless continuum of care between the two departments."

One of the key elements for implementing an early goal-directed therapy protocol in the emergency department is to have a "champion," stressed Dr. Trzeciak. "For us, Mary Stauss, RN, a nurse-educator for emergency medicine as well as a coauthor of the study, played a crucial role. Without her championing early goal-directed therapy throughout the emergency department and getting all of the nurses on board, it probably never would have gained acceptance in clinical practice at our institution."

"Our data demonstrate that [early goal-directed therapy] is not just a research innovation but also a viable clinical practice parameter that can be successfully built into the armamentarium of severe sepsis care [in] the [emergency department]," they concluded.

—Gale Jurasek

Reference
1. Trzeciak S, Dellinger RP, Abate NL, et al. Translating research to clinical practice: a 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department. Chest. 2006;129:225-232.

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