Early goal directed therapy for sepsis and septic shock: collaborative implementation models

Introduction

There is strong evidence that early goal directed therapy (EGDT) for patients with severe sepsis and septic shock leads to a survival benefit, as well as a reduction in morbidity and mortality, hospital stay, and costs. Despite the accepted evidence behind this practice, few centers have successfully implemented EGDT. No data currently exist regarding various models for instituting EGDT.

Objective

This pilot investigation describes two EGDT implementation models: (1) the medical intensive care unit (MICU)-initiated model; and (2) the emergency department (ED)-initiated model.

Methods

This is a prospective, descriptive study reporting a qualitative assessment of the advantages of, and relative barriers for, two models of EGDT implementation. The models were developed by two tertiary care hospitals. Patients eligible for the EGDT protocol were those with suspected infection criteria and either septic shock (systolic blood pressure < 90 despite 30 cm³/kg fluid resuscitation) or lactate (> 4 mmol/l). Implementation at each center included a 1-month initial phase comprised of MICU and ED physician and nursing staff education. The MICU-driven protocol conducted a 2-month baseline data collection period.

Results

Both models are collaborative, but vary in terms of initiation of the protocol. The MICU-driven model developed and introduced a protocol with ensuing support from the ED. The ED-driven model developed and introduced a protocol with ensuing support derived from the MICU. Timing of patient identification, protocol compliance and ED transfer time to the MICU are continuously evaluated in both models. Insertion of an ScvO₂ central venous oximetry catheter (PreSep) is shared between theMICU and ED teams based on ED acuity, operator skill, and physiologic urgency. The MICU-driven protocol is strongly supported by the intensive care staff; early transfer from the ED to the MICU is a priority. During the course of this study, timing of patient identification and MICU/ED collaboration continues to improve. The ED-driven protocol team has found that early identification and initiation of the protocol, in combination with strong support from the ICU, results in collaborative streamlining based on ED and MICU workloads. Both institutions have found that challenges in patient identification and line insertion present the most time-consuming obstacles to protocol initiation.

Conclusion

Implementation of EGDT protocols is possible through a collaborative process, whether driven by intensive care unit or emergency department teams. Frequent education and collaborative communication appear to be key elements for success.