- Journal club critique
- Open Access
Early recognition and treatment of non-traumatic shock in a community hospital
© BioMed Central Ltd 2006
- Published: 1 March 2006
Sebat F, Johnson D, Musthafa AA, Watnik M, Moore S, Henry K, Saari M: A multidisciplinary community hospital program for early and rapid resuscitation of shock in nontrauma patients. Chest 2005, 127:1729–1743 .
To determine the effect of a community hospital-wide program enabling nurses and prehospital personnel to mobilize institutional resources for the treatment of patients with nontraumatic shock. The hypothesis was that a systems-based approach to early recognition and treatment of shock decreases hospital mortality.
Design and setting
Prospective historically-controlled single-center study in a 180-bed community hospital.
Patients in shock who were candidates for aggressive therapy.
From January 1998 to May 2000, patients in shock received standard therapy (control group). During the month of June 2000, intensive education of all healthcare providers (pre-hospital personnel, nurses and physicians) took place. From July 2000 through June 2001, patients in shock (protocol group) were managed with a hospital-wide shock program. The program used a systems-based team approach that consisted of five components: staff education to enhance early recognition and treatment of shock; empowerment of non-physician providers to mobilize hospital resources; rapid use of protocol-directed therapy; early involvement of intensivists; and prompt transfer of patients to the ICU. Goal-directed treatment protocols were utilized based on the "VIPPS" approach to shock, including: early support of ventilation and oxygenation; rapid infusion of volume; pharmacologic therapy, such as antibiotics and vasopressors; and disease specific interventions.
The primary endpoint was hospital mortality. Secondary endpoints were the identification of shock patients, times to interventions, length of stay, and discharge location.
Eighty-six and 103 patients were in the control and protocol groups, respectively. Baseline characteristics were similar. The protocol group had significant reductions in the median times to interventions, as follows: intensivist arrival, 2:00 h to 50 min (p < 0.002); ICU/operating room admission, 2 h 47 min to 1 h 30 min (p < 0.002); 2 L fluid infused, 3 h 52 min to 1 h 45 min (p < 0.0001); and pulmonary artery catheter placement, 3 h 50 min to 2 h 10 min (p = 0.02). Good outcomes (ie, discharged to home or to a rehabilitation center) were more likely in the protocol group than in the control group (p = 0.02). The hospital mortality rate was 40.7% in the control group and 28.2% in the protocol group (p = 0.035).
Similar to current practice in patients who have experienced trauma or cardiac arrest, the empowerment of nonphysician providers to mobilize hospital resources for the care of patients with shock is effective. A community hospital program incorporating the education of providers, the activation of a coordinated team response, and early goal-directed therapy expedited appropriate treatment and was temporally associated with improved outcomes. Randomized multicenter trials are needed to further assess the impact of the shock program on outcomes.
Although the authors draw comparisons between their shock program and more broadly-based medical emergency, or rapid response, teams, patients in shock comprise a minority of patients in crisis [4, 5]. This leads to an important question regarding the field of "crisis medicine." Should a crisis team be sub-specialized? The effort and subsequent indoctrination of this program into the culture of this community hospital should be applauded. Because of the above-mentioned limitations, we recommend a multi-center prospective trial prior to universal adoption of the shock team approach.
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