Abstract
IntroductionThe purpose of the present study was to measure the incidence and outcome of septic patients presenting at the emergency department (ED) with criteria for early goal-directed therapy (EGDT).MethodThis hospital-based, retrospective, observational study using prospectively collected electronic databases was based in a teaching hospital in Melbourne, Australia. We conducted outcome-blinded electronic screening of patients with infection admitted via the ED from 1 January 2000 to 30 June 2003. We obtained data on demographics, laboratory and clinical features on admission. We used paper records to confirm electronic identification of candidates for EGDT and to study their treatment. We followed up all patients until hospital discharge or death.ResultsOf 4,784 ED patients with an infectious disease diagnosis, only 50 fulfilled published clinical inclusion criteria for EGDT (EGDT candidates). Of these patients, 37 (74%) survived their hospital admission, two (4%) died in the ED, eight (16%) died in the intensive care unit and three (6%) died in the ward. After review of all ward cardiac arrests and non-NFR ('not for resuscitation') ward deaths, we identified a further two potential candidates for EGDT for an overall mortality of 28.8% (15 out of 52 patients). Analysis of treatment showed that twice as many (70%) of the EGDT candidates received vasopressor therapy in the ED, and their initial mean central venous pressure (10.8 mmHg) was almost twice that in patients from the EGDT study conducted by Rivers and coworkers.ConclusionIn an Australian teaching hospital candidates for EGDT were uncommon and, in the absence of an EGDT protocol, their mortality was lower than that reported with EGDT.
Highlights
The purpose of the present study was to measure the incidence and outcome of septic patients presenting at the emergency department (ED) with criteria for early goal-directed therapy (EGDT)
In an Australian teaching hospital candidates for EGDT were uncommon and, in the absence of an EGDT protocol, their mortality was lower than that reported with EGDT
The selection process was blinded to outcome. From this primary cohort we identified patients with severe sepsis or septic shock by selecting all patients who died in the ED, required care in the intensive care unit (ICU), required care in the high dependency unit (HDU; including all patients who died in the HDU), died in the general ward from cardiac arrest, and died in the general wards without a 'not for resuscitation' (NFR) order
Summary
There is no information on how frequently such patients attend the ED in different health care systems, institutions, or geographical settings, and on their mortality outside the single institution in which the EGDT trial was conducted. Such information would be of value in improving our understanding the external validity of the EGDT approach, assessing the possible workload for a sepsis team, clarifying the 'therapeutic opportunity' associated with EGDT and helping other investigators to power multicenter randomized controlled trials of EGDT. The US National Institutes of Health recently funded one such study (ProCESS), which will conduct preliminary feasibility work prior to randomization
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