Implementation Of Early Goal-directed Therapy Research Articles

Cost-Effectiveness of Early Goal-Directed Therapy Using the FloTrac/EV1000 Platform in Patients Undergoing Coronary Artery Bypass Graft with Cardiopulmonary Bypass: A Retrospective Analysis

Background: Coronary artery bypass graft (CABG) with cardiopulmonary bypass (CPB) is a high-risk surgery with significant morbidity resulting in a prolonged stay in the intensive care unit (ICU) at an increased cost. Early goal-directed therapy (EGDT) using the FloTrac/EV1000 platform improved outcomes in these patients with shorter ICU stay but with extra cost for a FloTrac transducer. Objective: To assess the cost-effectiveness of implementing the FloTrac/EV1000 in these patients. Materials and Methods: The present study was a retrospective study. Sixty adult patients who underwent CABG with CPB were included and divided into two groups: the EV1000 and the Control group. The EV1000 group was managed with EGDT protocol using FloTrac/EV1000 platform. The Control group was managed using a standard protocol. The ICU and hospital stay of both groups were compared. Then, the authors assessed the daily ICU cost by including another 62 patients admitted to the cardiovascular and thoracic (CVT) ICU. Finally, the extra cost of a FloTrac transducer was compared with the saved CVT ICU cost. Results: The EV1000 group had a shorter CVT ICU stay, with mean difference of –23.7 h (95% CI –34.5 to –12.9, p<0.001). The EV1000 group had a shorter ventilator time, as well as a shorter hospital stay. The average daily CVT ICU cost was 10,020.05 Baht. The extra cost of a FloTrac sensor was 5,000 Baht. The saved cost of CVT ICU exceeds the cost of a FloTrac by 5,020.05 Baht. Conclusion: The implementation of EGDT using the FloTrac/EV1000 platform in patients undergoing CABG with CPB improved patients’ outcomes resulting in less CVT ICU cost and better resource management of CVT ICU beds. The extra cost of the FloTrac sensor was offset by the larger amount of CVT ICU cost that was saved. Keywords: Cost-effectiveness; Early goal-directed therapy; FloTrac; Intensive care unit; ICU stay

Early Goal-Directed Therapy Using FloTrac/EV1000 Platform for Hemodynamic Optimization to Improve Perioperative Outcomes in Patients Undergoing Major Abdominal Surgery: A Randomized Controlled Trial

Objective: To compare the efficacy of early goal-directed therapy (EGDT) based on the FloTrac/EV1000 platform versus standard care to improve perioperative outcomes in patients undergoing major abdominal surgery. Materials and Methods: Forty patients undergoing major abdominal surgery were randomized to the Control or EGDT group. The Control group was managed to achieve a mean arterial pressure (MAP) of 65 to 90 mmHg, a central venous pressure of 8 to 12 mmHg, a urine output of 0.5 mL/kg/h or more, and an SpO₂ of more than 95%. The EGDT group was managed to achieve similar goals using information from the FloTrac/ EV1000 platform by receiving fluid to maintain stroke volume variation (SVV) of less than 13%, inotropic drugs to achieve a cardiac index (CI) of 2.2 to 4.0 L/min/m⁻², and/or vasoactive drugs to achieve a systemic vascular resistance index (SVRI) of 1,600 to 2,500 dynes·s/cm⁻⁵/m². Results: There were 20 patients in each group. The EGDT group received more colloid (p=0.035). The MAP and SVRI of both groups were comparable. The SVV of the Control group was higher (p=0.002), while the CI of the EGDT group was higher (p<0.001). The EGDT group had a shorter intubated time and a shorter stay in the ICU, with a mean difference of –3.95 h (95% CI –7.85 to –0.05, p=0.047) and –14.75 h (95% CI –25.38 to –4.12, p=0.008), respectively. The EGDT group had shorter hospital stays, albeit without significance (p=0.273). No postoperative complication was detected. Conclusion: Implementation of EGDT using FloTrac/EV1000, compared to conventional care, in patients undergoing major abdominal surgery results in shorter intubated time and shorter stay in the ICU. The shorter hospital stay did not achieve statistical significance. Keywords: Early goal-directed therapy; Major abdominal surgery; Perioperative outcome; Intubation time; ICU stay; Hospital stay

Comparative study on the outcome of Early Goal Directed Therapy (EGDT) versus standard care in pediatric septic shock patients: A prospective open labeled randomized controlled trial

Background : Sepsis in children is a noteworthy cause of morbidity and mortality all over the world. Given the crucial need to reduce the mortality from sepsis, conflicting results from adult studies and lack of high quality pediatric controlled study warrant a trial to examine the effectiveness of early goal directed therapy (EGDT) versus standard care in Indian patients. Methods : The trial was a prospective open labeled randomized controlled trial conducted from 1st July 2015 to 30th June 2017. All children from one month of age to 12 years with septic shock fulfilling the inclusion criteria were enrolled in the study. Eligible patients were randomized and allocated one of the two study groups (EGDT Group and standard care group). If the patient was assigned to EGDT, the EGDT protocol adapted from Rivers et al. was commenced by the treating team within one hour of enrollment. If the patient was assigned to standard care, no changes were made to the plan of the treating team. Results : The 110 patients were recruited from July 2015 to June 2017. Out of 110 patients, 54 patients were randomized to the EGDT group and 56 randomized to the standard care group. The trial had to be stopped after an interim analysis by the independent data monitoring committee indicated the futility of the study. The overall all-cause mortality at 28 days of the study population was 53.6%. Children in the EGDT group had 46.3% mortality while children in the standard care group had 60.7% mortality (p=0.13). There was 14.4% absolute risk reduction of mortality in the EGDT group. There was no difference in any secondary outcome regarding the proportion of patients achieving therapeutic end points at 6 hours, use and duration of organ support, SOFA and PeLOD score and length of PICU and hospital stay. Conclusion : Our study suggests that the implementation of the early goal directed therapy (EGDT) by the addition of intermittent ScvO2 monitoring and protocolized management did not improve mortality in the EGDT group compared to standard care group. The implementation of EGDT needed the greater intensity of treatment in the form of inotrope and packed RBCs transfusion requirement.

Clinical Outcomes of Early Goal-Directed Therapy vs Usual Care for Patients With Early Septic Shock: A Meta-analysis of Randomized Controlled Trials

SESSION TITLE: Sepsis and Shock Posters SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: Early goal-directed therapy (EGDT) has been endorsed as a key therapeutic strategy in the management of early septic shock aiming to improve survival and reduce length of hospitalization. However; evidence is conflicting regarding the efficacy of EGDT compared to usual care. METHODS: A systematic literature review identified publications of randomized controlled trials (RCT) evaluating EGDT in early septic shock were used to obtain data. Odds ratios (OR) and 95% confidence intervals (CI) computed using the Mantel-Haenszel method. Random effect model was used in the analysis of all variables as they were heterogeneous. Publication bias was tested by funnel plot and Egger's regression. RESULTS: Four RCT involving 3999 patients were included in the meta-analysis. Compared to usual-care group, patients who assigned to the EGDT group showed no significant difference in the rate of in-hospital mortality (OR 0.92; 95% CI, 0.72 - 1.19, P = 0.53, I2 = 59.11), 28 days mortality (OR 0.84; 95% CI, 0.62 - 1.15, P = 0.28, I2 = 62.07), 90 days mortality (OR 0.91; 95% CI, 0.76- 1.10, P = 0.34, I2 = 36.54), respiratory support (OR 1.05; 95% CI, 0.88-1.26, P = 0.59, I2 = 37.72), and the rate of renal support (OR 1.04; 95% CI, 0.84- 1.28, P = 0.7433, I2 = 0.00). However; there is significant difference in the rate of cardiovascular support as more support was needed in EGDT group (OR 1.41; 95% CI, 1.170-1.691, P = 0.00029, I2 = 43.57). CONCLUSIONS: In patients presented with early septic shock, the implementation of EGDT was not superior to usual care in improving in-hospital mortality, 28 days mortality, 90 days mortality, respiratory and renal support. Patients in the EGDT group required more cardiovascular support. CLINICAL IMPLICATIONS: This analysis demonstrated that EGDT has not reduced mortality as compared to usual care in patients with early septic shock. This raise the question on whether EGDT implementation will remain the base of treatment for severe sepsis. DISCLOSURE: The following authors have nothing to disclose: Mohsin Salih, Mohamed Ayan, Mlatoum Hamza, Moataz Gaddor, Mohamed Gashouta, Erika Leung, George Mansour, Haitham AlAshry, Mahmoud Traina No Product/Research Disclosure Information

Sepsis,severe sepsis and septic shock: the importance of early recognition

Early recognition of severe sepsis and septic shock, early initiation of effective interventions, implementation of early goal-directed therapy may be key approaches for reducing the mortality and improving the prognosis. This article focused on the staging diagnosis systems for sepsis (PIRO sepsis classification system) and the systematic early warning or rapid response system. We also discussed the diagnostic value of biomarkers, proteomics and metabolomics in sepsis and severe sepsis. No single marker as golden standard has emerged that can provide clinicians with all the information they need for early recognition of sepsis. Therefore, we suggested that clinicians should have even more reason to combine the sepsis symptoms, signs and biomarkers for a comprehensive evaluation, and that they needed to dynamically monitor the changes in these parameters, in order to make reasonable clinical decisions and strategies. Key words: Sepsis; Diagnosis; Screening; Children

The Impact of a Nurse Practitioner Rapid Response Team on Systemic Inflammatory Response Syndrome Outcomes

Early recognition of systemic inflammatory response syndrome (SIRS) can significantly alter outcomes such as mortality, unplanned intensive care unit admissions, and cost. Through utilization of a nurse practitioner rapid response team (NP-RRT) and a revised database query, earlier identification of SIRS patients and consistent implementation of early goal-directed therapy (EGDT) on the medical-surgical units would positively impact SIRS outcomes. A database query that indicated when patients had 2 or more of the SIRS criteria and anion gap acidosis was initiated. The NP-RRT reviewed the triggered patients, and if blood cultures, lactic acid levels, volume resuscitation, or antibiotics were not in place, they were either ordered or recommended to the physicians. All 4 components of EGDT were more frequently discussed with physicians at a statistically significant level. Individual components of EGDT had high levels of implementation. Unplanned intensive care unit admissions were reduced by 3.25% after intervention with a cost savings of approximately $250 000. After initiation of the database query, patients seen by the NP-RRT were more acutely ill, with a statistically higher mean anion gap acidosis, and as a result, mortality was essentially unchanged. Improved detection of SIRS and successful implementation of EGDT led to a bridging of the evidence-to-practice gap. Future recommendations on earlier detection of lactic acidosis were rendered as a consequence of this study. The NP-RRT will continue to use the database query to identify SIRS patients in a timely manner and expedite EGDT.

1065

Introduction: Mortality in patients with septic shock has been decreasing since implementation of early-goal directed therapy (EGDT) in 2001. The purpose of this study was to measure the accomplishment of the four components in the EGDT, namely a central venous pressure 8-12 mmHg, mean arterial pressure ≥65 mmHg, superior vena cava oxygen saturation 70%, and urine output ≥0.5 ml/kg/h; and estimating the correlation of this and other variables with mortality. Methods: This was a transversal prospective cohort study, in which 208 adult patients admitted at an emergency department of a Mexican third-level hospital, with diagnosis of septic shock were included, from november 2011 to december 2012. Cohort was divided in groups "death" and "discharge from ICU" for analysis, compared with chi-square, student's t- test and non-parametric tests if necessary; also adjustment with Mantel-Haenszel's stratified analysis, construction of ROC (receiver operating characteristic) curves, Spearman's correlation, as well as lineal and logistic regression between multiple variables was done. Results: With a 50% mean predicted death by APACHE II score, actual mortality was 65%. All four-goals were accomplished in <15% of total cohort. Mortality was null in patients with four-goals achieved, versus 100% in zero-goals achieved group; in the first group, relative risk (RR) for survival was 4.3 statistically significant (p= <0.001), even after adjustment to severity of disease and other potential bias variables (p= <0.001). Increasing number of attained goals and mortality were inversely correlated (Spearman's rho= 0.76; p= <0.001). A longer stay at emergency department (ED) before hospitalization was associated with more delay in shock resolution (p= <0.001), furthermore patients with a stay at ED >7.5 hours had a RR 4.17 (p=<0.001) for death. Conclusions: Local attainment of early-goal directed therapy components is alarmingly low, resulting in higher figures of mortality than those on current literature. A critical stay time at ED as a new death predictor was estimated; therefore, an improvement in triage of patients for management, and/or implementation of rapid response teams is needed, with a high potential for saving lives.

The Effect of Emergency Department Crowding and Time of Day Upon the Adherence to Early Goal-Directed Therapy

Emergency department (ED) crowding has been shown to impact the delivery of care for time-sensitive conditions (acute stroke, myocardial infarction). Aggressive and timely management of severe sepsis/septic shock through the protocolized care bundle, early goal directed therapy (EGDT), has been shown to improve mortality. We sought to analyze the effect of ED crowding and time of day upon the initiation of EGDT and time to critical interventions within the ED for patients with severe sepsis/septic shock. Retrospective chart review of EGDT-eligible (lactate >4 mmol/L or persistent hypotension) patients (≥2 SIRS criteria; a confirmed or suspected source of infection; presence of at ≥1 acute organ dysfunction), admitted to an urban, level I trauma center from the ED, 5/2008-2/2010. Four validated measures of ED crowding (occupancy, waiting patients, admitted patients, patient-hours) were assigned at the time of triage. Adjusted odds ratios (OR) were calculated for administration of intravenous fluids (IVF) and antibiotics (ABX), and implementation of EGDT. Odds ratios were adjusted for patient demographic data (age, sex, SOFA score, and comorbidities) and analyzed for differences in time of day and ED crowding measures. A total of 2,913 patients were identified; 1,033 patients met Rivers’ criteria; 652 were treated with EGDT. Mean age was 57.3 years; 46.1% African-American, in-hospital mortality was 26%. Compared to patients presenting from 7pm-12am, patients presenting from 7am-7pm were less likely to have IVF started within ≤1 hour (OR 0.73), whereas from 12am-7am patients were more likely (OR 1.52). As occupancy and patient-hours increased, patients were less likely to receive IVF ≤1 hour (OR 0.73, 0.64). Overnight, patients were more likely to receive ABX ≤1 and ≤3 hours (OR 1.37, 1.73). Increased ED occupancy, patient hours, and the number of boarding inpatient admissions negatively impacted administration of ABX ≤3 hours (OR 0.77, 0.77, 0.75). Initiation of EGDT for all patients meeting criteria was significantly more likely to occur as occupancy increased (OR 1.52) but less likely as the number of boarding inpatients increased (OR 0.39). The administration of critical interventions (IVF ≤1 hour and antibiotics ≤1 or ≤3 hours) was delayed during daytime and evening hours when adjusting for patient level factors. ED crowding, (occupancy rate, patient hours, and inpatient boarding) negatively impacts the delivery of time-sensitive interventions. Boarding admitted inpatients in the ED decreases the initiation rate of EGDT for patients meeting criteria. EDs must be mindful of crowding measures as they attempt to optimize delivery of time-sensitive therapies to critically ill patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Implementation of early goal-directed therapy and the surviving sepsis campaign resuscitation bundle in Asia

To examine the impact of implementing sepsis bundle in multiple Asian countries, having 'team' vs. 'non-team' models of patient care. Prospective cohort study. Eight urban hospitals, five countries in Asia. Adult patients with severe sepsis or septic shock. Implementation was divided into six quartiles: Baseline, Education and four Quality Improvement quartiles. Quarterly bundle compliance and in-hospital mortality with respect to bundle completion and implementation model. In the team model, the implementation was championed by intensivists, where the bundle was completed in the intensive care unit. The non-team model led by emergency physicians completed the bundle in the emergency department as part of standard care. Five hundred and fifty-six patients were enrolled. The overall in-hospital mortality rate was 29.9%, and 67.1% of the patients had septic shock. Compliance to the bundle was 13.3, 26.9, 37.5, 45.9, 48.8 and 54.5% over the six quartiles of implementation (P < 0.01). With team model, compliance increased from 37.5% baseline to 88.2% in the sixth quartile (P < 0.01), whereas hospitals with a non-team model increased compliance from 5.2 to 39.5% (P < 0.01). Crude in-hospital mortality was better in the patients who received the entire bundle (24.5 vs. 32.7%, P = 0.04). Bundle completion was associated with crude in-hospital mortality reduction (odds ratio 0.67, 95% confidence interval 0.45-0.99), but this survival benefit disappeared after adjustment for confounding variables. Through education and quality improvement efforts, initially low sepsis bundle compliance was improved in Asia. A team model was more effective in achieving bundle compliance compared with a non-team model.

Nurses’ Critical Role in Identifying Sepsis and Implementing Early Goal-Directed Therapy

Nurses play a critical role in detecting early sepsis-related manifestations and improving adherence to implementation of early goal-directed therapy. Educating staff about sepsis management through translation of best practices is critical to improving sepsis-related outcomes.

Local Cutaneous Necrosis Secondary to a Prolonged Peripheral Infusion of Methylene Blue in Vasodilatory Shock

To report a case of methylene blue extravasation and subsequent tissue necrosis in a patient with refractory septic shock. A 47-year-old female presented with febrile neutropenia secondary to chemotherapy. The patient quickly decompensated to refractory septic shock in the critical care unit despite implementation of early goal-directed therapy as well as intravenous norepinephrine and vasopressin to stabilize her hemodynamic status. She received a 16-hour infusion of 1% methylene blue 0.25 mg•kg(-1)•h(-1), titrated up to 0.5 mg•kg(-1)•h(-1), via a peripheral intravenous catheter. Ten hours after the start of the methylene blue infusion, she experienced a local extravasation injury, which led to distal digital necrosis. While her hemodynamic status improved dramatically, allowing discharge from the intensive care unit and eventually to home, the extravasation site became necrotic and required debridement and skin graft. Methylene blue is a vasoactive chemical that has been shown to provide hemodynamic stability in the treatment of refractory septic shock. Methylene blue administration is not considered standard of practice in the treatment of refractory septic shock and many aspects of its dosing, route, duration, and adverse effects are poorly described. As such, there is little guidance for its administration. We postulate that, in our patient, in the presence of systemic vasopressin and norepinephrine, methylene blue caused extensive vasoconstriction at the site of extravasation, resulting in tissue ischemia and necrosis. Tissue necrosis secondary to peripheral intravenous extravasation has not been previously described and is not listed as an adverse outcome on the drug monograph. The Naranjo probability scale indicates that the tissue necrosis was probably caused by the methylene blue extravasation. To mitigate future risk to limb and skin, we recommend that methylene blue infusions be delivered via central venous catheter. Extra care should be given to patients with risk factors for extravasation, such as sedation, presence of systemic disease, proximal intravenous puncture sites, and improperly placed catheters.

7 Skipping Lines: Predicting Unattempted Thoracic Central Venous Catheterization in Septic Patients Eligible for Early Goal-Directed Therapy

Implementation of the Rivers protocol of early goal-directed therapy has been demonstrated to reduce morbidity, mortality, and health care resource consumption in patients with severe sepsis and septic shock. Despite the evidence in its favor, however, emergency department (ED) implementation of early goal-directed therapy has been variable and incomplete. One impediment to protocol adherence is the requirement for thoracic central venous catheterization, a procedure both time- and resource-intensive.

Implementation of Early Goal-directed Therapy for Septic Patients in the Emergency Department: A Review of the Literature

The Surviving Sepsis Campaign outlines the elements of early goal-directed therapy when treating patients with sepsis in the emergency department. The success of these guidelines relies on their implementation in order to attain optimal patient outcomes. The purpose of this article is to review the literature regarding the implementation of the sepsis guidelines in emergency departments. Using the search terms systemic inflammatory response syndrome, emergency service, and sepsis, the Cumulative Index of Nursing and Allied Health, MEDLINE, and Cochrane database were searched for information pertaining to implementing early goal-directed therapy for sepsis in the emergency department. Studies that discussed collaboration, preplanning, and education were able to implement monitoring of central venous pressure, mean arterial pressure, and central venous oxygen saturation. However, nursing interventions recommended by the Surviving Sepsis Campaign such as measuring urine output and obtaining blood cultures were less often considered. This review provides some factors important for the successful implementation of the Surviving Sepsis Campaign guidelines. Operational and system issues significantly influenced the success of implementing sepsis protocols or bundles. More research is needed to overcome barriers to implementing early goal-directed therapy and to uncover which elements of the guidelines are most important and feasible to achieve optimal patient outcomes.

Cost-effectiveness of an emergency department-based early sepsis resuscitation protocol*

Guidelines recommend that sepsis be treated with an early resuscitation protocol such as early goal-directed therapy. Our objective was to assess the cost-effectiveness of implementing early goal-directed therapy as a routine protocol. Prospective before and after study. Large urban hospital emergency department with >110,000 visits/yr. The target population was patients with consensus criteria for septic shock. We excluded those with age <18 yrs, no aggressive care desired, or need for immediate surgery. Clinical and cost data were prospectively collected on two groups: 1) patients from 1 yr before; and 2) 2 yrs after implementing early goal-directed therapy as standard of care. Before phase patients received nonprotocolized care at attending discretion. The primary outcomes were 1-yr mortality, discounted life expectancy, and quality-adjusted life-years. Using costs and quality-adjusted life-years, we constructed an incremental cost-effectiveness ratio and performed a net monetary benefit analysis, producing the probability that the intervention was cost-effective given different values for the willingness to pay for a quality-adjusted life-year. Two hundred eighty-five subjects, 79 in the before and 206 in the after phases, were enrolled. Treatment with early goal-directed therapy was associated with an increased hospital cost of $7,028 and an increase in both discounted sepsis-adjusted life expectancy and quality-adjusted life years of 1.5 and 1.3 yrs, respectively. Early goal-directed therapy use was associated with a cost of $5,397 per quality-adjusted life-years gained and the net monetary benefit analysis indicates a 98% probability (p = .038) that early goal-directed therapy is cost-effective at a willingness to pay of $50,000 per quality-adjusted life-years. Implementation of early goal-directed therapy in the emergency department care of patients with severe sepsis is cost-effective.

12: Implementation of Early Goal-Directed Therapy and the Surviving Sepsis Campaign Resuscitation Bundle In Asia Is Associated With Decreased Mortality: Analysis of a Team Versus Non-Team Model of Care for the ATLAS Investigators

Evidence from America and Europe suggests that successful implementation of the Surving Sepsis Campaign severe sepsis resuscitation bundle including early goal-directed therapy is associated with significant outcome benefit. This study examines the impact of implementing such bundle in multiple Asian countries having team versus non-team models of care. The study is a multi-national, prospective interventional cohort of adult severe sepsis or septic shock patients presenting to the emergency department (ED) of 8 hospitals in Korea, Singapore, India, Taiwan, and China. Implementation of the bundle was divided into six quartiles from July 1, 2008 to December 31, 2009: Baseline, Education, and four Quality Improvement quartiles. Components of the bundle included: 1) lactate measured; 2) blood cultures prior to antibiotics; 3) fluid bolus given; 4) antibiotics by 3 hours; 5) achieve CVP > 8 mm Hg by 6 hours; and 6) achieve ScvO2 > 70% by 6 hours. Three hospitals with team model were championed by intensive care medicine, with initiation of the bundle in the ED and completion in the ICU setting by a focused multi-disciplinary team. Five hospitals with non-team model were championed by emergency medicine, with completion of the bundle in the ED as part of standard care. Five-hundred and fifty-seven patients were enrolled with age 61+/-18 yrs, APACHE II 22+/-8, lactate 4.7+/-3.2 mmol/L, 72% septic shock, 50% mechanical ventilation, and 31% Inhospital mortality. ED length of stay was 13+/-32 hours and hospital length of stay 13+/-14 days. Compliance to all items of the bundle was 13, 27, 38, 46, 49, and 55% (p=0.01) over the six quartiles of implementation. Comparing compliance in the first quartile to 6th quartile, hospitals with team increased from 38 to 76%, whereas hospitals with non-team increased from 3 to 29% (p<0.001). Throughout the study period, patients who received the entire bundle had mortality of 25%, compared to 34% mortality in patients who only received some components of the bundle (p=0.03). Baseline compliance to the severe sepsis resuscitation bundle is low in Asia and similar to other published data in Europe and America. Through education and quality improvement efforts, improved compliance and outcome benefit was achieved. A team model was more effective compared to a non-team model of implementation in achieving compliance.

175: Implementation of Early Goal-Directed Therapy: Which Components Are Not Performed?

175: Implementation of Early Goal-Directed Therapy: Which Components Are Not Performed?

Implementation of early goal-directed therapy for severe sepsis and septic shock: A decision analysis

Implementation of early goal-directed therapy for severe sepsis and septic shock: A decision analysis

Implementation of Early Goal-Directed Therapy for Severe Sepsis and Septic Shock: A Decision Analysis: Huang DT, Clermont G, Dremsizov TT, et al. Crit Care Med 2007;35:2090–100

Implementation of Early Goal-Directed Therapy for Severe Sepsis and Septic Shock: A Decision Analysis: Huang DT, Clermont G, Dremsizov TT, et al. Crit Care Med 2007;35:2090–100

Surviving sepsis in Scotland: is the emergency department ready?

The Surviving Sepsis Campaign (SSC) guidelines were established to improve outcomes for patients with severe sepsis. Early goal-directed therapy (EGDT) forms a key part of the SSC guidelines and has been shown to reduce mortality rates in septic shock. However, implementation of EGDT requires specific knowledge and skills. Provision of optimal emergency care for patients with severe sepsis necessitates provision of these skills in the emergency department (ED). In the United Kingdom, all patients must be treated in the ED and discharged or admitted within a 4-hour time target.

Implementation of early goal-directed therapy for severe sepsis and septic shock: A decision analysis

Early goal-directed therapy (EGDT) reduced mortality from septic shock in a single-center trial. However, implementation of EGDT faces several barriers, including perceived costs and logistic difficulties. We conducted a decision analysis to explore the potential costs and consequences of EGDT implementation. Estimates of effectiveness and resource use were based on data from the original trial and published sources. Implementation costs and lifetime projections were modeled from published sources and tested in sensitivity analyses. We generated incremental cost-effectiveness ratios from the hospital (short-term) and U.S. societal (lifetime) perspectives, excluding nonhealthcare costs, and applying a 3% annual discount. Simulation of an average U.S. emergency department. Total of 1,000 simulation cohorts (n = 263 for each cohort) of adult patients with severe sepsis/septic shock. EGDT under three alternative implementation strategies: emergency department-based, mobile intensive care unit team, and intensive care unit-based (after emergency department transfer). For an average emergency department, we estimated 91 cases per yr, start-up costs from $12,973 (intensive care unit-based) to $26,952 (emergency department-based), and annual outlay of $100,113. EGDT reduced length of stay such that net hospital costs fell approximately 22.9% ($8,413-$8,978). EGDT implementation had a 99.4% to 99.8% probability of being dominant (saved lives and costs) from the hospital perspective, and cost from $2,749 (intensive care unit-based) to $7019 (emergency department-based) per quality-adjusted life-yr with 96.7% to 97.7% probability of being <$20,000 per quality-adjusted life-yr from the societal perspective. The intensive care unit-based strategy was the least expensive, because of lower start-up costs, but also least effective, because of implementation delay, and all three strategies had similar cost-effectiveness ratios. Sensitivity analyses showed these estimates to be particularly sensitive to EGDT's effect on mortality and intensive care unit length of stay, but insensitive to other variables. EGDT has important start-up costs, and modest delivery costs, but assuming LOS and mortality are reduced, EGDT can be cost-saving to the hospital and associated with favorable lifetime cost-effectiveness projections.