title: Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock.
abstract: OBJECTIVE
  To determine the clinical effectiveness of implementing early goal-directed therapy (EGDT) as a routine protocol in the emergency department (ED).
  
  
  METHODS
  Prospective interventional study conducted over 2 years at an urban ED. Inclusion criteria included suspected infection, criteria for systemic inflammation, and either systolic BP < 90 mm Hg after a fluid bolus or lactate concentration >/= 4 mol/L. Exclusion criteria were age < 18 years, contraindication to a chest central venous catheter, and need for immediate surgery. We prospectively recorded preintervention clinical and mortality data on consecutive, eligible patients for 1 year when treatment was at the discretion of board-certified emergency physicians. We then implemented an EGDT protocol (the intervention) and recorded clinical data and mortality rates for 1 year. Prior to the first year, we defined a 33% relative reduction in mortality (relative mortality reduction that was found in the original EGDT trial) to indicate clinical effectiveness of the intervention.
  
  
  RESULTS
  We enrolled 79 patients in the preintervention year and 77 patients in the postintervention year. Compared with the preintervention year, patients in the postintervention year received significantly greater crystalloid volume (2.54 L vs 4.66 L, p < 0.001) and frequency of vasopressor infusion (34% vs 69%, p < 0.001) during the initial resuscitation. In-hospital mortality was 21 of 79 patients (27%) before intervention, compared with 14 of 77 patients (18%) after intervention (absolute difference, - 9%; 95% confidence interval, + 5 to - 21%).
  
  
  CONCLUSIONS
  Implementation of EGDT in our ED was associated with a 9% absolute (33% relative) mortality reduction. Our data provide external validation of the clinical effectiveness of EGDT to treat sepsis and septic shock in the ED.
authors.affiliation: Assistant Director of Research, Department of Emergency Medicine, 1000 Blythe Blvd, MEB 304e, Carolinas Medical Center, Charlotte, NC 28203, USA. alan.jones@carolinas.org
authors.forename: Alan E
authors.initials: AE
authors.lastname: Jones
authors.forename: Anne
authors.initials: A
authors.lastname: Focht
authors.forename: James M
authors.initials: JM
authors.lastname: Horton
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Kline
mesh_terms: D002985:Clinical Protocols; D004636:Emergency Service, Hospital; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends*; D006786:Hospitals, Urban; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods* / Q000401:mortality; D012772:Shock, Septic / Q000401:mortality / Q000628:therapy*; D016896:Treatment Outcome; D014505:Urban Population; D014662:Vasoconstrictor Agents / Q000008:administration & dosage*
chemical_list: D014662:Vasoconstrictor Agents