One year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study.
BACKGROUND
Early structured resuscitation of severe sepsis has been suggested to improve short term mortality; however, no previous study has examined the long-term effect of this therapy. We sought to determine one year outcomes associated with implementation of early goal directed therapy (EGDT) in the emergency department (ED) care of sepsis.


METHODS
We performed a longitudinal analysis of a prospective before and after study conducted at a large urban ED. Adult patients were enrolled if they had suspected infection, 2 or more systemic inflammatory response criteria, and either systolic blood pressure (SBP) <90 mmHg after a fluid bolus or lactate >4 mM. Exclusion criteria were: age <18 years, no aggressive care desired, or need for immediate surgery. Clinical and outcomes data were prospectively collected on consecutive eligible patients for 1 year before and 2 years after implementing EGDT. Patients in the pre-implementation phase received non-protocolized care at attending physician discretion. The primary outcome was mortality at one year.


RESULTS
285 subjects, 79 in the pre- and 206 in the post-implementation phases, were enrolled. Compared to pre-implementation, post-implementation subjects had a significantly lower ED SBP (72 vs. 85 mm Hg, P < 0.001) and higher sequential organ failure assessment score (7 vs. 5, P = 0.0004). The primary outcome of 1 year mortality was observed in 39/79 (49%) pre-implementation subjects and 77/206 (37%) post-implementation subjects (difference 12%; P = 0.04).


CONCLUSIONS
Implementation of EGDT for the treatment of ED patients with severe sepsis and septic shock was associated with significantly lower mortality at one year.
Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, North Carolina 28203, USA. mike.puskarich@carolinas.org
Michael A
MA
Puskarich
Michael R
MR
Marchick
Jeffrey A
JA
Kline
Michael T
MT
Steuerwald
Alan E
AE
Jones
D000328:Adult; D000368:Aged; D002985:Clinical Protocols; D003422:Critical Care / Q000379:methods; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009657:North Carolina / Q000453:epidemiology; D011446:Prospective Studies; D012720:Severity of Illness Index; D012772:Shock, Septic / Q000401:mortality* / Q000628:therapy*