title: Factors associated with nonadherence to early goal-directed therapy in the ED.
abstract: BACKGROUND
  Protocol-driven early goal-directed therapy (EGDT) has been shown to reduce mortality in patients with severe sepsis and septic shock in the ED. EGDT appears to be underused, even in centers with formalized protocols. The aim of our study was to identify factors associated with not initiating EGDT in the ED.
  
  
  METHODS
  This was a cohort study of 340 EGDT-eligible patients presenting to a single center ED from 2005 to 2007. EGDT eligibility was defined as a serum lactate >or= 4 mmol/L or systolic BP< 90 mm Hg after volume resuscitation. EGDT initiation was defined as the measurement of central venous oxygen saturation via central venous catheter. Multivariable logistic regression was used to adjust for potential confounding.
  
  
  RESULTS
  EGDT was not initiated in 142 eligible patients (42%). EGDT was not completed in 43% of patients in whom EGDT was initiated. Compliance with the protocol varied significantly at the physician level, ranging from 0% to 100%. Four risk factors were found to be associated independently with decreased odds of initiating EGDT: female sex of the patient (P = .001), female sex of the clinician (P = .041), serum lactate (rather than hemodynamic) criterion for EGDT (P = .018), and nonconsultation to the Severe Sepsis Service (P < .001).
  
  
  CONCLUSIONS
  Despite a formalized protocol, we found that EGDT was underused. We identified potential barriers to the effective implementation of EGDT at the patient, clinician, and organizational level. The use of a consultation service to facilitate the implementation of EGDT may be an effective strategy to improve protocol adherence.
authors.affiliation: Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA 19104, USA. mark.mikkelsen@uphs.upenn.edu
authors.forename: Mark E
authors.initials: ME
authors.lastname: Mikkelsen
authors.forename: David F
authors.initials: DF
authors.lastname: Gaieski
authors.forename: Munish
authors.initials: M
authors.lastname: Goyal
authors.forename: Andrea N
authors.initials: AN
authors.lastname: Miltiades
authors.forename: Jeffrey C
authors.initials: JC
authors.lastname: Munson
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Pines
authors.forename: Barry D
authors.initials: BD
authors.lastname: Fuchs
authors.forename: Chirag V
authors.initials: CV
authors.lastname: Shah
authors.forename: Scarlett L
authors.initials: SL
authors.lastname: Bellamy
authors.forename: Jason D
authors.initials: JD
authors.lastname: Christie
mesh_terms: D000328:Adult; D000368:Aged; D001784:Blood Gas Analysis; D002985:Clinical Protocols; D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D019983:Guideline Adherence / Q000458:organization & administration*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D018802:Patient-Centered Care / Q000458:organization & administration*; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D012307:Risk Factors; D018805:Sepsis / Q000209:etiology / Q000401:mortality / Q000628:therapy*