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01-03-2013 | Original Article

Implementation of modified early-goal directed therapy for sepsis in the emergency center of a comprehensive cancer center

Authors: Katy M. Hanzelka, Sai-Ching J. Yeung, Gary Chisholm, Kelly Willis Merriman, Susan Gaeta, Imrana Malik, Terry W. Rice

Published in: Supportive Care in Cancer | Issue 3/2013

Abstract

Purpose

The investigation examines the impact of a standardized sepsis order set and algorithm utilizing non-invasive monitoring for early-goal directed therapy (EGDT) in an emergency center setting on the clinical outcomes of sepsis in cancer patients.

Methods

Single-center, retrospective study comparing clinical outcomes of sepsis before and after routine usage of a standardized order set and algorithm for non-invasive elements of EGDT for sepsis in an emergency center of a comprehensive cancer center. The outcomes measures evaluated were 28-day in-hospital mortality, intensive care unit length of stay, hospital length of stay, goal mean arterial pressure and urine output within the first 6 h of treatment, time to measurement of lactic acid, and appropriateness and timeliness of initial antibiotic therapy.

Results

The 28-day in-hospital mortality was significantly lower in the post-intervention group compared to the pre-intervention group (20 vs. 38 %, p = 0.005). The percentages of patients who reached their goal mean arterial pressure (74 vs. 90 %, p = 0.004) and goal urine output (79 vs. 96 %, p = 0.002) during the first 6 h of treatment were higher the after than the before group. No significant differences were detected in the rest of the outcome measures.

Conclusions

Implementation of a standardized sepsis order set and algorithm to improve compliance with the non-invasive elements of EGDT for sepsis in cancer patients in the emergency center setting was associated with a decreased 28-day in-hospital mortality rate.

Heron M, Hoyert DL, Murphy SL et al (2009) Deaths: final data for 2006. Natl Vital Stat Rep 57(14):1–134PubMed

Williams MD, Braun LA, Cooper LM et al (2004) Hospitalized cancer patients with severe sepsis: analysis of incidence, mortality, and associated costs of care. Crit Care 8(5):R291–R298PubMedCrossRef

Danai PA, Moss M, Mannino DM, Martin GS (2006) The epidemiology of sepsis in patients with malignancy. Chest 129(6):1432–1440PubMedCrossRef

Martin GS, Mannino DM, Eaton S et al (2003) The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 348(16):1546–1554PubMedCrossRef

Alberti C, Brun-Buisson C, Burchardi H et al (2002) Epidemiology of sepsis and infection in ICU patients from an international multicentre cohort study. Intensive Care Med 28(2):108–121PubMedCrossRef

Angus DC, Linde-Zwirble WT, Lidicker J et al (2001) Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 29(7):1303–1310PubMedCrossRef

Rivers E, Nguyen B, Havstad S et al (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345(19):1368–1377PubMedCrossRef

Dellinger RP, Levy MM, Carlet JM et al (2008) Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med 36(1):296–327PubMedCrossRef

Micek ST, Roubinian N, Heuring T et al (2006) Before–after study of a standardized hospital order set for the management of septic shock. Crit Care Med 34(11):2707–2713PubMedCrossRef

10.

Shapiro NI, Howell MD, Talmor D et al (2006) Implementation and outcomes of the multiple urgent sepsis therapies (MUST) protocol. Crit Care Med 34(4):1025–1032PubMedCrossRef

11.

Nguyen HB, Corbett SW, Steele R (2007) Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased morality. Crit Care Med 35(4):1105–1112PubMedCrossRef

12.

Kortgen A, Niederprum P, Bauer M (2006) Implementation of an evidenced-based “standard operating procedure” and outcome in septic shock. Crit Care Med 34(4):943–949PubMedCrossRef

13.

Sebat F, Johnson D, Musthafa AA et al (2005) A multidisciplinary community hospital program for early and rapid resuscitation of shock in nontrauma patients. Chest 127(5):1729–1743PubMedCrossRef

14.

Shorr AF, Micek ST, Jackson WL Jr et al (2007) Economic implications of an evidence-based sepsis protocol: can we improve outcomes and lower costs? Crit Care Med 35(5):1257–1262PubMedCrossRef

15.

Trzeciak S, Dellinger RP, Abate N et al (2006) Translating research to clinical practice: a 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department. Chest 129(2):225–232PubMedCrossRef

16.

Thiel SW, Asghar MF, Micek ST et al (2009) Hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis. Crit Care Med 37(3):819–824PubMedCrossRef

17.

Jones AE, Focht A, Horton JM, Kline JA (2007) Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock. Chest 132(2):425–432PubMedCrossRef

18.

Puskarich MA, Marchick MR, Kline JA et al (2009) 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. Crit Care 13(5):R167PubMedCrossRef

19.

Levy MM, Dellinger RP, Townsend SR et al (2010) The surviving sepsis campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med 38:367–374PubMedCrossRef

20.

Casserly B, Baram M, Walsh P et al (2011) Implementing a collaborative protocol in a sepsis intervention program: lesion learned. Lung 189:11–19PubMedCrossRef

21.

De Miguel-Yanes JM, Andueza-Lillo JA, Gonzalez-Ramallo VJ (2006) Failure to implement evidence-based clinical guidelines for sepsis at the ED. Am J Emerg Med 24(5):553–559PubMedCrossRef

22.

Cronshaw HL, Daniels R, Bleetman A et al (2011) Impact of the Surviving Sepsis Campaign on the recognition and management of severe sepsis in the emergency department: are we failing? Emerg Med J 28:670–675PubMedCrossRef

23.

Jones AE, Kline JA (2005) Use of goal-directed therapy for severe sepsis and septic shock in academic emergency departments. Crit Care Med 33(8):1888–1889PubMedCrossRef

24.

Nguyen HB, Oh J, Otero RM et al (2010) Standardization of severe sepsis management: a survey of methodologies in academic and community settings. J Emerg Med 38(2):122–130PubMedCrossRef

25.

Carlbom DJ, Rubenfeld GD (2007) Barriers to implementing protocol-based sepsis resuscitation in the emergency department—results of a national survey. Crit Care Med 35:2525–2532PubMedCrossRef

26.

Lyon RM, McNally SJ, Hawkins M et al (2010) Early goal-directed therapy: can the emergency department deliver? Emerg Med J 27:355–358PubMedCrossRef

27.

O’Neill R, Morales J, Jule M. Early goal-directed therapy for severe sepsis/septic shock: which components of treatment are more difficult to implement in a community-based emergency department? J Emerg Med 2012 doi:10.1016/j.jemermed.2011.03.024

28.

Mikkelsen ME, Gaieski DF, Goyal M et al (2010) Factors associated with nonadherence to early-goal directed therapy in the ED. Chest 138(3):551–558PubMedCrossRef

29.

Marik PE, Baram M, Vahid B (2008) Does the central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 134:172–178PubMedCrossRef

30.

Shapiro NI, Howell MD, Talmor D et al (2005) Serum lactate as a predictor of mortality in emergency department patients with infection. Ann Emerg Med 45(5):524–528PubMedCrossRef

31.

Trzeciak S, Dellinger RP, Chansky ME et al (2007) Serum lactate as a predictor of mortality in patients with infection. Intensive Care Med 33(6):970–977PubMedCrossRef

32.

Mikkelsen ME, Miltiades AN, Gaieski DF et al (2009) Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med 37(5):1670–1677PubMedCrossRef

33.

Mato AR, Luger SM, Heitjan et al (2010) Elevation in serum lactate at the time of febrile neutropenia in hemodynamically-stable patients with hematologic malignancies is associated with the development of septic shock within 48 hours. Cancer Biol Ther 9(8):585–589PubMedCrossRef

34.

Jones AE, Shapiro NI, Trzeciak S et al (2010) Lactate clearance vs. central venous oxygen saturation as goals of early sepsis therapy. JAMA 303(8):739–746PubMedCrossRef

35.

Nguyen HB, Rivers EP, Knoblich BP et al (2004) Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med 32(8):1637–1642PubMedCrossRef

36.

Arnold RC, Shapiro NI, Jones AE et al (2009) Multicenter study of early lactate clearance as a determinant of survival in patients with presumed sepsis. Shock 32(1):35–39PubMedCrossRef

37.

Hall WH, Ramachandran R, Narayan S, Jani AB, Vijayakumar S (2004) An electronic application for rapidly calculating Charlson comorbidity score. BMC Cancer 4:94PubMedCrossRef

38.

Ibrahim EH, Sherman G, Ward S et al (2000) The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest 118(1):146–155PubMedCrossRef

39.

Leibovici L, Shraga I, Drucker M et al (1998) The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection. J Intern Med 244(5):379–386PubMedCrossRef

40.

Iregui M, Ward S, Sherman G, Fraser VJ, Kollef MH (2002) Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. Chest 122(1):262–268PubMedCrossRef

41.

Kollef MH, Ward S, Sherman G et al (2000) Inadequate treatment of nosocomial infections is associated with certain empiric antibiotic choices. Crit Care Med 28(10):3456–3464PubMedCrossRef

42.

Kumar A, Roberts D, Wood KE, Light B et al (2006) Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinate of survival in human septic shock. Crit Care Med 34(6):1589–1596PubMedCrossRef

43.

Bagshaw SM, Lapinsky S, Dial S, Arabi Y et al (2009) Acute kidney injury in septic shock: clinical outcomes and impact of duration of hypotension prior to initiation of antimicrobial therapy. Intensive Care Med 35(5):871–881PubMedCrossRef

44.

Larche J, Azoulay E, Fieux F, Mesnard L et al (2003) Improved survival of critically ill cancer patients with septic shock. Intensive Care Med 29(10):1688–1695PubMedCrossRef

Title: Implementation of modified early-goal directed therapy for sepsis in the emergency center of a comprehensive cancer center
Authors: Katy M. Hanzelka
Sai-Ching J. Yeung
Gary Chisholm
Kelly Willis Merriman
Susan Gaeta
Imrana Malik
Terry W. Rice
Publication date: 01-03-2013
Publisher: Springer-Verlag
Published in: Supportive Care in Cancer / Issue 3/2013
Print ISSN: 0941-4355
Electronic ISSN: 1433-7339
DOI: https://doi.org/10.1007/s00520-012-1572-y

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