Early Goal-Directed Therapy: Improving Mortality and Morbidity of Sepsis in the Emergency Department

Background: The growing number of patients with severe sepsis or septic shock and the resulting mortality rate (30%) require changes in the current protocols used to treat these conditions. Through adaptation of early goal-directed therapy (EGDT), Carolinas Medical Center developed a process improvement strategy for decreasing mortality associated with severe sepsis and septic shock. Before implementing the EDGT protocol, the ED did not follow a written management protocol for septic patients. Methods: Following establishment of an interdisciplinary team, several process improvement activities were conducted, including the development of a standardized algorithm and treatment protocol, a physician order sheet, a nursing flow sheet, and a code sepsis response team. Results: A total of 381 patients were enrolled: 79 in the pre-intervention phase and 302 in the postintervention phase. Mortality rates decreased from 27% pre-intervention to 19% postintervention (-8% absolute mortality; 95% confidence interval [C. I.], 7-9; p = .2138). There were significant differences between the pre-and postintervention groups for endotracheal intubation (17%, p = .0012), crystalloid infusion (1.4 L, p < .0001), vasopressor administration (33%, p <.0001), and packed red blood cells (34%, p < .0001). Both groups were generally similar in their demographics, comorbidities, and vital signs. Discussion: As a result of this process improvement initiative, patients who might have received delayed and/or inadequate treatment for severe sepsis or septic shock are now receiving effective, life-saving treatment. Because of the emphasis on training, consistency in applying the protocol, relatively few changes in current ED practice, and low direct expenditures for equipment, the protocol can be easily integrated into existing ED environments to allow hospitals to quickly implement this successful, best-practice program.