A Multidisciplinary Community Hospital Program for Early and Rapid Resuscitation of Shock in Nontrauma Patients

Sebat, Frank; Johnson, David; Musthafa, Amjad A.; Watnik, Mitchell; Moore, Sheva; Henry, Kristen; Saari, Mary

doi:10.1378/chest.127.5.1729

Cited by 123 publications

(78 citation statements)

References 51 publications

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“…Most studies excluded during the full-text review did not meet our criteria for a study of an RRS or were observational studies or review articles. For instance, Sebat et al 32 published a study of a "shock team" at a community hospital that intervened when any patient suffered nontraumatic shock; the study did not meet our inclusion criteria as all patients were admitted to the ICU, most directly from the emergency department. Another frequently cited study, by Bristow et al, 16 was excluded as it was a case-control study.…”

Section: Resultsmentioning

confidence: 99%

Effects of rapid response systems on clinical outcomes: Systematic review and meta‐analysis

Ranji

Auerbach

Hurd

et al. 2007

Journal of Hospital Medicine

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BACKGROUNDA rapid response system (RRS) consists of providers who immediately assess and treat unstable hospitalized patients. Examples include medical emergency teams and rapid response teams. Early reports of major improvements in patient outcomes led to widespread utilization of RRSs, despite the negative results of a subsequent cluster‐randomized trial.PURPOSETo evaluate the effects of RRSs on clinical outcomes through a systematic literature review.DATA SOURCESMEDLINE, BIOSIS, and CINAHL searches through August 2006, review of conference proceedings and article bibliographies.STUDY SELECTIONRandomized and nonrandomized controlled trials, interrupted time series, and before‐after studies reporting effects of an RRS on inpatient mortality, cardiopulmonary arrests, or unscheduled ICU admissions.DATA EXTRACTIONTwo authors independently determined study eligibility, abstracted data, and classified study quality.DATA SYNTHESISThirteen studies met inclusion criteria: 1 cluster‐randomized controlled trial (RCT), 1 interrupted time series, and 11 before‐after studies. The RCT showed no effects on any clinical outcome. Before‐after studies showed reductions in inpatient mortality (RR = 0.82, 95% CI: 0.74‐0.91) and cardiac arrest (RR = 0.73, 95% CI: 0.65‐0.83). However, these studies were of poor methodological quality, and control hospitals in the RCT reported reductions in mortality and cardiac arrest rates comparable to those in the before‐after studies.CONCLUSIONSPublished studies of RRSs have not found consistent improvement in clinical outcomes and have been of poor methodological quality. The positive results of before‐after trials likely reflects secular trends and biased outcome ascertainment, as the improved outcomes they reported were of similar magnitude to those of the control group in the RCT. The effectiveness of the RRS concept remains unproven. Journal of Hospital Medicine 2007;2:422–432. © 2007 Society of Hospital Medicine.

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Section: Resultsmentioning

confidence: 99%

Effects of rapid response systems on clinical outcomes: Systematic review and meta‐analysis

Ranji

Auerbach

Hurd

et al. 2007

Journal of Hospital Medicine

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“…20% of cases. Prior studies 2-8, [31][32][33][34][35] suggest that the observed mortality in the cohort would have been lower had EGDT been implemented effectively and these benefi ts appear to last beyond the initial hospitalization. 36 Despite significantly higher APACHE II scores in the EGDT-initiated group, their observed mortality was comparable to the EGDT non-initiated group, suggesting both a benefi t were decreasing in 98% (60/61) of the occult shock patients who did not receive EGDT; levels remained Ն 4 mmol/L in 25% (15/61) of cases.…”

Section: Discussionmentioning

confidence: 98%

Factors Associated With Nonadherence to Early Goal-Directed Therapy in the ED

Mikkelsen

Gaieski

Goyal

et al. 2010

Chest

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551 Severe sepsis and septic shock are associated with signifi cant morbidity and mortality. 1 Early goaldirected therapy (EGDT), a strategy of early hemodynamic optimization that targets central venous pressure (CVP), mean arterial pressure (MAP), and central venous oxygen saturation (Scv o 2 ) goals, reduced mortality when implemented in the ED of a single center. 2 Several observational studies have 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 defi ned as a serum lactate Ն 4 mmol/L or systolic BP , 90 mm Hg after volume resuscitation. EGDT initiation was defi ned 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 signifi cantly 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 5 .001), female sex of the clinician ( P 5 .041), serum lactate (rather than hemodynamic) criterion for EGDT ( P 5 .018), and nonconsultation to the Severe Sepsis Service ( P , .001). Conclusions: Despite a formalized protocol, we found that EGDT was underused. We identifi ed 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.

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“…6 Finally, due to our retrospective study design, we were unable to record details of fluid resuscitation such as whether the fluid was delivered with rapid and repeated fluid challenges, and whether the fluids were administered with resuscitation algorithms and according to physiological goals. 6,[21][22][23][24][25] The inability to control for potential imbalances in these factors limits our ability to identify possible associations between hospital mortality and increased quantity of fluid.…”

Section: Discussionmentioning

confidence: 99%

Resuscitating patients with early severe sepsis: A Canadian multicentre observational study

McIntyre

Fergusson

Cook

et al. 2007

Can J Anesth/J Can Anesth

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Background: Fluid resuscitation is a key factor in restoring hemodynamic stability and tissue perfusion in patients with severe sepsis. We sought to examine associations of the quantity and type of fluid administered in the first six hours after identification of severe sepsis and hospital mortality, intensive care unit (ICU) mortality, and organ failure. Methods:A retrospective, multicentre cohort study was undertaken at five Canadian tertiary care ICUs. We identified patients with severe sepsis admitted to the ICU between July 1, 2000, and June 30, 2002, using both administrative and clinical databases. Patients were included if they were hypotensive, had an infectious source, and at least two systemic inflammatory response syndrome criteria. We recorded total quantity and type of fluid administered for the first six hours after severe sepsis was identified. The first episode of hypotension defined the starting point for collection of fluid data. Multivariable regression analyses were performed to examine associations between quantity and type of fluid administered and hospital/ICU mortality, and organ failure.Results: Of 2,026 potentially eligible patient charts identified, 496 patients met eligibility criteria. The mean age and Acute Physiology and Chronic Health Evaluation score (APACHE II) were 61.8 ± 16.5 yr and 29.0 ± 8.0, respectively. No associations between quantity or type of fluid administered and hospital mortality or ICU mortality were identified, and there were no statistically significant associations between quantity or type of fluid administered and organ failure. However, more fluid resuscitation was associated with an increased risk of cardiovascular failure [odds ratio (OR) and 95% confidence interval Conclusion:An association between hospital mortality and quantity or type of fluid administered in the first six hours after the diagnosis of severe sepsis was not identifiable. These findings should be considered as hypothesis-generating and warrant confirmation or refutation by randomized controlled trials.

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A Multidisciplinary Community Hospital Program for Early and Rapid Resuscitation of Shock in Nontrauma Patients

Cited by 123 publications

References 51 publications

Effects of rapid response systems on clinical outcomes: Systematic review and meta‐analysis

Effects of rapid response systems on clinical outcomes: Systematic review and meta‐analysis

Factors Associated With Nonadherence to Early Goal-Directed Therapy in the ED

Resuscitating patients with early severe sepsis: A Canadian multicentre observational study

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