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Detroit, MI
Dr. Rivers is Senior Staff Attending, Departments of Emergency Medicine and Surgery, Director of Research, Department of Emergency Medicine, Henry Ford Hospital, Wayne State University.
Correspondence to: Emanuel P. Rivers, MD, MPH, FCCP, Henry Ford Hospital, CFP-270, 2799 W Grand Blvd, Detroit, MI 48202-2608; e-mail: erivers1{at}hfhs.org
Dr. Stephen Trzeciak and colleagues1 should be congratulated on their publication in CHEST (see page 225). November 8, 2005 was the fourth anniversary of the original publication of our article2 on early goal-directed therapy (EGDT) in severe sepsis and septic shock. In replicating this study, Trzeciak et al1 not only were the first to publish similar results to the original study; more importantly, they answered the frequently posed question of whether these results can be translated into reality.
EGDT is simply a protocol derived from components that have long been recommended as standard care for the septic patient in the setting of the ICU.3 The novelty of this protocol is that it is applied initially at patient presentation instead of at ICU admission. Therefore, EGDT was not an emergency department (ED) study or therapy; it was a study that provided "best care" to the sepsis patient as early as possible. This happened to be in the ED. In this more contemporary version of EGDT by Trzeciak et al,1 other recommended sepsis therapies including the use of recombinant activated protein C, corticosteroids, glucose control, and protective lung strategies were also included as standard operating procedures.4 These additional therapies perhaps contributed to an even greater mortality benefit of 16% that was realized in the original EGDT study.2
It is well recognized that sepsis outcomes are directly related to delays in diagnosis and treatment.5 The presence of shock during the first 24 h of hospital admission has been shown to be the best predictor for the need for mechanical ventilation.6 Levy et al7 recently published a clinical model that showed outcomes for patients with severe sepsis are closely related to early (baseline to day 1 here) improvement, or lack thereof, in organ function and clinical improvement on subsequent days may have little additional impact on the likelihood of survival and early changes in organ function. Thus, the hypothesis that providing hemodynamic optimization and other therapies at the most proximal point of hospital arrival instead of waiting until ICU admission would improve outcome is not a "rocket science" concept.2 In spite of the intuitive nature of the study (treat early not late) and reception of a level B recommendation (second highest) by the Surviving Sepsis Campaign,4 implementation still remains a challenge by some.8 The fact the EGDT is no longer a single-center study also reduces the number of places where some seek academic refuge (accept status quo) rather than doing the right thing for the patient.7
While this study revealed a similar mortality benefit shown by the original study, the question remained: can we do this at our hospital?8 Trzeciak et al1 went beyond the science and dealt with the "real-life" issues that included establishing a cooperative relationship between the ED and the ICU. This is significant and underappreciated by many who read the original publication. While the science and components of early hemodynamic optimization became the "lightening rod" for EGDT, the study was in reality a sepsis quality initiative. This seems to have escaped the scientific minds of those who have eagerly scrutinized the study. This sepsis quality initiative challenged a paradigm of practice that we all know exist. Septic patients wait in our EDs too long and receive too little care before ICU admission. Furthermore, timely care, even in the ICU, is not as good as we think.9 There are > 114 million ED visits per year; of these visits, approximately 350,000 are sepsis patients.10 This represents approximately 50% of the sepsis cases treated in hospitals per year in the United States, thus, the ED is a significant portal of entry and an obvious target for quality improvement.
In establishing a sepsis quality initiative, the first step is to confront reality and realize that the institution has a problem in how it processes septic patients from the ED to the ICU. Lundberg et al5 reminds us that it is problematic even at academic institutions. Once this reality is accepted, the following steps include: (1) creating early detection or screening for high-risk patients; (2) organizing and mobilizing resources to provide care once the patient is identified, whether ED or ICU; (3) providing a seamless and organized continuum of care from the ED to the ICU; (4) providing education of all involved personnel; and (5) feedback, quality assurance, assessing outcomes, and cost-effective analysis. This is the essence of what Trzeciak et al1 did in their study. They began with establishing a relationship with two departmental interfaces, the ED and the ICU. This ED-ICU relationship was initially recognized and recently solidified by the Surviving Sepsis Campaign.11 This relationship was essential for improving outcomes for acute myocardial infarction, stroke, and trauma, so it must not be overlooked in the care of the septic patient. All of these aforementioned diseases required similar implementation models to realize improved outcomes.
Reality television has captured the attention of many viewers because it deals with unscripted and uncensored life issues. Many times, clinical science publications, while well scripted and performed under meticulous research conditions, do not show the realities of implementation. All too often, scientific scrutiny and waiting for the perfect trial becomes a convenient excuse. In the case of EGDT, the reduction to practice of this concept requires significant effort, even though it makes common sense. This study is a perfect example of "implementation science" that successfully showed us how to reduce science to practice. This study has an originality of its own: it conquered reality.
Footnotes
Dr. Rivers has done consultant work for Biosite, Inc., Chiron, the Lilly Corporation, and Edwards Lifesciences over the last year. As a consultant, he helped advise the company in developing, but holds no patent rights to, catheters used for early, goal-directed therapy.
References
This article has been cited by other articles:
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  A D Reuben, A V Appelboam, I Higginson, J G Lloyd, and N I Shapiro Early goal-directed therapy: a UK perspective. Emerg. Med. J., November 1, 2006; 23(11): 828 - 832. [Abstract] [Full Text] [PDF]
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