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Failure to implement evidence-based clinical guidelines for sepsis at the ED.
Am J Emerg Med. 2006 Sep; 24(5):553-9.AJ

Abstract

OBJECTIVE

The main objective was to evaluate if consensus "bundle" measures to optimize the treatment of sepsis have been integrated in our routine practice. We also tried to identify variables significantly associated to mortality.

METHODS

An observational, unblinded study of those patients who, according to their physicians, met criteria for sepsis under its different stages of severity was conducted. Six items as proposed by surviving sepsis campaign were evaluated: (1) measurement of blood lactate; (2) obtaining blood samples for culture before use of antibiotics; (3) early use of antibiotics (>3 h); (4) fluid replacement with at least 20 mL/kg of crystalloids in the first hour, unless contraindicated, if hypotension or blood lactate >4 mmol/L; (5) use of vasoactive drugs, other than dopaminergic doses of dopamine, if hypotension or shock; (6) measurement of central venous pressure and central venous O2 saturation in shock. Data concerning several aspects of diagnosis, treatment, and consultation to ICU were collected.

RESULTS

Compliance with published guidelines is poor after evaluating the 6 items proposed: 12.5% of shocked patients had determinations of blood lactate; 15% of septic patients had no blood cultures drawn; 32% had received their first dose of antibiotics in the first 3 hours after admission; 46.6% of the cases of severe sepsis or shock received a fluid aggressive therapy; 43.3% of the patients with an indication for vasoactive drugs received them; no patient had central venous pressure monitoring at the ED. In addition, intensive care specialists were seldom consulted (17%). Having used dopaminergic doses of dopamine and having a respiratory focus as a source of infection were independently associated to mortality, respective OR: 21 ([1.7-254.9]; 95% CI) and 9.6 ([1.7-52]; 95% CI).

CONCLUSIONS

The "bundle" measures proposed in the surviving sepsis campaign seem not to have had enough impact in our ED. This is the start point of a "plan-do-study-act" process directed to improve the outcome of patients with sepsis at our institution.

Links

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Authors+Show Affiliations

De Miguel-Yanes JM
Emergency Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain. jdemiguel.hgugm@salud.madrid.org
Andueza-Lillo JA
No affiliation info available
González-Ramallo VJ
No affiliation info available
Pastor L
No affiliation info available
Muñoz J
No affiliation info available

MeSH

APACHEAdultAgedAged, 80 and overAnti-Bacterial AgentsClinical ProtocolsCritical CareDrug Utilization ReviewEmergency MedicineEmergency Service, HospitalEvidence-Based MedicineFemaleFluid TherapyGuideline AdherenceHumansLactic AcidLogistic ModelsMaleMiddle AgedOutcome and Process Assessment, Health CareSepsisShock, SepticSpainSurvival AnalysisVasodilator Agents

Pub Type(s)

Evaluation Study
Journal Article

Language

eng

PubMed ID

16938593

Citation

De Miguel-Yanes, José M., et al. "Failure to Implement Evidence-based Clinical Guidelines for Sepsis at the ED." The American Journal of Emergency Medicine, vol. 24, no. 5, 2006, pp. 553-9.
De Miguel-Yanes JM, Andueza-Lillo JA, González-Ramallo VJ, et al. Failure to implement evidence-based clinical guidelines for sepsis at the ED. Am J Emerg Med. 2006;24(5):553-9.
De Miguel-Yanes, J. M., Andueza-Lillo, J. A., González-Ramallo, V. J., Pastor, L., & Muñoz, J. (2006). Failure to implement evidence-based clinical guidelines for sepsis at the ED. The American Journal of Emergency Medicine, 24(5), 553-9.
De Miguel-Yanes JM, et al. Failure to Implement Evidence-based Clinical Guidelines for Sepsis at the ED. Am J Emerg Med. 2006;24(5):553-9. PubMed PMID: 16938593.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Failure to implement evidence-based clinical guidelines for sepsis at the ED. AU - De Miguel-Yanes,José M, AU - Andueza-Lillo,Juan A, AU - González-Ramallo,Víctor J, AU - Pastor,Luis, AU - Muñoz,Javier, PY - 2005/12/19/received PY - 2006/01/14/revised PY - 2006/01/15/accepted PY - 2006/8/30/pubmed PY - 2006/10/13/medline PY - 2006/8/30/entrez SP - 553 EP - 9 JF - The American journal of emergency medicine JO - Am J Emerg Med VL - 24 IS - 5 N2 - OBJECTIVE: The main objective was to evaluate if consensus "bundle" measures to optimize the treatment of sepsis have been integrated in our routine practice. We also tried to identify variables significantly associated to mortality. METHODS: An observational, unblinded study of those patients who, according to their physicians, met criteria for sepsis under its different stages of severity was conducted. Six items as proposed by surviving sepsis campaign were evaluated: (1) measurement of blood lactate; (2) obtaining blood samples for culture before use of antibiotics; (3) early use of antibiotics (>3 h); (4) fluid replacement with at least 20 mL/kg of crystalloids in the first hour, unless contraindicated, if hypotension or blood lactate >4 mmol/L; (5) use of vasoactive drugs, other than dopaminergic doses of dopamine, if hypotension or shock; (6) measurement of central venous pressure and central venous O2 saturation in shock. Data concerning several aspects of diagnosis, treatment, and consultation to ICU were collected. RESULTS: Compliance with published guidelines is poor after evaluating the 6 items proposed: 12.5% of shocked patients had determinations of blood lactate; 15% of septic patients had no blood cultures drawn; 32% had received their first dose of antibiotics in the first 3 hours after admission; 46.6% of the cases of severe sepsis or shock received a fluid aggressive therapy; 43.3% of the patients with an indication for vasoactive drugs received them; no patient had central venous pressure monitoring at the ED. In addition, intensive care specialists were seldom consulted (17%). Having used dopaminergic doses of dopamine and having a respiratory focus as a source of infection were independently associated to mortality, respective OR: 21 ([1.7-254.9]; 95% CI) and 9.6 ([1.7-52]; 95% CI). CONCLUSIONS: The "bundle" measures proposed in the surviving sepsis campaign seem not to have had enough impact in our ED. This is the start point of a "plan-do-study-act" process directed to improve the outcome of patients with sepsis at our institution. SN - 0735-6757 UR - https://www.unboundmedicine.com/medline/citation/16938593/Failure_to_implement_evidence_based_clinical_guidelines_for_sepsis_at_the_ED_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0735-6757(06)00023-4 DB - PRIME DP - Unbound Medicine ER -