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Original Research: CRITICAL CARE MEDICINE |

Prospective External Validation of the Clinical Effectiveness of an Emergency Department-Based Early Goal-Directed Therapy Protocol for Severe Sepsis and Septic Shock*

Alan E. Jones, MD; Anne Focht, RN, MSN; James M. Horton, MD; Jeffrey A. Kline, MD
Author and Funding Information

*From the Department of Emergency Medicine (Drs. Jones and Kline), Clinical Care Management (Ms. Focht), and Department of Internal Medicine (Dr. Horton), Carolinas Medical Center, Charlotte, NC.

Correspondence to: Alan E. Jones, MD, Assistant Director of Research, Department of Emergency Medicine, 1000 Blythe Blvd, MEB 304e, Carolinas Medical Center, Charlotte, NC 28203; e-mail: alan.jones@carolinas.org



Chest. 2007;132(2):425-432. doi:10.1378/chest.07-0234
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Objective: To determine the clinical effectiveness of implementing early goal-directed therapy (EGDT) as a routine protocol in the emergency department (ED).

Methods: Prospective interventional study conducted over 2 years at an urban ED. Inclusion criteria included suspected infection, criteria for systemic inflammation, and either systolic BP < 90 mm Hg after a fluid bolus or lactate concentration ≥ 4 mol/L. Exclusion criteria were age < 18 years, contraindication to a chest central venous catheter, and need for immediate surgery. We prospectively recorded preintervention clinical and mortality data on consecutive, eligible patients for 1 year when treatment was at the discretion of board-certified emergency physicians. We then implemented an EGDT protocol (the intervention) and recorded clinical data and mortality rates for 1 year. Prior to the first year, we defined a 33% relative reduction in mortality (relative mortality reduction that was found in the original EGDT trial) to indicate clinical effectiveness of the intervention.

Results: We enrolled 79 patients in the preintervention year and 77 patients in the postintervention year. Compared with the preintervention year, patients in the postintervention year received significantly greater crystalloid volume (2.54 L vs 4.66 L, p < 0.001) and frequency of vasopressor infusion (34% vs 69%, p < 0.001) during the initial resuscitation. In-hospital mortality was 21 of 79 patients (27%) before intervention, compared with 14 of 77 patients (18%) after intervention (absolute difference, − 9%; 95% confidence interval, + 5 to − 21%).

Conclusions: Implementation of EGDT in our ED was associated with a 9% absolute (33% relative) mortality reduction. Our data provide external validation of the clinical effectiveness of EGDT to treat sepsis and septic shock in the ED.

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