Chest
Volume 138, Issue 3, September 2010, Pages 551-558
Journal home page for Chest

Original Research
Critical Care Medicine
Factors Associated With Nonadherence to Early Goal-Directed Therapy in the ED

https://doi.org/10.1378/chest.09-2210Get rights and content

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 defined as a serum lactate ≥ 4 mmol/L or systolic BP< 90 mm Hg after volume resuscitation. EGDT initiation was defined 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 significantly 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 = .001), female sex of the clinician (P = .041), serum lactate (rather than hemodynamic) criterion for EGDT (P = .018), and nonconsultation to the Severe Sepsis Service (P < .001).

Conclusions

Despite a formalized protocol, we found that EGDT was underused. We identified 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.

Section snippets

Materials and Methods

The Institutional Review Board of the University of Pennsylvania approved the study with an informed consent waiver. This was a retrospective cohort study of EGDT-eligible patients admitted through the University of Pennsylvania ED between 2005 and 2007. In late 2004, our ED institutionalized a Severe Sepsis protocol to identify and treat all EGDT-eligible patients. EGDT eligibility was defined as a serum lactate ≥ 4 mmol/L in hemodynamically stable patients (occult shock) or systolic BP < 90

Baseline Characteristics

The EGDT-eligible cohort included 340 adults (Fig 1). The age range of the cohort was 18 to 101 years and 54% were men. Septic shock was the criterion for EGDT in 183 patients (54%); 157 (46%) fulfilled occult shock criteria.

EGDT was not initiated in 142 patients (42%). The EGDT group (n = 198) received more IV fluids (P < .001), vasoactive agents (P < .001), and central venous catheterizations (P < .001) (Table 2). The inhospital mortality rate was 33% in the EGDT-initiated group and 30% in

Discussion

In this single-center cohort study, we found that EGDT was not initiated in 42% of eligible patients and was incomplete in 43% of patients in whom EGDT was initiated. We identified potential barriers to the initiation of EGDT at the patient, clinician, and organizational level. At the patient level, sex and severity of illness appeared to influence the decision to initiate EGDT. We found that the rate of EGDT use varied widely at the physician level and the sex of the physician appeared to

References (42)

  • NI Shapiro et al.

    Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol

    Crit Care Med

    (2006)
  • A Kortgen et al.

    Implementation of an evidence-based “standard operating procedure” and outcome in septic shock

    Crit Care Med

    (2006)
  • ST Micek et al.

    Before-after study of a standardized hospital order set for the management of septic shock

    Crit Care Med

    (2006)
  • RP Dellinger et al.

    Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

    Crit Care Med

    (2004)
  • Institute of Medicine

    Crossing the Quality Chasm: A New Health System for the 21st Century

    (2001)
  • MD Cabana et al.

    Why don't physicians follow clinical practice guidelines? A framework for improvement

    JAMA

    (1999)
  • GD Rubenfeld et al.

    Barriers to providing lung-protective ventilation to patients with acute lung injury

    Crit Care Med

    (2004)
  • R Kalhan et al.

    Underuse of lung protective ventilation: analysis of potential factors to explain physician behavior

    Crit Care Med

    (2006)
  • ME Mikkelsen et al.

    Potential reasons why physicians underuse lung-protective ventilation: a retrospective cohort study using physician documentation

    Respir Care

    (2008)
  • NJ Umoh et al.

    Patient and intensive care unit organizational factors associated with low tidal volume ventilation in acute lung injury

    Crit Care Med

    (2008)
  • AE Jones et al.

    Use of goal-directed therapy for severe sepsis and septic shock in academic emergency departments

    Crit Care Med

    (2005)
  • Cited by (0)

    Funding/Support: This study was supported in part by the National Institutes of Health, National Heart, Lung and Blood Institute, Bethesda, MD [Training Grant T32 HL07891].

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

    View full text