The Gist: Over the past decade, the Surviving Sepsis Campaign and Early Goal-Directed Therapy have altered the perception and management of sepsis These guidelines and other crucial ED interventions change frequently, as evidenced by upcoming changes to the sepsis guidelines. Yet, differences remain between academic and community settings in the implementation of these protocols. With the help of FOAM there is hope in closing the disparity!
I've completed nearly all of my third year clerkships at two community hospitals that serve a rather large, multi-state rural catchment area (the primary hospital's ED has >57,000 visits/year). The clinical experience is incredible and I train with outstanding, bright physicians. As I follow podcasts, blogs, and tweets, however, I've discovered that the academic accepted "standard of care" or "best practice" often differs from community practice. I was dismayed to find that our EDs don't use waveform capnography in intubations/procedural sedation, use ultrasound outside of FAST or vascular access, and only initiated post-arrest hypothermia within the past few months. (Note: I dislike referring to community and academic EDs in such a homogeneous fashion, as I'm aware there is quite a spectrum of practice, but these terms align with current discourse and seemed suitable.)
The paper that got me thinking: Early Goal-directed Therapy (EGDT) for Severe Sepsis/Septic Shock: Which Components of Treatment are More Difficult to Implement in a Community-based Emergency Department?
- Assesses the results after implementation of an EGDT protocol for severe sepsis and septic shock in a community hospital (>65,000 visits/year) from 2008-2009.
- 66/85 patients received antibiotics in first hour
- 58/85 patients received a 2L fluid bolus in first hour (68%)
- These patients were more likely to survive to hospital discharge
- 79% (n=50) of patients needing vasopressors received these drugs.
- Central line in 55/85 patients (65%, 95% CI 54–74%)
- CVP recorded in the ED 23/85 patients (27%, 95% CI 18–36%).
- ScvO2 (central venous oxygen saturation) measured in 13/85 patients
But what do these results really point to?
- This paper found that the most invasive components (A-lines, central lines) of their resuscitation bundle were followed less frequently. The authors concluded that this may have partially resulted from providers/staff feeling uncomfortable with these invasive procedures. This rationalization seems odd as this community based ED also houses an EM residency program, but this is one of the most frequently cited challenges to sepsis protocol (solution = procedure hungry medical students?).
- Furthermore, the CVP and ScvO2 were rarely recorded, even in the presence of a central line. The CVP has been pretty much discarded, but the ScvO2? Did these providers get the information they needed to direct therapy in other ways? If so, it's not documented in this article. It's also unlikely, given that the Jones article in JAMA on lactate clearance wasn't published until 2010.
- The fluid resuscitation goal of at least 2L of fluids in the first hour was only met in 68% of the patients. This goal was pre-determined and didn't focus on patient response to boluses. This is one of the seemingly easiest measures to implement and, in this particular patient population, was associated with a mortality benefit.
Is there a solution?
By following EM literature and updates in an asynchronous and self-directed method, I see great alternatives/solutions to some of these issues and barriers. For example, EMCrit's CME option could act as an incentive/inspiration for community doctors to implement cutting edge EM locally...while satisfying required CME (see real-life example on PHARM podcast below).
- Really understand the importance of sepsis and champion excellent, early sepsis care. Parts I, II, and III from EMCrit (with Dr. Rivers himself).
- I admit that I kept these videos on my iPhone/computer for quite some time before I ran out of my favorite podcasts and needed something to get me through a workout. Sepsis just didn't seem as sexy as all of the airway and trauma talk but this definitely changed my perspective and the videos are quite good...I think I'm probably not alone in my initial attitude (especially if you look at the compliance rate with the severe sepsis protocol in the above study). To entice other medical students there's a Septris game from Stanford.
- Assessing Fluid Responsiveness with Ultrasound and Passive Leg Raise. Courtesy of the amazing Ultrasound Podcast parts 1 and 2. Only have a minute and a smart phone?
- Lactate Clearance! The use of non-invasive sepsis protocols that use lactate clearance instead of ScvO2 are somewhat controversial but, in any case, are better than not measuring either (referencing above study), especially in your less sick severe sepsis patients. Dr. Scott Weingart's EMCrit site has non-invasive sepsis protocols and answers to popular questions about lactate. I first learned about this on the excellent EMCrit Podcast 22.
- What about pressors? Free Emergency Medicine Talks comes through again with Dr. Evie Marcolini's lecture on pressor choice. She also has a talk on antibiotic choice in sepsis.
- Want to put it all together? Dr. Weingart has an entire Severe Sepsis Protocol available.
Beyond sepsis...the podcast that kept me thinking:
There is hope for clinician driven change in the community-based setting.
- I found inspiration in a recent episode #16 of the PHARM podcast on delayed sequence intubation (DSI) where Dr. Rob Bryant shares his experience implementing DSI in the community setting. He shared his DSI protocols with others via PHARM and EMCrit. It is truly amazing to see such dissemination of knowledge and experience, flattening the playing ground for clinicians.
O'Neill R, Morales J, Jule M. Early Goal-directed Therapy (EGDT) for Severe Sepsis/Septic Shock: Which Components of Treatment are More Difficult to Implement in a Community-based Emergency Department? Journal of Emergency Medicine. Volume 42, Issue 5, May 2012, Pages 503–510