Wednesday, July 09, 2008

Why haven’t we done a better job of implementing early goal directed therapy?

Last December the journal Critical Care ran a supplement on the treatment of sepsis focusing on activated protein C. One article I found useful was a general overview of sepsis management. It gave an insightful analysis on putting best evidence into practice. That seems to be a particularly difficult task when it comes to early goal directed therapy (EGDT).

With the exception of timely and appropriate antibiotic therapy EGDT is the most robust of the measures advocated in the Surviving Sepsis Campaign. Despite that fact, as well as the fact that it’s been several years since publication of Rivers’s classic paper validating EGDT, implementation is not as widespread as it should be. Even after all these years we seem to be in the talking stage of implementation. Why?

Barriers to implementation are both institutional and cultural. I mentioned the institutional barriers before. Briefly, when it’s not a “core measure” that will show up on public report cards it’s difficult to convince a hospital to commit resources. (Unfortunately, hospital administrators probably don’t realize that EGDT shortens ICU stay and can save money). Should EGDT become a publicly reported core measure? I doubt it. Think of the unintended consequences---hasty and ill advised central lines, transfusions and inotropes come to mind.

A significant cultural barrier may exist in the emergency department, where EGDT, or at least its initial phase, is supposed to be carried out. But with the current concerns over ED crowding the big push nowadays is “throughput.” Just read emergency medicine professor Richard Bukata’s rant on ED crowding in a recent piece from Emergency Medicine News:

The philosophy is to sacrifice the ED and its patients for the sake of the rest of the hospital. Until recently, the perceived consequence of this decision was to reinforce the general beliefs of the community that EDs are associated with long waits and a litany of other indignities.

ED staff become frustrated and exasperated because it seems they are powerless to change the situation. The concept that excess patients are, in reality, a hospital challenge rather than simply an ED challenge has been a tough sell when you look at the typically impotent actions taken to address the problem.


…why aren't regulatory agencies interested in the problem? It is obviously dangerous to be working in an environment that is substantially over capacity. It is obviously a problem when ED patients wait hours to see a doctor. It is obviously a problem when the rate of patients leaving the ED without being seen is five percent to 10 percent. With the mantra of patient safety on everyone's lips, how can these obvious problems be overlooked? It would be one thing if there were truly nothing that could be done, but this is fundamentally untrue. There are myriad solutions that have been demonstrated to facilitate turnaround times in the ED. It requires the hospital leadership (both medical staff and administration) to have the stomach to make some hard and not-so-hard

Why not offer incentives? If the CEO's annual bonus were linked to ED patient throughput, it is guaranteed that most hospitals would see their problem solved. This may sound like an inflammatory statement, but truly, the only one who can fix the ED problem is the CEO. It is a top-down initiative. Driven by money or fear, it can be fixed. Money has already been suggested; make it a criterion for the bonus, and watch what happens. But what about fear? For all practical purposes, the most feared entity in the hospital world is the Joint Commission, and its ability to shut down a hospital gives it unprecedented clout. So why hasn't the Joint Commission taken on the hospitals, given its passion for patient safety and multiple initiatives in this matter? The crowded ED is a blatant patient safety issue, much more so than medication reviews by pharmacists, medication reconciliation, time-outs, or two patient IDs.

Clearly safety concerns surrounding ED crowding may, in the minds of some, be in conflict with other quality and safety goals including the implementation of EGDT. The notion that some patients, even after being designated for admission, should remain in the department for an extended time to receive ongoing treatment may be foreign to some ED types. In Rivers’s original study the entire six hours of EGDT were delivered by the ED (the intensivists in the ICU were blinded to the type of ED treatment patients received). Such an arrangement would be impractical in many departments and undoubtedly evoke howls of protest from ED personnel.

Although the review cites evidence of poor ED adherence to sepsis guidelines (one example here) this paper reports successful ED implementation. In most institutions collaboration across hospital departments works best. Initial rapid screening can be done in the ED. If the patient is eligible for EGDT a sepsis page is sent. A sepsis team presents and initiates therapy. The protocol continues in the department until an ICU bed is available.

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