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Protocol-Based Care for Septic Shock

Protocol-Based Care for Septic Shock

Until recently, the hospital mortality of patients with severe sepsis and septic shock was 50%. In 2001, a single-center ED study found that mortality in patients with severe sepsis or septic shock was significantly lower among those treated according to a 6-hour protocol of early goal-directed therapy (EGDT) than for those receiving standard therapy. That study involved a specific protocol in which intravenous fluids, vasopressors, inotropes, and blood transfusions were adjusted to reach central hemodynamic targets. “Many wondered if all the EGDT steps were needed and if changes in critical illness care have since altered the impact of the catheter-guided sepsis care,” says Donald M. Yealy, MD. To address this question, Dr. Yealy and colleagues designed a multicenter trial comparing alternative resuscitation strategies in patients with septic shock. Published in the New England Journal of Medicine, the study tested whether protocol-based resuscitation was superior to usual care. They also tested whether a protocol with central hemodynamic monitoring to guide treatments was superior to a simpler protocol that used bedside exams to trigger care. “We wanted to see if we could achieve better outcomes by simply recognizing septic shock early and treating it aggressively with fluids and vasopressors absent a catheter-based algorithm,” says Dr. Yealy. Key Findings Conducted in 31 U.S. EDs and in 1,351 enrollees, Dr. Yealy and colleagues randomly assigned patients with septic shock to one of three groups for 6 hours of resuscitation: 1. Protocol-based EGDT given by a dedicated two-person team. 2. Protocol-based standard therapy by the same team that did not require the placement of a central venous catheter, administration ofninotropes, or blood transfusions. 3....

Improving Sepsis Care in the ED

For patients with severe sepsis and septic shock in the ED, studies have shown that goal-directed therapy is effective. However, many EDs throughout the country have not implemented such protocols. In a recent study, a survey was conducted by investigators in New York. The purposes were to identify and address specific barriers to optimal sepsis treatment and to maximize benefits of implementing a planned sepsis treatment initiative. According to findings, several barriers to a quantitative resuscitation protocol for sepsis were identified, including: The inability to perform central venous pressure monitoring. The inability to perform central venous oxygen saturation monitoring. Limited physical space in the ED. Lack of sufficient nursing staff. Among nurses, the greatest perceived contributor to delays in treatment was a delay in diagnosis by physicians. For physicians, a delay in availability of ICU beds and nursing delays were the greatest barriers. The majority of respondents reported that written protocols would be helpful, even with these perceptions. The authors concluded that the knowledge gaps and procedural hurdles identified by their survey can help inform educational and process components for initiatives to improve sepsis care in the ED. Abstract: Journal of Emergency Nursing, November...

A Safety Program to Decrease SSIs

Surgical site infections (SSIs) are the most common complication facing colorectal surgery patients, occurring in 15% to 30% of cases. SSIs prolong hospitalization, increase readmissions, require subsequent treatment, affect quality of life, and increase healthcare costs to the tune of $1 billion annually. Research has not shown an association between adherence to well-known infection control process measures and substantial SSI reduction. While the occurrence of SSIs can never be fully eliminated in any feasible scheme, many can be prevented. Addressing SSIs as a Team In a study published in the August 2012 Journal of the American College of Surgeons, my colleagues and I found that physicians and nurses often feel as though they know what needs to be done to improve safety for colorectal surgery patients, but they feel disempowered. Using these perceptions as the basis for our study, we tested the implementation of a surgery-based comprehensive unit-based safety program (CUSP) designed to address SSIs. Participants in CUSP met monthly for as little as 1 hour in small groups of surgeons, nurses, operating room technicians, and anesthesiologists, along with a senior hospital executive who ensured access to necessary resources. CUSP team members identified six key interventions that were believed to help reduce SSIs: 1. Standardization of skin preparation. 2. Prescription of preoperative chlorhexidine showers. 3. Restricted use of by-mouth bowel cleansing solution before procedures. 4. Warming of patients in the pre-anesthesia area. 5. Adoption of enhanced sterile techniques for bowel and skin portions of the case. 6. Addressing lapses in prophylactic antibiotics. With a focus on these areas, simple safety checklists were created, and caregivers were urged to speak...

CDI: Making the Case for Better Prevention Efforts

Clostridium difficile infection (CDI) is a common and sometimes fatal healthcare–associated infection. It manifests as diarrhea that often recurs and can progress to toxic megacolon, sepsis, and death. “The incidence, mor­tality, and healthcare costs resulting from CDIs in hospitalized patients have reached historic highs,” says L. Clifford McDonald, MD, FACP, FSHEA. “CDI often occurs in patients in healthcare settings where antibiotics are prescribed and symp­tomatic patients are concentrated.” From 2000 to 2009, the number of hospitalized patients with any CDI discharge diagnoses more than doubled; the number with a primary CDI diagnosis more than tripled. “While the incidence of other healthcare-associated infections has declined, the incidence of CDI has increased,” Dr. McDonald says. Evidence-based guidelines are available for preventing CDI in hospitals, but the degree to which adherence to these guidelines can effectively help prevent these infections is unknown. Analyzing the Impact of CDI In the March 13, 2012 Morbidity & Mortality Weekly Report, Dr. McDonald and colleagues published a study that sought to identify healthcare exposures for CDI, determine the pro­portion of CDI occurring outside hospital settings, and assess whether prevention programs can effectively reduce CDI. The research team analyzed population-based data from the Emerging Infections Program as well as present-on-admission and hospital-onset, laboratory-identified CDI events that were reported to the National Healthcare Safety Network (NHSN). When analyzing data from the Emerging Infec­tions Program, 10,342 CDIs were identified. “Overall, 94% of all CDIs were related to various precedent and concurrent healthcare exposures,” says Dr. McDonald. “About three-fourths of CDIs had their onset occur outside of hospitals [Figure 1]. It should also be noted that some cases occurred in...
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