An emergency department sepsis protocol associated with sustained mortality benefit at two year foll

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An emergency department sepsis protocol
associated with sustained mortality benefit at
two year follow-up
Stenstrom R, Grafstein E, MacRedmond R, Dodek P,
Helmich E, Hollohan K, Nebre R, Innes G,
Schueyermeyer F, Hunte G, Harris D, Westman J,
Christenson J. Department of Emergency Medicine
and Department of Critical Care, St Pauls
Hospital Vancouver. University of British
Columbia, Vancouver BC, Canada.
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BACKGROUND

• Over 700,000 cases of severe sepsis/year
• Leading cause of death in non-coronary ICUs

28 day Mortality
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BACKGROUND

• Delays in fluids and antibiotics associated with
  increased mortality
• ED unable to perform invasive monitoring
• Implementation of ED protocol shown to save lives
  in many settings, including St Pauls

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OBJECTIVE

• To compare mortality for two years following ED
  diagnosis of severe sepsis or septic shock before
  and after the implementation of the sepsis
  protocol at St Pauls Hospital

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St Pauls Severe Sepsis/Septic Shock Study

• DESIGN
• Cohort study Before-after design
• SETTING
• St Pauls Hospital Vancouver British Columbia,
  Canada. A tertiary care inner city ED with
  65,000 patient visits per year

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1. Severe sepsis or septic shock2. BC
Resident3. No DNR 4. Admitted directly to ICU
from emergency department
Inclusion and Exclusion Criteria
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Sepsis
Infection
Severe Sepsis
Sepsis with ?1 organ failure OR lactate gt 4.0

• ? 2 SIRS infection
• Temperature ?38oC or ?36oC
• HR ?90 beats/min
• Respirations ?20/min
• Altered mental status (GCS lt 15)

Infection Inflammatory response to
microorganisms, or Invasion of normally sterile
tissues
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Procedure

• Protocol implemented July 2005
• Random sampling of ED patients meeting inclusion
  criteria between February 2003 and May 2005
  (BEFORE GROUP)
• Random sampling of ED patients meeting inclusion
  criteria between October 2005 and July 2006
  (AFTER GROUP)
• Minimum 2 year follow-up by linkage to BC
  Provincial Vital Statistics Database - provides
  date and cause of death

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Outcome

• All cause mortality

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Results Subject Characteristics
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Results Survival analysis
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Limitations

• Before after study design and secular trends
• Which components of protocol?
• Sustained benefit?

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Conclusion

• Implementation of an ED sepsis protocol
  demonstrated a sustained, 2 year mortality
  benefit in patients with severe sepsis and septic
  shock.

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Thank you!
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