Clinical Review

Early Recognition: The Rate-Limiting Step to Quality Care for Severe Sepsis Patients in the Emergency Department

Journal of Clinical Outcomes Management. 2015 May;22(5)

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The 2014 randomized trial of Protocol-Based Care for Early Septic Shock (ProCESS) revisited this concept, comparing the Rivers 2001 protocol to both a current guideline-based non-invasive algorithmic protocol and what had become usual ED care in the interim [54]. The ProCESS trial, which operationalized a team of bedside providers to direct care for each of the 3 distinct arms, found no significant difference between the arms in terms of 90-day and 1-year mortality, but mortality was approximately 10% less in all arms compared with the intervention arm of the Rivers trial. Further, subjects in each of the 3 arms received in excess of 2 L intravenous fluid resuscitation pre-randomization and 4.4–5.5 L when resuscitation spanned from pre-randomization to 6 hours post-randomization. The conclusion drawn is that the commonalities between the arms—early fluid resuscitation, early antibiotics, and the option to use physiologic measures as markers of the adequacy of treatment, all guided by bedside ED providers—are the most important factors for surviving sepsis. And the result is that practitioners have refined these tools over a decade, leading to steady improvements in survival.

Consistent with the ProCESS trial, a recent Australia and New Zealand trial confirmed no significant difference in 90-day mortality between protocolized EGDT and current usual care for septic shock within an ED [55]. Consistent with ProCESS and ProMISe [56], subjects enrolled in ARISE received in excess of 2.5 L in resuscitation pre-randomization, which when paired with fluid resuscitation in the 0-6 hour post-randomization period (1.96 L in the EGDT arm and 1.71 in the usual-care arm) resulted in resuscitation in the 4.5 to 5L range during the initial resuscitation. The ARISE trial was unique in that appropriate antibiotic administration was a requirement prior to randomization, ensuring that this important driver of mortality reduction was standardized between the two arms of the trial. In summary, while the ideal fluid resuscitation amount is unknown, requires a personalized approach, and further investigation is required to effectively incorporate non-invasive measures to guide fluid responsiveness, early and aggressive resuscitation paired with early antibiotic administration are essential aspects of effective sepsis management.

The Efferent Arm: Structure And Processes To Improve Outcomes

The efferent arm of the system, beyond risk stratification, requires the implementation of optimal staffing and processes to care for the septic patient. While options will vary, preparation is a requisite, as are strategies that efficiently lead the clinician at the bedside to the use of evidence-based medicine ( Table 2 ).

Personnel and Staffing

Quality care for the septic patient requires immediate availability of a multidisciplinary care team, including physicians and nurses with critical care experience who can be rapidly deployed to the bedside. The location of care provision may include on-going care in the initial ED room assignment or transfer to a dedicated area for the care of the critically ill patient within the ED.

To provide optimal care in the era of overcrowding and delayed transfer to an ICU, a movement towards ED intensive care units (ED-ICUs) has emerged [57]. The models of practice range from a model based upon ED intensivists, with expertise in critical care medicine, providing care within the traditional structure of an ED, to a model wherein a portion of the ED is assigned for the care of the critically ill for extended periods of time beyond the initial resuscitation. As these models mature from resuscitation bays capable of scaling up based on need to dedicated ED-ICUs, investments in shared Unit leadership (physician and nursing), staffing (physician, critical care nursing, respiratory therapy, critical care pharmacist) and processes of care (eg, multidisciplinary rounds) in line with established ICUs will be necessary.