Mid-Level Providers

Mid-Level Providers

Who they are, what they do, and why they’re changing emergency medicine

How to make sense of the puzzle and improve your practice.

When Patients Lie

When Patients Lie

How to Spot Deception, What You Can Do, and Why it Matters

Accusing anyone of lying is serious business, but when that person is your patient, the stakes are even higher. 

Raves and Saves

Raves and Saves

Advanced Emergency Management at Mass Gatherings

EM is crucial at drug-fueled electronic dance festivals, like this month’s Electric Zoo in New York.  

Transfusion Confusion

Transfusion Confusion

Knowing the Real Risks of Blood Transfusion

This routine procedure bears real risks and should be handled accordingly.

The ABCs (and T) of Rural EM

The ABCs (and T) of Rural EM

Situational Awareness is Key

When you’re practicing in the middle of nowhere, planning out a timely patient transfer can be as critical as securing…

DNR Means Do Not Treat . . . and Other End-of-Life Care Myths

DNR Means Do Not Treat . . . and Other End-of-Life Care Myths

Debunking 5 Fallacies

Improve your EOL care and communicate more effectively.

Through the Looking Glass

Through the Looking Glass

Three Novel Use Cases for Google Glass in the ED

How might augmented reality change your practice?

Augmented ED

Augmented ED

The future of emergency medicine?

EPs in Rhode island overcome hurdles to trial Glass for telemedicine and consider other applications.

All About Metoclopramide (Reglan)

All About Metoclopramide (Reglan)

Know the risks

Reglan should be used with caution if patients have Parkinson’s disease or are on antipsychotics.

Physicians Won't Be Silenced

Physicians Won't Be Silenced

ACEP's Gag Order Rejected

EPM readers speak out against ACEP’s new ruling prohibiting incoming leaders from answering questions from non-ACEP publications.

Changemaker

Changemaker

How One EP Transformed Mental Health Admissions in Virginia

Debra Perina combined her experience as a coroner with her time leading an ED to challenge the establishment.

Get the Gear Off

Get the Gear Off

Removing the Helmet and Pads is Crucial to Treating Spinal Injuries from Football

Up to 25% of c-spine injuries from football collisions may be exacerbated by the poor removal of helmet and pads.

The War on Death

The War on Death

by Greg Henry, MD

The guns and butter debate is really over, I guess.

How Do I Know if I'm Being Paid Fairly?

How Do I Know if I'm Being Paid Fairly?

Trust is key

I get paid based on my productivity, but I don't trust that my company is paying me accurately.

The Stethoscope of the Future

The Stethoscope of the Future

Bedside Ultrasound

The applications of bedside ultrasound have gone well beyond scanning the gallbladder . . . to the lungs?

The Medical Malpractice Rundown: A State-by-State Report Card

The Medical Malpractice Rundown: A State-by-State Report Card

When it comes to medical liability laws and culture, where you live matters.

Find out how your state stacks up against the other 49.

Oxygen is a Drug— Act Accordingly

Oxygen is a Drug— Act Accordingly

Understanding the dangers of indiscriminate oxygenation in the ED setting

As with many things in medicine, dogma seems to overpower the evidence in this arena. 

Gag Order

Gag Order

New ruling prohibits would-be ACEP leaders from answering questions from non-ACEP publications.

Greg Henry seldom fails to deliver on a promise. But this time, it looks like it’s out of his control.

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Educational Objectives:

After evaluating this article participants will be able to:

1. Incorporate into practice the critical components of early goal directed treatment for sepsis.
2. Identify the areas of controversy surrounding EGDT and rationally apply the principles to clinical practice.
3. Improve awareness, regarding the recognition and aggressive management of sepsis to improve patient outcomes

 

Pro: Research Supports It

by Brian M. Fuller, MD & Emanuel Rivers, MD, MPH
 
Ten years after the study was completed, Early Goal Directed Therapy (EGDT) for the treatment of severe sepsis and septic shock continues to generate much controversy and debate. In spite of multiple publications supporting its findings, questions continue about its therapeutic endpoints, general applicability in “real world’ scenarios, and whether continued research comparing EGDT to a control group is unethical, among others.

Sepsis is common, lethal, and expensive. It is responsible for over 225,000 deaths per year and is the most expensive disease requiring hospitalization since 1997, accounting for over $50 billion per year in health care costs. This disease is highly relevant to emergency medicine as over 50% of these patients are admitted through the emergency department (ED). To answer the question of “Does EGDT work?” one needs to only look at the data to find socioeconomic benefits.

The original EGDT trial found a mortality reduction from 46.5% in the control group to 30.0% in the EGDT group. In 2006, analysis of available randomized and observational data from 12 other academic and community centers, totaling 1,298 patients, yielded similar results. Mortality was reduced from 44.8% in the control group to 24.5% in the EGDT group. Put another way, for every 5 patients treated with EGDT, one life was saved! This is a better number than aspirin + streptokinase for acute myocardial infarction 5-week mortality (NNT=19) or tPA for acute ischemic stroke within 4.5 hours (NNT=15). To date, there are at least 24 peer reviewed publications, totaling over 2,000 patients citing outcome benefit with EGDT, with mortality reductions ranging from 9% to 40%. Furthermore, there are at least 28 published abstracts, increasing the total to over 10,000 patients, with similar results.

Not only does EGDT provide mortality benefit it also decreases health care resource consumption. Examples include decrease in vasopressor use, hospital and intensive care unit length of stay, and mechanical ventilation days. In summary, data from over 10,000 patients shows that an early, upstream intervention (EGDT) provided in the ED has significant positive downstream benefits. With an average ED wait time of over 5 hours for an ICU bed, there are few options other than making this an ED intervention. This benefit has been shown not only in the academic setting, but in the community as well. In fact, this data includes over 1,100 patients in the community setting and it shows an average absolute mortality reduction of 20.9%.

In an era of increasing scrutiny with respect to health care dollars, a program such as EGDT should demonstrate fiscal justification. It has been shown in academic centers that EGDT provides a 23.4% reduction in hospital costs, a cost per life saved of $32,336, and a median reduction in hospital facility charges of 39.2%. Implementation of a sepsis protocol has been shown to decrease total costs ($16,103 vs. $21,985), showing that implementation of a sepsis protocol can save lives and “result in substantial savings in an otherwise very expensive condition”. In a before and after implementation study, EGDT decreased cost on average by $9,346.60 per patient, resulting in an average cost savings of $4 million every six months. Whether EGDT is provided by an ED based, mobile intensive care unit team, or ICU based approach, all have similar cost effectiveness ratios.

The concept of EGDT was provided in 1976 in the first emergency medicine journal. Building on these concepts, the original EGDT trial proved benefit of an aggressive and early goal-oriented approach to shock reversal. Unfortunately, EGDT remains controversial. Despite the data, current detractors to EGDT continue to question which parts of the protocol drive benefit. Why should we really care? In the early stages of shock, whether you resuscitate your patient to a preset oxygen delivery, central venous pressure, or central venous mixed oxygen saturation, it may not matter. It is likely that EGDT is greater as a whole than the sum of its parts and searching for the most effective component is missing the point: EGDT has been shown for almost a decade and in thousands of patients that it is beneficial. Detractors also state that the benefit of EGDT is that we are simply monitoring our patients better when instituting the protocol. No monitoring device in the history of medicine, unless linked with a therapy that improves outcome, has ever been shown to improve outcome. That is true for pulse oximetry all the way to pulmonary artery catheterization. Understanding these historical precedents, one can understand that it is not the monitoring, but EGDT,  that is improving outcome.

The overwhelming majority of the data shows that EGDT works and shows how important a specialty response is to saving lives. Despite this, we may be losing the vision of responding to challenge as well as change. We follow stroke protocols, acute coronary syndrome protocols and trauma protocols routinely. And yet, a study originating from our own specialty with robust supportive evidence continues to be questioned. These questions are not supported by evidence. So if you want to save lives, save your institution money, and improve your department’s standing in the house of medicine, employing EGDT in the treatment of severe sepsis and septic shock will accomplish all of your goals!

Brian Fuller, MD, is an assistant professor of anesthesiology and emergency medicine at Washington University School of Medicine in St. Louis.

Emanuel Rivers, MD, MPH, IOM, is the vice chairman and research director at Henry Ford Hospital, and is a clinical professor at Wayne State University.

 
 
 
Continue next to read the Con side by Kevin Klauer, DO
Too Many Assumptions
 
 

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