, Volume 189, Issue 1, pp 11–19 | Cite as

Implementing a Collaborative Protocol in a Sepsis Intervention Program: Lessons Learned

  • Brian Casserly
  • Michael Baram
  • Patricia Walsh
  • Andrew Sucov
  • Nicholas S. Ward
  • Mitchell M. Levy


The objective of this prospective cohort study was to see the effect of the implementation of a Sepsis Intervention Program on the standard processes of patient care using a collaborative approach between the Emergency Department (ED) and Medical Intensive Care Unit (MICU). This was performed in a large urban tertiary-care hospital, with no previous experience utilizing a specific intervention program as routine care for septic shock and which has services and resources commonly available in most hospitals. The study included 106 patients who presented to the ED with severe sepsis or septic shock. Eighty-seven of those patients met the inclusion criteria for complete data analysis. The ED and MICU staff underwent a 3-month training period followed by implementation of a protocol for sepsis intervention program over 6 months. In the first 6 months of the program’s implementation, 106 patients were admitted to the ED with severe sepsis and septic shock. During this time, the ED attempted to initiate the sepsis intervention protocol in 76% of the 87 septic patients who met the inclusion criteria. This was assessed by documentation of a central venous catheter insertion for continuous SvO2 monitoring in a patient with sepsis or septic shock. However, only 48% of the eligible patients completed the early goal-directed therapy (EGDT) protocol. Our data showed that the in-hospital mortality rate was 30.5% for the 87 septic shock patients with a mean APACHE II score of 29. This was very similar to a landmark study of EGDT (30.5% mortality with mean APACHE II of 21.5). Data collected on processes of care showed improvements in time to fluid administration, central venous access insertion, antibiotic administration, vasopressor administration, and time to MICU transfer from ED arrival in our patients enrolled in the protocol versus those who were not. Further review of our performance data showed that processes of care improved steadily the longer the protocol was in effect, although this was not statistically significant. There was no improvement in secondary outcomes, including total length of hospital stay, MICU days, and mortality. Implementation of a sepsis intervention program as a standard of care in a typical hospital protocol leads to improvements in processes of care. However, despite a collaborative approach, the sepsis intervention program was underutilized with only 48% of the patients completing the sepsis intervention protocol.


Early goal direct therapy (EGDT) Resuscitation Sepsis Medical intensive care unit (MICU) Emergency department (ED) Implementation 


  1. 1.
    (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 342(18):1301–1308Google Scholar
  2. 2.
    Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ Jr, Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) Study Group (2001) Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 344(10):699–709CrossRefPubMedGoogle Scholar
  3. 3.
    Han YY, Carcillo JA, Dragotta MA, Bills DM, Watson RS, Westerman ME, Orr RA (2003) Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics 112(4):793–799CrossRefPubMedGoogle Scholar
  4. 4.
    Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M, Early Goal-Directed Therapy Collaborative Group (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345(19):1368–1377CrossRefPubMedGoogle Scholar
  5. 5.
    He ZY, Gao Y, Wang XR, Hang YN (2007) [Clinical evaluation of execution of early goal directed therapy in septic shock]. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 19(1):14–16PubMedGoogle Scholar
  6. 6.
    Kortgen A, Niederprum P, Bauer M (2006) Implementation of an evidence-based “standard operating procedure” and outcome in septic shock. Crit Care Med 34(4):943–949CrossRefPubMedGoogle Scholar
  7. 7.
    Sebat F, Johnson D, Musthafa AA, Watnik M, Moore S, Henry K, Saari M (2005) A multidisciplinary community hospital program for early and rapid resuscitation of shock in nontrauma patients. Chest 127(5):1729–1743CrossRefPubMedGoogle Scholar
  8. 8.
    Shapiro NI, Howell MD, Talmor D, Lahey D, Ngo L, Buras J, Wolfe RE, Weiss JW, Lisbon A (2006) Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol. Crit Care Med 34(4):1025–1032CrossRefPubMedGoogle Scholar
  9. 9.
    Trzeciak S, Dellinger RP, Abate NL, Cowan RM, Stauss M, Kilgannon JH, Zanotti S, Parrillo JE (2006) Translating research to clinical practice: a 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department. Chest 129(2):225–232CrossRefPubMedGoogle Scholar
  10. 10.
    Bilkovski RN, Rivers EP, Horst HM (2004) Targeted resuscitation strategies after injury. Curr Opin Crit Care 10(6):529–538CrossRefPubMedGoogle Scholar
  11. 11.
    Chapman M, Gattas D, Suntharalingam G (2005) Why is early goal-directed therapy successful—is it the technology? Crit Care 9(4):307–308CrossRefPubMedGoogle Scholar
  12. 12.
    Frey B, Macrae DJ (2005) Goal-directed therapy may improve outcome in complex patients—depending on the chosen treatment end point. Intensive Care Med 31(4):508–509CrossRefPubMedGoogle Scholar
  13. 13.
    Gunn SR, Fink MP, Wallace B (2005) Equipment review: the success of early goal-directed therapy for septic shock prompts evaluation of current approaches for monitoring the adequacy of resuscitation. Crit Care 9(4):349–359CrossRefPubMedGoogle Scholar
  14. 14.
    Rhodes A, Bennett ED (2004) Early goal-directed therapy: an evidence-based review. Crit Care Med 32(11 Suppl):S448–S450CrossRefPubMedGoogle Scholar
  15. 15.
    Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM, Surviving Sepsis Campaign Management Guidelines Committee (2004) Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32(3):858–873CrossRefPubMedGoogle Scholar
  16. 16.
    Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL, International Surviving Sepsis Campaign Guidelines Committee, American Association of Critical-Care Nurses, American College of Chest Physicians, American College of Emergency Physicians, Canadian Critical Care Society, European Society of Clinical Microbiology and Infectious Diseases, European Society of Intensive Care Medicine, European Respiratory Society, International Sepsis Forum, Japanese Association for Acute Medicine, Japanese Society of Intensive Care Medicine, Society of Critical Care Medicine, Society of Hospital Medicine, Surgical Infection Society, World Federation of Societies of Intensive and Critical Care Medicine (2008) Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 36(1):296–327; erratum in: Crit Care Med 36(4):1394–1396Google Scholar
  17. 17.
    Boyd O, Grounds RM, Bennett ED (1993) A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA 270(22):2699–2707CrossRefPubMedGoogle Scholar
  18. 18.
    Polonen P, Ruokonen E, Hippelainen M, Poyhonen M, Takala J (2000) A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Anesth Analg 90(5):1052–1059CrossRefPubMedGoogle Scholar
  19. 19.
    Castro R, Regueira T, Aguirre ML, Llanos OP, Bruhn A, Bugedo G, Dougnac A, Castillo L, Andresen M, Hernández G (2008) An evidence-based resuscitation algorithm applied from the emergency room to the ICU improves survival of severe septic shock. Minerva Anestesiol 74(6):223–231PubMedGoogle Scholar
  20. 20.
    Gao F, Melody T, Daniels DF, Giles S, Fox S (2005) The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study. Crit Care 9(6):R764–R770CrossRefPubMedGoogle Scholar
  21. 21.
    Jones AE, Focht A, Horton JM, Kline JA (2007) Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock. Chest 132(2):425–432CrossRefPubMedGoogle Scholar
  22. 22.
    Lin SM, Huang CD, Lin HC, Liu CY, Wang CH, Kuo HP (2006) A modified goal-directed protocol improves clinical outcomes in intensive care unit patients with septic shock: a randomized controlled trial. Shock 26(6):551–557CrossRefPubMedGoogle Scholar
  23. 23.
    Micek ST, Roubinian N, Heuring T, Bode M, Williams J, Harrison C, Murphy T, Prentice D, Ruoff BE, Kollef MH (2006) Before-after study of a standardized hospital order set for the management of septic shock. Crit Care Med 34(11):2707–2713CrossRefPubMedGoogle Scholar
  24. 24.
    Cardoso T, Carneiro AH, Ribeiro O, Teixeira-Pinto A, Costa-Pereira A (2010) Reducing mortality in severe sepsis with the implementation of a core 6-hour bundle: results from the Portuguese community-acquired sepsis study (SACiUCI study). Crit Care 14(3):R83CrossRefPubMedGoogle Scholar
  25. 25.
    Castellanos-Ortega A, Suberviola B, Garcia-Astudillo LA, Holanda MS, Ortiz F, Llorca J, Delgado-Rodríguez M (2010) Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: results of a three-year follow-up quasi-experimental study. Crit Care Med 38(4):1036–1043CrossRefPubMedGoogle Scholar
  26. 26.
    Ferrer R, Artigas A, Levy MM, Blanco J, Gonzalez-Diaz G, Garnacho-Montero J, Ibáñez J, Palencia E, Quintana M, de la Torre-Prados MV, Edusepsis Study Group (2008) Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA 299(19):2294–2303CrossRefPubMedGoogle Scholar
  27. 27.
    Huang DT, Clermont G, Dremsizov TT, Angus DC (2007) Implementation of early goal-directed therapy for severe sepsis and septic shock: a decision analysis. Crit Care Med 35(9):2090–2100CrossRefPubMedGoogle Scholar
  28. 28.
    McIntyre LA, Hebert PC, Fergusson D, Cook DJ, Aziz A (2007) A survey of Canadian intensivists’ resuscitation practices in early septic shock. Crit Care 11(4):R74CrossRefPubMedGoogle Scholar
  29. 29.
    Reade MC, Huang DT, Bell D, Coats TJ, Cross AM, Moran JL, Peake SL, Singer M, Yealy DM, Angus DC, British Association for Emergency Medicine, UK Intensive Care Society, UK Society for Acute Medicine, Australasian Resuscitation in Sepsis Evaluation Investigators, Protocolized Care for Early Septic Shock Investigators (2010) Variability in management of early severe sepsis. Emerg Med J 27(2):110–115Google Scholar
  30. 30.
    Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR (1999) Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 282(15):1458–1465CrossRefPubMedGoogle Scholar
  31. 31.
    Kalil AC, Sun J (2008) Why are clinicians not embracing the results from pivotal clinical trials in severe sepsis? A Bayesian analysis. PLoS One 3(5):e2291CrossRefPubMedGoogle Scholar
  32. 32.
    Kalil AC, Sun J (2008) How many patients with severe sepsis are needed to confirm the efficacy of drotrecogin alfa activated? A Bayesian design. Intensive Care Med 34(10):1804–1811CrossRefPubMedGoogle Scholar
  33. 33.
    Mikkelsen ME, Gaieski DF, Goyal M, Miltiades AN, Munson JC, Pines JM, Fuchs BD, Shah CV, Bellamy SL, Christie JD (2010) Factors associated with non-adherence with early goal-directed therapy in the emergency department. Chest 138(3):551–558CrossRefPubMedGoogle Scholar
  34. 34.
    Nguyen HB, Corbett SW, Steele R, Banta J, Clark RT, Hayes SR, Edwards J, Cho TW, Wittlake WA (2007) Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med 35(4):1105–1112CrossRefPubMedGoogle Scholar
  35. 35.
    Wager GC (2005) Critical care physicians are proponents of early, aggressive, multifaceted therapy. Crit Care Med 33(3):702CrossRefPubMedGoogle Scholar
  36. 36.
    Grobbee DE, Hoes AW (1997) Confounding and indication for treatment in evaluation of drug treatment for hypertension. BMJ 315(7116):1151–1154PubMedGoogle Scholar
  37. 37.
    Bosco JL, Silliman RA, Thwin SS, Geiger AM, Buist DS, Prout MN, Yood MU, Haque R, Wei F, Lash TL (2010) A most stubborn bias: no adjustment method fully resolves confounding by indication in observational studies. J Clin Epidemiol 63(1):64–74CrossRefPubMedGoogle Scholar
  38. 38.
    Kalil AC (2010) Does recombinant activated protein C work in patients with severe sepsis? Crit Care Med 38(4):1217–1220CrossRefPubMedGoogle Scholar
  39. 39.
    Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, Schorr C, Artigas A, Ramsay G, Beale R, Parker MM, Gerlach H, Reinhart K, Silva E, Harvey M, Regan S, Angus DC, Surviving Sepsis Campaign (2010) The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med 38(2):367–374CrossRefPubMedGoogle Scholar
  40. 40.
    Shapiro NI, Howell M, Talmor D (2005) A blueprint for a sepsis protocol. Acad Emerg Med 12(4):352–359CrossRefPubMedGoogle Scholar
  41. 41.
    Sivayoham N (2007) Management of severe sepsis and septic shock in the emergency department: a survey of current practice in emergency departments in England. Emerg Med J 24(6):422CrossRefPubMedGoogle Scholar
  42. 42.
    Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ, ACCP/SCCM Consensus Conference Committee (2009) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. 1992. Chest 136(5 Suppl):e28Google Scholar
  43. 43.
    Marshall JC, Dellinger RP, Levy M (2010) The Surviving Sepsis Campaign: a history and a perspective. Surg Infect (Larchmt) 11(3):275–281CrossRefGoogle Scholar
  44. 44.
    Townsend SR, Schorr C, Levy MM, Dellinger RP (2008) Reducing mortality in severe sepsis: the Surviving Sepsis Campaign. Clin Chest Med 29(4):721–733, xGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Brian Casserly
    • 1
  • Michael Baram
    • 2
  • Patricia Walsh
    • 2
  • Andrew Sucov
    • 2
  • Nicholas S. Ward
    • 2
  • Mitchell M. Levy
    • 2
  1. 1.Memorial Hospital of Rhode IslandBrown UniversityPawtucketUSA
  2. 2.Rhode Island HospitalBrown UniversityProvidenceUSA

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