[Show abstract][Hide abstract] ABSTRACT: Treatment of nontraumatic shock is often delayed or inadequate due to insufficient knowledge or skills of front-line healthcare providers, limited hospital resources, and lack of institution-wide systems to ensure application of best practice. As a result, mortality from shock remains high. We designed a study to determine whether outcomes will be improved by a hospital-wide system that educates and empowers clinicians to rapidly identify and treat patients in shock with a multidisciplinary team using evidenced-based protocols.
Single-center trial before and after implementation of a hospital-wide rapid response system for early identification and treatment of patients in shock.
A 180-bed regional referral center in northern California.
A total of 511 adult patients who met criteria for shock during a 7-yr period.
We designed a rapid response system that included a comprehensive educational program for clinicians on earlier recognition of shock, empowerment of front-line providers using specific criteria to initiate therapy, mobilization of the rapid response team, protocol goal-directed therapy, and early transfer to the intensive care unit. Outcome feedback was provided to foster adoption.
We measured times to key interventions and hospital mortality 2.5 yrs before and until 5 yrs after system initiation. Times to interventions and mortality decreased significantly over time before and after adjusting for confounding factors. Interventions times, including shock alert activation, infusion of 2 L of fluid, central venous catheter placement, and antibiotic administration, were significant predictors of mortality (p < .05). Overall and septic subgroup mortality decreased from before system implementation through protocol year 5 from 40% to 11.8% and from 50% to 10%, respectively (p < .001).
Over time, a rapid response system for patients in shock continued to reduce time to treatment, resulting in a continued decrease in mortality. By year 5, only three patients needed to be treated to save one additional life.
Critical Care Medicine 12/2007; 35(11):2568-75. DOI:10.1097/01.CCM.0000287593.54658.89 · 6.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the effect of a community hospital-wide program enabling nurses and prehospital personnel to mobilize institutional resources for the treatment of patients with nontraumatic shock.
Historically controlled single-center study.
A 180-bed community hospital.
Patients in shock who were candidates for aggressive therapy.
From January 1998 to May 31, 2000, patients in shock received standard therapy (control group). During the month of June 2000, intensive education of all health-care providers (ie, prehospital personnel, nurses, and physicians) took place. From July 1, 2000, through June 30, 2001, patients in shock (protocol group) were managed with a hospital-wide shock program. The program included early recognition of shock and the initiation of therapy by nonphysicians. Frontline personnel mobilized a shock team, which used goal-directed resuscitation protocols, early intensivist involvement, and rapid transfer to the ICU where protocols specific to shock etiology were implemented. Measurements and main results: Eighty-six and 103 patients, respectively, were enrolled in the control and protocol groups. Baseline characteristics were similar. The protocol group had significant reductions in the median times to interventions, as follows: intensivist arrival, 2:00 h to 50 min (p < 0.002); ICU/operating room admission, 2 h 47 min to 1 h 30 min (p < 0.002); 2 L fluid infused, 3 h 52 min to 1 h 45 min (p < 0.0001); and pulmonary artery catheter placement, 3 h 50 min to 2 h 10 min (p 0.02). Good outcomes (ie, discharged to home or to a rehabilitation center) were more likely in the protocol group than in the control group (p = 0.02). The hospital mortality rate was 40.7% in the control group and 28.2% in the protocol group (p = 0.035).
Similar to current practice in patients who have experienced trauma or cardiac arrest, the empowerment of nonphysician providers to mobilize hospital resources for the care of patients with shock is effective. A community hospital program incorporating the education of providers, the activation of a coordinated team response, and early goal-directed therapy expedited appropriate treatment and was temporally associated with improved outcomes. Randomized multicenter trials are needed to further assess the impact of the shock program on outcomes.
[Show abstract][Hide abstract] ABSTRACT: Determining the correct diagnosis of patients with dyspnea can be challenging. Early and accurate determination of the cause of dyspnea is vital in instituting timely and appropriate interventions. Hemodynamic parameters may aid in the evaluation of dyspnea, but are difficult to assess by physical exam. Impedance cardiography (ICG) is a newly validated method of determining hemodynamic parameters noninvasively. The purpose of this study was to determine the accuracy in differentiating cardiac from noncardiac causes of dyspnea utilizing ICG-derived hemodynamic parameters compared with that of emergency department (ED) physicians after initial history, physical, and laboratory tests. The final diagnosis, which was made retrospectively after review of the patient's hospital record by a senior ED physician blinded to the ICG data, was compared with the treating ED physician's and the ICG diagnoses. Thirty-eight patients who presented with dyspnea to a community ED were included in the study. There were significant differences in values of cardiac index by ICG (2.2 vs. 3.1; p<0.0001), systolic time ratio (0.52 vs. 0.37; p<0.01) and velocity index (32.9 vs. 42.7; p<0.01) between the cardiac and noncardiac groups, respectively. ICG measurements demonstrated greater sensitivity (92 vs. 83%), specificity (88 vs. 77%), and positive and negative predictive values (79 vs. 63% and 96 vs. 91%, respectively) compared with the ED physician in distinguishing cardiac from noncardiac cause of dyspnea. ICG can aid ED physicians in making more rapid and accurate determinations of cardiac vs. noncardiac cause of dyspnea.