Chest
Clinical Investigations in Critical CareA Multidisciplinary Community Hospital Program for Early and Rapid Resuscitation of Shock in Nontrauma Patients
Section snippets
Study Design and Approval
We conducted a single-center pilot study in a 180-bed community hospital with 44 critical care beds (open ICU) using a prospective two-group comparison of all patients who were identified as being in shock (prehospital, ED, or inpatient) before and after implementation of a comprehensive program of early recognition and rapid treatment in a nonteaching hospital. After-hours in-house physician coverage was provided solely by the ED. The institutional review board for human research approved the
Implementation
After 2.5 years of planning and 1 month of intensive education, we launched the Shock Program (described in the “Materials and Methods” section) and continued the education of providers in the early recognition and treatment of shock. Prehospital personnel, nurses, and physicians were empowered to mobilize a Shock Team and cart, initiate rapid goal-directed therapy, and the rapid transfer of the patient to a shock bed in the ICU, which was available at all times. This program has been adopted
Discussion
Shock continues to exact a high mortality despite advances in intensive care. Delay in treatment beyond the critical “golden hour” leads to multiorgan dysfunction, and increased morbidity and mortality.14344 Health-care providers who are first on the scene, whether they are prehospital personnel, nurses, or physicians, vary greatly in their knowledge and skills, and often underestimate the severity of illness until it is too late.19202122 Outside the critical care setting, the initial
Conclusion
To our knowledge, this is the first time that a program incorporating the education of health-care providers in the earlier recognition and treatment of shock, a systems-based team approach, and the early goal-directed therapy of patients with nontraumatic shock has been shown to be possible and beneficial in a community hospital setting. This program empowered nurses and prehospital personnel to rapidly mobilize hospital resources, expedited appropriate therapy, and was temporally associated
Hypovolemic Shock ED Protocol (June 2000)
The goals of the protocol are as follows: MAP, ≥ 70 mm Hg; UO, > 30 mL/h (excluding patients in oliguric renal failure); warm extremities; capillary refill, ≤ 3 s; central venous pressure (CVP), > 12 mm Hg; CI, ≥ 2.7, or Svo2, ≥ 60; and avoid significant worsening of oxygenation with volume therapy (ie, a significant decrease in Pao2/Fio2 ratio).
The protocol is as follows:
- ↓
Systolic BP (SBP) < 90 mm Hg: Administer crystalloid (normal saline solution [NS]/lactated Ringer solution [LR]) or
References (53)
- et al.
Elevation of cardiac output and oxygen delivery improves outcome in septic shock
Chest
(1992) - et al.
Effect on ICU mortality of a full-time critical care specialist
Chest
(1989) - et al.
Effects of a medical intensivist on patient care in a community teaching hospital
Mayo Clin Proc
(1997) - et al.
Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia
Chest
(2000) - et al.
Early fluid resuscitation improves outcomes in severely burned children
Resuscitation
(2000) - et al.
Prospective study of the treatment of septic shock
Lancet
(1978) - et al.
The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults
Chest
(1991) - et al.
The ethics of sample size: two-sided testing and one-sided thinking
J Clin Epidemiol
(2001) - et al.
Improving the utilization of medical crisis teams (condition C) at an urban tertiary care hospital
J Crit Care
(2003) - et al.
Early goal-directed therapy in the treatment of severe sepsis and septic shock
N Engl J Med
(2001)
Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care: a pilot study in a tertiary-care hospital
Med J Aust
Cardiogenic shock
Ann Intern Med
Has the mortality of septic shock changed with time
Crit Care Med
Epidemiology of sepsis: an update
Crit Care Med
Treating sepsis
N Engl J Med
A shock team in a general hospital
Anesth Analg
The medical emergency team
Anaesth Intensive Care
Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team
Med J Aust
A prospective before-and-after trial of a medical emergency team
Med J Aust
Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study
BMJ
A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients
JAMA
Prospective trial of supranormal values as goals of resuscitation in severe trauma
Arch Surg
Meta-analysis of hemodynamic optimization in high-risk patients
Crit Care Med
Elevation of systemic oxygen delivery in the treatment of critically ill patients
N Engl J Med
A trial of goal-oriented hemodynamic therapy in critically ill patients: SvO2 Collaborative Group
N Engl J Med
Septic shock: an analysis of outcomes for patients with onset on hospital wards versus intensive care units
Crit Care Med
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This study was funded in part by unrestricted grants from Redding Medical Center, Merck Pharmaceutical, Inc, Eli Lilly Company, Pfizer, Inc, and Edwards Lifesciences. Merck Pharmaceuticals has provided a $90,000 unrestricted grant in support of this study. Their product, Primaxin, is in our antibiotic algorithm for septic shock.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestjournal.org/misc/reprints.shtml).