Chest
Volume 127, Issue 5, May 2005, Pages 1729-1743
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Clinical Investigations in Critical Care
A Multidisciplinary Community Hospital Program for Early and Rapid Resuscitation of Shock in Nontrauma Patients

https://doi.org/10.1378/chest.127.5.1729Get rights and content

Objective

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.

Design

Historically controlled single-center study.

Setting

A 180-bed community hospital.

Patients

Patients in shock who were candidates for aggressive therapy.

Interventions

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).

Conclusion

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.

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

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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).

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