Early, aggressive treatment for severe infection reduces death rates, length of hospital stay

November 07, 2001

DETROIT - Patients treated more aggressively for severe infection in the Emergency Department before they are admitted to the hospital had lower death rates, less risk of organ failure and spent less time in the hospital, according to a Henry Ford Hospital study published in the Nov. 8 issue of The New England Journal of Medicine.

Severe infection, otherwise known as severe sepsis and septic shock, accounts for as many deaths every year - an estimated 215,000 - as heart attacks. It is the 11th leading cause of death in the United States. The disease and its related complications account for more than $16 billion annually in hospital costs nationally. The cost to Henry Ford Hospital alone is $100 million annually.

"We feel this study could have significant implications on the current understanding of severe infection and how it's treated," says Emanuel P. Rivers, M.D., director of research at Henry Ford's Department of Emergency Medicine and lead author of the study.

"The treatment shown to be effective in this study is generally routine in the Intensive Care Unit (ICU). But we've shown that the treatment is even more effective when applied at earlier stages in the Emergency Department."

Standard diagnostic methods such as a physical examination, vital signs (blood pressure and heart rate) and urine output can fail to detect significant decreases in oxygen delivery to vital organs in the early stages of severe infection. In their study, Henry Ford researchers found that treating patients in the Emergency Department with a more aggressive and sophisticated method of intervention, called Early Goal Directed Therapy (EGDT), is more effective than the standard treatment and improves patient outcomes.

The study involved 263 patients treated for severe infection in the Emergency Department from 1997-2000. Of the 263 patients enrolled, 130 were treated with EGDT and 133 with standard care.

The study showed that:"We have to provide more aggressive and sophisticated care for these critically ill patients as soon as they come in the door," Rivers says.

"We provide early, aggressive and more sophisticated care for stroke, trauma and heart attack patients in these 'golden hours' and it has proven to save lives. When we combined early detection with aggressive treatment for severe infection in as little as the first six hours, we found dramatic decreases in mortality, organ failure and use of hospital resources."

Henry Ford has since implemented EGDT as the standard protocol for treating severe infection in its Emergency Department, a Level 1 trauma center that specializes in trauma, heart attacks and stroke and treats nearly 100,000 patients annually.

The components of EGDT are derived from treating patients with severe infection in the ICU. However, this is the first study of its kind to investigate the efficacy of EGDT for treating patients in the Emergency Department. Like any serious illness, time is crucial to identifying and treating severe infection, thus reducing the risk of organ failure and mortality.

Patients in the EGDT group received significantly more therapy, including fluid and heart medication in the first six hours of treatment in the Emergency Department before they were admitted to the ICU. The EGDT group generally had fewer complications during their hospital stay.

Treatment in the EGDT group was guided by an eight-inch fiber optic catheter inserted into the heart to monitor blood oxygen levels. The catheter enabled doctors to quickly detect and respond to critical decreases in oxygen delivery to vital organs. Critical decreases in oxygen delivery to vital organs, or global tissue hypoxia, leads to organ failure and death.

Researchers in the study found that significant decreases in oxygen delivery to vital organs occurred even when physical examination, vital signs and urine output were normal in the Emergency Department.

Meanwhile, patients in the standard care study group received routine treatment based on physical examination, vital signs, blood pressure and urine output. They also received a standard catheter inserted into the heart that monitored blood pressure in the heart instead of blood oxygen levels.

In the last 25 years, Rivers says, medicine has seen few breakthroughs that have changed the outcomes of patients with severe infection. Nationally, more than 300,000 patients are treated for severe infection in Emergency Departments annually. Because incidence of this disease increases with age, the number of cases is projected to significantly rise as the population ages.

"Given these findings," Rivers says, "the potential to improve patient outcomes should not be viewed as a burden of delivering a higher level of care in the early settings, but as a significant opportunity to effectively decrease the negative socioeconomic consequences.

"Early-goal-directed therapy provided at the earliest stage of severe infection produces significant short and long-term benefits."
The study was supported by the Henry Ford Health System Fund for Research, a Weatherby Healthcare Resuscitation Fellowship, Edwards Lifesciences and Nova Biomedical.

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Henry Ford Health System

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