Source/ Citation

Hanzelka, K., Yeung, S., Chisholm, G.,

Merriman, K., Gaeta, S., Malik, I., & Rice, T.
(2013). Implementation of modified early-goal
directed therapy for sepsis in the emergency
center of a comprehensive cancer center.
Supportive Care In Cancer, 21(3), 727-734.
doi:10.1007/s00520-012-1572-y

Purpose / Problem

Design / Sample

purpose of the
prospective cohort
study was to show
that the
implementation of
the SSC resuscitation
bundle as
standard care in
multiple hospital, as
well as to examine
the effect of a team
model of the
implementation
on bundle
compliance.

The sample
population was
Eight Urban
Hospitals. Adults
patients who were
septic. 556
patients were
enrolled in this
study.

To examine the
impact of a
standardized
sepsis order set and
algorithm utilizing
non-invasive
monitoring for earlygoal directed therapy
(EGDT) in an

Subjects used in
this study were
patients that
presented
themselves in the
ED with sepsis
along with a form
of cancer that
included

Instruments /
Measures
A standardized
bundle completion
checklist was used
as the compliance
measurement tool.
The following
checklist includes
(i) lactate measured;
(ii) blood cultures
obtained
prior to antibiotics;
(iii) antibiotics
administered by 3 h;
(iv)
fluid bolus given;
(v) central venous
pressure (CVP)
.8 mmHg achieved
by 6 h; (vi) mean
arterial pressure
(MAP) .65 mmHg
achieved by 6 h; and
(vii) ScvO2 .70%
achieved by 6 h.
The study was a
single-center
retrospective cohort
design
using a historical
control group
The Charlson
comorbidity score

Results
The overall inhospital mortality
rate was 29.9%,
and 67.1% of
the patients had
septic shock. With
team model,
compliance
increased from
37.5% baseline to
88.2% in the sixth
quartile
(P, 0.01), whereas
hospitals with a
non-team model
increased
compliance from
5.2 to 39.5%

Hematologic
malignancy was
common in the
study group with
leukemia
patients
accounting for 32
% of the
population and

Strengths /
Weaknesses
limitations in the
study included a less
standardized
educational
program; however it
allowed the
participating
hospitals the
freedom to develop
their own strategies
of implementation.
Strength :The
analysis of teammodel approach. A
team model was
more effective
compared
with a non-team
model of
implementation in
achieving
compliance
to the bundle.
Limitations of this
study is its
retrospective nature
and selection
criteria.
Direct cause and
effect cannot be
concluded from this

emergency center
setting on the clinical
outcomes of sepsis
in cancer patients.

Leukemia,
Lyphoma, Lung
Breast, and Gastro
Sample size 100 as
part of the
retrospective study
and 100 people for
the EGDT

was used to compare

the impact of cancer
type, stage of
disease, and
comorbidities
A specific algorithm
was designed for the
healthcare team to
identify patients has
septic and well as an
algorithm for
resuscitation
The study contain
results Before
(Group) the
implementation of
protocol and an
after (Group) the
implementation of
the protocol.

lymphoma
patients
accounting for 17
% of the
population.
28 Day in hospital
mortality rate :
38% before and
20% in the after
Hospital Length of
stay 10.3 days
before and 8.1
days after
ICU length of stay
5.1 Before and 2.5
after

A Sample size of
100 Participants in
the before group and
a 100 participants in
the after group.

Banta, J., Joshi, K., Beeson, L., & Nguyen, H.

(2012). Patient and hospital characteristics
associated with inpatient severe sepsis mortality
in California, 2005-2010. Critical Care

The primary
objective of this
study was to identify
which patient

Public-use data for

20052010 were
used
in this

Uses a cross
sectional study
utilizing data across
community hospitals

During the 6-yr

study period, there
were 215,662
deaths, for an

study
A randomized trial
would not have been
possible in
this situation
because
implementation of
the project required
education of the
entire EC staff
making it impossible
to have a
control group not
affected by the
concept of EGDT.
Another point of
discussion is the
difficulty in
obtaining severity of
illness
scores, such as
SOFA and APACHE
II, in a retrospective
study. At the time
this data was
retrospectively
collected, there
was no reliable
documentation of
Glasgow Come
Score
Data was collected
from those patient
classified as severe
by International

Medicine, 40(11), 2960-2966.

doi:10.1097/CCM.0b013e31825bc92f

Zhao, Y., Li, C., & Jia, Y. (2013). Evaluation of

the Mortality in Emergency Department Sepsis

demographic, patient
health, and hospital
characteristics
were associated with
in-hospital mortality.
A secondary
objective was to
determine the relative
influence of these
characteristics
on mortality.

To determine an
effective method for

retrospective,
cross-sectional
analysis of
discharges from
nonfederal,
general acute
hospitals in
California.
A total of
1,213,219 patients
for adults
(aged 18 yrs)
having
International
Classification
diagnosis and
procedure codes
indicating severe
sepsis.

in California

A total of 501
adult ED patients

All cases had data

recorded for age,

Patient demographic
was used such as
gender race, age etc

Differences in
patient and hospital
characteristics
between patients
who died and those
who survived
hospitalization were
assessed using
chi-square test for
categorical variables
and
t test for continuous
variables

overall in hospital
mortality rate of
17.8%
Inpatient
mortality
increased with
increasing age
and was higher
among males,
whites,
Asian/Pacific
Islanders, nonHispanics,
and those with
Medicare coverage
severe septic
patients who were
discharged in this
study, with
those discharges
having a 27.1%
inpatient
mortality rate.
Three of the 17
Charlson-Deyo
comorbidity
indexes most
common were
congestive heart
failure, chronic
pulmonary
disease, and renal
disease
501 patients, 319
(63.7%) had

Classification of
Disease-9 Codes.
The study may have
exclude patients that
were not Classified
as severe.
Also different
hospitals may have
different approaches
to coding severe
sepsis.
Strengths : study
demonstrated
important
findings regarding
associations of
patient
and hospital
characteristics with
inpatient severe
sepsis mortality

The concentrations
of PCT, IL-6 and

score combined with procalcitonin in septic

patients. American Journal Of Emergency
Medicine, 31(7), 1086-1091.
doi:10.1016/j.ajem.2013.04.008

predicting severity of
sepsis and 28-day
mortality of
emergency
department (ED)
patients, we
compared the
Mortality in
Emergency
Department Sepsis
(MEDS)
score with
procalcitonin (PCT),
interleukin-6 (IL-6),
and C-reactive
protein (CRP) and
evaluated the MEDS
score combined with
relevant biomarkers.

with sepsis were

selected for this
prospective
clinical study. The
optimal
combination was
assessed by
logistic regression.
All caseswere
divided into the
sepsis group (319
cases)
and the severe
sepsis and septic
shock group (182
cases) according
to the severity of
sepsis, as well as
the
survivor group
(367 cases) and
nonsurvivor group
(134 cases)
according to the
28-day outcomes.

sex, address,
telephone
number, vital signs
(heart rate, blood
pressure, respiratory
rate,
oxygen saturation,
temperature), altered
conscious state,
nursing
home resident
status,
comorbidities,
complete blood cell
count, white
blood cell
differential count,
blood gas analysis,
biochemical profile
(hepatic and renal
function, and
electrolyte
concentrations),
chest xray,
and results for
blood, phlegm, or
urine culture.
The MEDS
score was calculated
by summing the
points of 9 variables
Levels of PCT and
IL-6 were measured

sepsis, 155
(30.9%) had
severe sepsis, and
27 (5.4%) had
septic shock.
These patients
included
277 men and 224
women who were
between 18 and 96
years old. A
total of 134
patients failed to
survive, and 28day mortality was
26.7%.
The MEDS score
of the severe
sepsis and septic
shock
group was
significantly
higher than that in
the sepsis group,
and it was
significantly
higher in
nonsurvivors than
in survivors (P b .
05). Similar
results were also
found for PCT, IL6, CRP levels, and
age. Variables of

CRP
started to rise, peak,
and plateau was
different among the
biomarkers. Blood
samples were taken
at the time of first
contact,
but controlling for
the same time point
of all samples could
not be
performed in the
ED. They only
obtained 1
biomarker
concentration at
the time of ED
evaluation and did
not investigate serial
time points

using enzyme-linked
immunosorbent
assay kits

Wang, H., Shapiro, N., Angus, D., & Yealy, D.

(2007). National estimates of severe sepsis in
United States emergency departments. Critical
Care Medicine, 35(8), 1928-1936.

Analyzes the
national estimates of
the number, timing,
ED
length of stay, and
case distribution of
patients presenting to
the
ED with suspected
severe sepsis.

Analysis of 2001
2004 ED data
from the National
Hospital
Ambulatory
Medical Care
SurveyAdult (age,
>18 yrs) patients
with suspected
severe
sepsis, defined as
the concurrent
presence of an
infection
(ED International
Classification of
Diseases, 9th
Revision;
ICD-9) diagnosis
of infection, or a
triage temperature
<96.8F
or >100.4F) and

describe the patients

who use ED
services nationally.
Using a four-stage
probability
design, the survey
samples
geographically
defined areas,
hospitals within
these areas,
emergency service
areas within the
emergency
departments of the
hospitals, and
patient visits
to the emergency
service areas.
Patient charts
are systematically
selected from an
assigned

the MEDS score

were all different
when the 2
outcomes of
severity of
sepsis and
mortality were
compared, except
for bands N5%
and
nursing home
resident.
During the 4-yr
study period, there
were an estimated
441.7 million ED
visits
in the United
States. Of 331.5
million
adult ED visits,
2,282, met
suspected severe
sepsis criteria.
Approximately 1
of every 33
adult patients with
an infection
presented
with suspected
severe sepsis.
Most patients with
suspected severe
sepsis had a fever,

We did not have

access to data
needed
to identify other
severe sepsis criteria
(e.g., the systemic
inflammatory
response
syndrome) (2). The
available vital signs
did not include
respiratory rate or
oxygen
saturation. We also
could not identify
occult
sepsis. Therefore,
our estimates
likely represent the
minimum burden
upon EDs
nationally; the true
number of

organ dysfunction
(ED ICD-9)
diagnosis of
organ dysfunction,
intubation, or a
triage systolic
blood pressure
<90 mm Hg).

4-wk period. NCHS

staff train and work
with
personnel at each
hospital to abstract
clinical
data from selected
charts
analyzed data using
Stata v.8.2

or respiratory or
genitourinary
infection (Table
2). Most
patients with
suspected severe
sepsis
had hypotension,
or respiratory or
cardiovascular
dysfunction.

cases may be higher.