Shock Teams Bring Favorable Effects to Patient Outcomes
Abstract & Commentary
By Nathan Shapiro, MD, MPH Dr. Shapiro is Research Director, Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA. Dr. Shapiro has reported that he is on the speaker's bureaus of Eli Lilly, Edwards Life Sciences, and is a researcher for Biosite.
Source: Sebat F, et al. A multidisciplinary community hospital program for early and rapid resuscitation of shock in nontrauma patients. Chest 2005:127:1729-1743.
Cardiogenic shock mortality ranges from 50-80% and septic shock 40-60%. The hallmark of shock is inadequate tissue perfusion, a condition that should be addressed immediately and reversed promptly to prevent organ failure and death. The team approach with a mobilization of resources has been well described in specific disease processes such as cardiac arrest and trauma; the authors of this manuscript proposed that all forms of shock deserve the same level of attention.
The objective of this study was to "determine the effect of a community hospital-wide program enabling personnel to mobilize institutional resources for the treatment of patients with nontraumatic shock." Protocols were developed that included screening criteria of hypotension (SBP < 90 mmHg or mean arterial pressure < 60 mmHg) plus one clinical criterion: respirations 20/min or more; oliguria less than 30 cc/hr; lactic acid more than 2.0 mmol/L or base excess -5 mmol/L or less; temperature 36° C or lower, cool extremities, or skin mottling; or anxiety, apathy, agitation, coma, or lethargy; or normotension plus three clinical criteria. If criteria still were present after a fluid bolus, then a shock alert was called. Personnel including nurses, pre-hospital providers, or physicians were empowered to call an alert.
Once a shock alert was called, a team of dedicated health care providers was mobilized, along with equipment and resources to perform an aggressive resuscitation. Patients were resuscitated using a combination of fluids and set goals to restore adequate perfusion. In some cases, these goals included invasive monitoring to meet a minimum SVO2 and cardiac index, using vasopressors and dobutamine in coordination with other therapies (see appendix in manuscript for details). There were established emergency department (ED) and intensive care unit (ICU) protocols based on the providers' classification of shock (e.g., anaphylactic, hypovolemic, cardiogenic, or septic). The septic shock pathway included an antibiotic algorithm along with a protocol very similar to that published by Rivers and colleagues.1 An ICU bed was reserved for a shock patient at all times to facilitate rapid transfer to the critical care setting.
During the one-year treatment period, there were 103 patients included in the protocol group; they were compared with 86 patients from the 30-month historical control period. The overall mortality was 40.7% for historical controls compared with 28.2% for the treatment group. The treatment group seemed to have benefited from earlier and more aggressive therapies. Notably, the protocol group had significant reduction in times to interventions: time to operating room/ICU admission 167 min vs 90 min (p < 0.002), 2 L fluid infused (232 min vs 105 minutes (p < 0.0001), intensivist arrival 120 min vs 50 min (p < 0.002). These markers represent a more aggressive and earlier resuscitation effort.
This is a provocative article with some compelling findings. It promotes the concept that shock in general —not just traumatic— perhaps deserves increased attention and a plan to mobilize additional hospital resources. It shows that through multidisciplinary teamwork, planning, and good resource utilization, we can improve the timeliness and strength of a resuscitation to improve outcomes. The overarching idea is that critically ill patients need ICU level care, no matter where they are. In the study, 66% of the patients were admitted from the ED, and many of the alerts were called either by the ED or by pre-hospital personnel transporting a patient. This approach attempts to change the timeline of the needed therapies as well as the location where they are initiated and the providers (including ED physicians and nurses) who are involved.
Although the study clearly represents an ambitious collaborative effort, some unanswered questions remain regarding the study design. The fact that it took 30 months to select 86 patients in the historical control group, compared with 103 patients enrolled during 12 months in the treatment group, suggests that there may have been some selection bias. Although the authors credited a hospital capacity expansion, with increased attention to shock patients as part of a protocol, patients may have been more aggressively identified. They tried to account for this by doing an ICD-9 search, which is helpful, but still leaves some doubts. They also performed a regression analysis to control for important differences. All of these techniques improved the validity, but still, some questions remain, and a definitive answer may be obtained only from a randomized trial.
There are important lessons to be learned from the methods and results of this paper: 1) early identification and treatment of shock is critical; 2) multidisciplinary collaboration is important; 3) the use of coordinated protocols tailored to the needs and abilities of an individual institution is a key component to change practice. There is a clear role for the ED —the principal portal of entry to the hospital — to assist in coordinating these efforts.
1. Rivers E, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-1377.