Implementing Early Goal-directed Therapy in the Emergency Setting: The Challenges and Experiences of Translating Research Innovations into Clinical Reality in Academic and Community Settings

Research knowledge translation into clinical practice pathways is a complex process that is often timeconsuming and resource-intensive.Recent evidence suggests that the use of early goal-directed therapy (EGDT) in the emergency department care of patients with severe sepsis and septic shock results in a substantial mortality benefit; however, EGDT is a time-and resource-intensive intervention.The feasibility with which institutions may translate EGDT from a research protocol into routine clinical care, among settings with varying resources, staff, and training, is largely unknown.The authors report the individual experiences of EGDT protocol development, as well as preimplementation and postimplementation experiences, at three institutions with different emergency department, intensive care unit, and hospital organization schemes. Keywords sepsis; early goal-directed resuscitation; knowledge translationEstimates indicate that sepsis occurs at an incidence of 3.0 cases per 1,000 persons per year, resulting in approximately 750,000 affected persons annually in the United States.The number of cases per 100,000 population of severe sepsis far exceeds the number of cases of acquired immunodeficiency syndrome, venous thromboembolism, and both colon and lung cancer.1-4 Sepsis ranks as the tenth leading cause of death in the United States, with an in-hospital mortality rate of 30% equating to approximately 215,000 U.S. deaths annually.1,5 The total annual cost to the United States directly attributable to this disease is $16.7 billion, and the incidence of sepsis is projected to increase by 1.5% per annum, resulting in more than one million cases per year by 2020. 1During the past 30 years, numerous new therapeutic strategies for sepsis have been investigated.Unfortunately, these therapies have had little impact on the mortality rate in patients with sepsis, and the in-hospital mortality rate of the past decade approximately equals the mortality rates from the 1970s.6 However, in 2001, Rivers et al. reported a substantial improvement in mortality among patients with severe sepsis and septic shock treated with early goal-directed therapy (EGDT).7 EGDT refers to the concept of using a protocol that contains