Knowledge translation in clinical medicine refers to the transfer of high-quality research evidence into effective changes in clinical decision-making and patient management. The failure to translate new knowledge into clinical practice is a major barrier to human benefit from biomedical research evidence.13
Factors that impede this knowledge translation are complex and include adequate systems support, understanding and synthesizing evidence, and finally implementing the evidence at the bedside.14
In this article, we summarize the experience of three institutions in attempts to implement the best practice of EGDT for the treatment of patients with severe sepsis and septic shock in the ED.
The application of the best available research evidence into routine clinical practice has been studied in various diseases, with largely unimpressive results. The application of easy but proven therapy such as aspirin administration in the ED occurred in only 80% of patients with acute myocardial infarction before implementing a standing clinical pathway.15
Thus, it is not surprising that more aggressive therapeutic interventions that are time and resource intensive, such as EGDT, have been slow to be adopted into clinical practice in the ED.10
It is estimated that this gap in knowledge translation results in only half of the patients in the United States receiving the recommended acute medical care.16
As can be noted from the detailed experiences of each center in this report, there are numerous barriers to the incorporation of EGDT into routine clinical practice. The consistent themes of the barriers that we recognized among our institutions in this report include the following: 1) differences in ED functioning and staffing, requiring adaptations of the EGDT protocol to fit the needs of each individual institution; 2) reluctance on the part of both EPs and admitting physicians to adapt to changes in patient management essential to the EGDT protocol, which required intensive education and continued meetings at each institution; 3) both the availability of new catheters and monitors and the training of staff to use this equipment was time- and labor-intensive and required tailoring to the need of each institution; and 4) the time and resources required for structured QA and quality improvement was an enormous task at all of the institutions, including proving to be almost impossible in the community setting due to lack of available resources.
A seven-step model has been proposed for optimal knowledge translation and includes awareness, acceptance, applicability, able, acted on, agreed to, and adhered to.14
During implementation of the best available evidence into clinical medicine, failures or “leaks” in the model are common. Such failures were observed during the implementation of EGDT at all of the institutions in this report. For example, “awareness” of the protocol by EPs and admitting physicians was a concern at CMC, given the large number of EPs and admitting physicians. Thus, a tremendous amount of effort, including multiple mandatory in-services for the EPs and multiple hospital medical staff informational mailings, was undertaken to address this potential leak in the model. Another concern at all the institutions was the potential effect of the protocol on ED throughput, which would be categorized in the “able” step of the model. This was addressed at all the institutions by designing a protocol that could be transitioned from the ED to the ICU. This method served to remove a potential undue burden of requiring six full hours of therapy to be delivered in the ED. Although we have presented only a few examples, we believe it would be beneficial for anyone considering implementation of EGDT to explore potential barriers and solutions based on a valid model such as the one discussed herein.
The intention of this article is to simply share our experiences in the process of implementing EGDT in various clinical practice settings with the hope that others can use this information when considering a similar practice change. As outlined previously, we observed several consistent themes in the process of implementing EGDT at various institutions, such as the need for an implantation team of champions who drive cultural change, an organized approach, upfront training, and ongoing efforts to track and troubleshoot problems. Although the solutions to these themes are often institution specific, clinicians considering implementing this therapy may utilize our experiences to avoid, or at least have insight into, some of the barriers that may be encountered during the implementation process.
Finally, we should note that all of the authors of this report are in agreement that the implementation of EGDT at their respective institutions has resulted in improved patient care and outcomes among patients with sepsis. However, this benefit should be taken in the context of the knowledge that all of the authors are describing the clinical effectiveness of the protocol and thus are unable to definitively describe the number of patients who qualified for the protocol but were not enrolled and the number of patients who received EGDT who were actually not septic.