Canadian association of emergency physicians sepsis treatment checklist: Optimizing sepsis care in canadian emergency departments

Objective: The Canadian Association of Emergency Physicians (CAEP) sepsis guidelines created by the CAEP Critical Care Practice Committee (C4) and published in the Canadian Journal of Emergency Medicine (CJEM) form the most definitive publication on Canadian emergency department (ED) sepsis care to date. Our intention was to identify which of the care items in this document are specifically necessary in the ED and then to provide these items in a tiered checklist that can be used by any Canadian ED practitioner. Methods: Practice points from the CJEM sepsis publication were identified to create a practice point list. Members of C4 then used a Delphi technique consensus process over May to October 2009 via e-mail to create a tiered checklist of sepsis care items that can or could be completed in a Canadian ED when caring for the septic shock patient. This checklist was then assessed for use by a survey of ED practitioners from varying backgrounds (rural ED, community ED, tertiary ED) from July to October 2010. Results: Twenty sepsis care items were identified in the CAEP sepsis guidelines. Fifteen items were felt to be necessary for ED care. Two levels of checklists were then created that can be used in a Canadian ED. Most ED physicians in community and tertiary care centres could complete all parts of the level I sepsis checklist. Rural centres often struggle with the ability to obtain lactate values and central venous access. Many items of the level II sepsis checklist could not be completed outside the tertiary care centre ED. Conclusion: Sepsis care continues to be an integral and major part of the ED domain. Practice points for sepsis care that require specialized monitoring and invasive techniques are often limited to larger tertiary care EDs and, although heavily emphasized by many medical bodies, cannot be reasonably expected in all centres. When the resources of a centre limit patient care, transfer may be required. Emergency department (ED) sepsis care is important and reduces mortality. Provision of this care can be improved through the use of sepsis protocols or guidelines.1-4 The Canadian Association of Emergency Physicians (CAEP) sepsis guidelines were published in 2008 to that end.5 Although meant to be all-encompassing and to present current "state of the art" care, some have requested a more user-friendly format.6 As well, controversy exists as to whether specialized invasive sepsis care is necessary in the ED.7 ED care in Canada varies, depending on patient location, access to tertiary care, ED volumes, time of operation, and practitioner access to treatment/monitoring skills and capabilities.8 At present, no publication has made an attempt to present sepsis care protocols based on the resources available within differing types of EDs. To meet the needs of all Canadian ED physicians, the CAEP Critical Care Practice Committee (C4) sought to take the CAEP sepsis guidelines it created and compile two checklists of care items. Although all items are felt to be necessary for optimal sepsis management, having two checklists with escalating levels of care should allow physicians in any Canadian ED to use the checklist that is more appropriate for their abilities and resources. ED sepsis care should be of short duration (< 6 hours) and attempt to ensure timely transfer to the most appropriate location for ongoing care (e.g., operating room, tertiary hospital, intensive care unit [ICU]). Remaining items were felt to be more important for inpatient care.