Procrastination Is the Thief of Time1: Surviving Guidelines

The title of this editorial is the first line of a Shakespearean-style sonnet, penned (the author more accurately stated, “penciled”) by a young schoolboy as a punishment for being late. The author later became a professor of poetry at both Cornell and Oxford Universities, and his message from more than half a century ago has a powerful bearing on the problems we face in healthcare today. Time has an inverse quality—the less time something takes, the greater we value the process. Time has an easily quantifiable value when measured in railway timetables and the speed of processing units in computers. In the management of critically ill patients, the more quickly treatment is started, the more likely the outcome will be satisfactory. The element of time in the resuscitation of an acutely compromised patient is obvious. A dilatory response to the early signs of deterioration in a patient’s condition will allow an unchecked decline to continue until the patient may really need the full services of the critical care team. The problem was summed up by R Adams Cowley, founder of the Maryland Institute of Emergency Medical Services, in his principle of the “Golden Hour”: “You can spend money, train doctors and nurses, develop drugs . . . but if you wait too long, none of these things help. Time is the one thing you can’t buy.” The resuscitation of patients with severe sepsis or septic shock gives a good example of how nipping it in the bud may not only stop the deterioration in the patient’s condition, but also be curative. Thirty years ago, Ledingham noted that many of the patients referred to him with septic shock were resuscitated with a prompt and vigorous administration of fluid and that with planned management, a reduction from 71% to 38% in the rate of mortality occurred during a 3-year period. Shoemaker also showed improved outcomes with early resuscitation designed to maximize oxygen delivery. Although their study has been criticized for lacking proper randomization, Heyland and colleagues felt there was a high probability that beneficial results were a consequence of early resuscitation. In 2001, Rivers and colleagues demonstrated that an immediate organized approach to resuscitation of patients with severe sepsis or septic shock was highly successful clinically and cost-effective. Many patients demonstrate their first manifestations of sepsis outside a critical care unit. Early appropriate resuscitation in cases of septic conditions saves lives. Recently, exciting new guidelines have been established as a result of the Surviving Sepsis Campaign and the work of various others who have been using outreach programs and medical emergency teams (METs) in their intensive care units (ICUs).