Opportunities for Emergency Medical Services care of sepsis

doi:10.1016/j.resuscitation.2009.11.008

Resuscitation

Volume 81, Issue 2, February 2010, Pages 193-197

https://doi.org/10.1016/j.resuscitation.2009.11.008 Get rights and content

Abstract

Objective

Emergency Medical Services (EMS) systems play key roles in the rapid identification and treatment of critical illness such as trauma, myocardial infarction and stroke. EMS often provides care for sepsis, a life-threatening sequelae of infection. In this study of Emergency Department patients admitted to the hospital with an infection, we characterized the patients receiving initial care by EMS.

Methods

We prospectively studied patients with suspected infection presenting to a 50,000 visit urban, academic ED from September 16, 2005–September 30, 2006. We included patients who had abnormal ED vital signs or required hospital admission. We identified patients that received EMS care. Between EMS and non-EMS patients, we compared patient age, sex, nursing home residency, vital signs, comorbidities, source of infection, organ dysfunction, sepsis severity and mortality. We analyzed the data using univariate odds ratios, the Wilcoxon rank-sum test and multivariate logistic regression.

Results

Of 4613 ED patients presenting with serious infections, 1576 (34.2%) received initial EMS care. The mortality rate among those transported by EMS was 126/1576 (8.0%) compared to 67/3037 (2.2%) in those who were not. Adjusted mortality was higher for EMS (OR 1.8, 95% CI: 1.3–2.6). Of patients who qualified for protocolized sepsis care in the ED, 99/162 (61.1%) were transported via EMS. EMS patients were more likely to present with severe sepsis (OR 3.9; 3.4–4.5) or septic shock (OR 3.6; 2.6–5.0). EMS patients had higher sepsis acuity (mortality in ED sepsis score 6 vs. 3, p < 0.001).

Conclusions

EMS provides initial care for over one-third of ED infection patients, including the majority of patients with severe sepsis, septic shock, and those who ultimately die. EMS systems may offer important opportunities for advancing sepsis diagnosis and care.

Introduction

Sepsis is the syndrome of microbial infection complicated by systemic inflammation. Sepsis may result in organ dysfunction, shock and death. Sepsis poses a major public health problem, afflicting over 750,000 hospitalized patients, resulting in almost 570,000 Emergency Department visits and causing over 215,000 deaths annually in the United States.1, 2 The successful treatment of sepsis requires timely diagnosis and early, aggressive resuscitation. Recent studies highlight that early, aggressive, structured resuscitative approach strategies can improve sepsis survival.3, 4

Emergency Medical Services (EMS) systems play key roles in the rapid identification and treatment of critical illnesses such as trauma, myocardial infarction and stroke.5, 6, 7, 8 In these organized community systems, EMS personnel provide early case recognition, initial resuscitative therapies and rapid transport to appropriate receiving medical facilities.

EMS often provides similar initial care to critically ill victims of infection and sepsis, performing essential interventions such as intravenous fluid therapy, ventilatory support and airway management. However, there are few organized descriptions of EMS sepsis care. In this study we describe the characteristics EMS of patients presenting to the ED with a serious infection.

Section snippets

Study design and setting

The Institutional Review Boards of the University of Alabama at Birmingham, University of Pittsburgh and Beth Israel Deaconess Medical Center approved this study. We studied a cohort of patients presenting to an urban academic Emergency Department (ED) and receiving admission to the hospital for treatment of an infection.

Study population

This study included patients ≥18 years of age presenting to the ED of the Beth Israel Deaconess Medical Center, Boston, Massachusetts, an urban, academic teaching hospital

Results

Of 4613 ED patients admitted to the hospital for an infection, 1576 (34.2%) received initial EMS care. The overall mortality rate for the population was 4.2%.

EMS patients were more likely to be elderly, female or nursing home residents (Table 1). EMS patients were more likely to have tachypnea, hypoxia, and initial hypotension. Serum lactate levels were slightly higher for EMS patients. EMS patients had higher numbers of comorbid conditions (2 vs. 1, Wilcoxon rank-sum p < 0.01) (Table 2). EMS

Discussion

Patients with infection and sepsis often present with acute organ failure and hemodynamic instability.¹⁴ While prior studies have described the hospital course of sepsis patients, few efforts have characterized the subset receiving initial care from EMS. In this series, EMS provided initial care for over one-third of patients hospitalized for infection. EMS cared for the highest acuity patients, including the majority with hemodynamic instability, severe sepsis and septic shock. EMS cared for

Conclusion

EMS provides initial care for over one-third of ED infection patients, including the majority of patients with severe sepsis and septic shock. EMS systems may offer important opportunities for advancing sepsis diagnosis and care.

Conflict of interest statement

The authors declare no financial or other conflicts of interest.

Funding

HEW and NIS conceived and designed the study. HEW and MDW obtained the data and performed the analysis. HEW drafted the manuscript, and all authors contributed substantially to its revision. HEW had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Acknowledgements

Dr. Wang received support from Clinical Scientist Development Award K08-HS013628 from the Agency for Healthcare Research and Quality, Rockville, Maryland. Dr. Shapiro received support from National Heart Lung and Blood Institute award R01 HL091757 and National Institute of General Medical Sciences award P50 GM076659. The funders had no direct role in the design or execution of the study or the composition of the resulting manuscript.

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Cited by (69)

Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report
2021, Annals of Emergency Medicine
Severe sepsis and septic shock in patients transported by prehospital services versus walk in patients to the emergency department
2021, American Journal of Emergency Medicine
Sepsis is a leading cause of death in the hospital for which aggressive treatment is recommended to improve patient outcomes. It is possible that sepsis patients brought in by emergency medical services (EMS) have a unique advantage in the emergency department (ED) which could improve sepsis bundle compliance.
To evaluate patient care processes and outcome differences between severe sepsis and septic shock patients in the emergency department who were brought in by EMS compared to non-EMS patients.
We performed a retrospective chart review of all severe sepsis and septic shock patients who declared in the ED during January 2012 thru December 2014. We compared differences in patient characteristics, patient care processes, sepsis bundle compliance metrics, and outcomes between both groups.
Of the 1066 patients included in the study, 387 (36.6%) were brought in by EMS and 679 (63.7%) patients arrived via non-EMS transport. In the multivariate regression model, time of triage to sepsis declaration (coeff = −0.406; 95% CI = −0.809, −0.003; p = 0.048) and time of triage to physician (coeff = −0.543; 95% CI = −0.864, −0.221; p = 0.001) was significantly shorter for EMS patients. We found no statistical difference in adjusted individual sepsis compliance metrics, overall bundle compliance, or mortality between both groups.
EMS transported patients have quicker sepsis declaration times and are seen sooner by ED providers. However, we found no statistical difference in bundle compliance or patient outcomes between walk in patients and EMS transported patients.
The prehospital assessment of patients with a final hospital diagnosis of sepsis: Results of an observational study
2019, Australasian Emergency Care
Citation Excerpt :
Among the patients included with a final diagnosis of sepsis, the EMS clinicians in the study managed to identify 36% in the prehospital phase. Previous studies [9,14,28] report varying results for the prehospital identification of sepsis patients, ranging from 6% to 34%. The varying results suggest that this patient group is a great challenge for prehospital organisations and future results are dependent on educational and organisational improvements.
Sepsis is a severe condition which affects 300–800/100,000 persons each year. There are indications that the prehospital identification of patients with sepsis is difficult. The aim of the study was, among patients with a final hospital diagnosis of sepsis, to compare emergency medical service (EMS) field assessments of patients in whom there was a prehospital suspicion of sepsis with those without this suspicion.
The study had a retrospective, observational design. The data used in the study were retrieved from the prehospital and hospital medical records of patients with a final hospital diagnosis of sepsis, transported to hospital by the EMS within a region in the south west of Sweden during a period of one year.
Among patients with a final diagnosis of sepsis (n = 353), the EMS identified the condition in 36% of the cases. These patients were characterised by more abnormal vital signs (a higher respiratory rate and heart rate and more frequent temperature abnormalities) and were more ambitiously assessed (more lung auscultations and more assessments of the degree of consciousness).
The EMS was already able to identify 36% of patients with a final diagnosis of sepsis in the prehospital phase. There were minor differences in the prehospital assessment between patients who were identified by the EMS nurse and those who were not.
Opportunities for achieving resuscitation goals during the inter-emergency department transfer of severe sepsis patients by emergency medical services: A case series
2019, Journal of Critical Care
This study aimed to describe the care provide by Emergency Medical Services (EMS) to severe sepsis patients being transferred between acute care hospitals and identify how that care contributes to sepsis care goals.
This was a single-center retrospective cohort study conducted at a 60,000-visit Midwestern academic emergency department, using run reports from 13 ambulance services transferring from 9 hospitals.
39 patients were included in the final cohort, transferred by 13 ambulance services from 9 hospitals. Included patients were adults with severe sepsis transferred by ambulance between 2009 and 2014. Thirty-nine patients were included in this cohort. 41% (n = 12) of patients received an adequate fluid bolus of 30 mL/kg (median 42.9 mL/kg crystalloid fluid, IQR 8.0 mL/kg) prior to tertiary care arrival. Seventeen percent (n = 2) of patients completed the adequate bolus during transfer time. Broad-spectrum antibiotics were initiated during transfer in 2 patients.
EMS sepsis care during transfer was limited. EMS crews primarily continued treatments previously initiated and did not take additional steps toward resuscitation targets. Data suggests the inter-emergency department transfer period may provide an opportunity to continue working toward treatment targets, though the time is currently underutilized.
Sepsis alerts in EMS and the results of pre-hospital ETCO2
2019, American Journal of Emergency Medicine
Citation Excerpt :
Of particular interest to our study of pre-hospital patient parameters predicting in-hospital patient outcomes was end tidal CO2 (ETCO2) and how it compares to first hospital lactate [5-8]. ETCO2 is a noninvasive method of providing another insight to patient status and patient management by EMS [9-16]. Devices that measure exhaled carbon dioxide are a mature and easy to use technology already available to field EMS.
Field sepsis alerts have the ability to expedite initial ED sepsis treatment. Our hypothesis is that in patients that meet EMS sepsis alert criteria there is a strong relationship between prehospital end-tidal carbon dioxide (ETCO2) readings and the outcome of diagnosed infection.
In 2014, our EMS service initiated a protocol requiring hospitals to receive notification of a “sepsis alert” on all suspected sepsis patients. The EMS service transports 70,000 patients/year to a number of urban centers. All patients transported to our major urban teaching hospital by our EMS service in one year in which a sepsis alert was announced were included in this study. The primary outcome variable was diagnosed infection and secondary outcomes were hospital admission, ICU admission and mortality. Positive lactate was defined as >4.0 mmol/L. ROC curve analysis was used to define the best cutoff for ETCO2.
351 patients were announced as EMS sepsis alert patients and transported to our center over a one year period. Positive outcomes were as follows: diagnosed infection in 28% of patients, hospital admission in 63% and ICU admission in 11%. The correlation between lactate and ETCO2 was −0.45. A ROC curve analysis of ETCO2 vs. lactate >4 found that the best cutoff to predict a high lactate was an ETCO2 of 25 or less, which was considered a positive ETCO2 (AUC = 0.73). 27% of patients had a positive ETCO2 and 24% had a positive lactate. A positive ETCO2 predicted a positive lactate with 76% accuracy, 63% sensitivity and 80% specificity. 27% of those with a positive ETCO2 and 44% of those with a positive lactate had a diagnosed infection. 59% of those with a positive ETCO2 and 89% of those with a positive lactate had admission to the hospital. 15% of those with a positive ETCO2 and 18% of those with a positive lactate had admission to the ICU. Neither lactate nor ETCO2 were predictive of an increased risk for diagnosed infection, hospital admission or ICU admission in this patient population.
While ETCO2 predicted the initial ED lactate levels it did not predict diagnosed infection, admission to the hospital or ICU admission in our patient population but did predict mortality.
Recognition of acute organ failure and associated fluid and oxygen resuscitation by emergency medical services of emergency department patients with a suspected infection
2019, International Emergency Nursing
Citation Excerpt :
In the present study we looked specifically at documentation of clinical signs of organ failure, necessary to recognize sepsis according to the sepsis 3.0 definition. Approximately ∼50% of the patients with a suspected infection were transported to the ED by EMS, correspondent to previous studies [6–11]. These patients were more severely ill and had a higher mortality.
Recognition of acute organ failure is essential for recognition and resuscitation of sepsis by emergency medical services (EMS). We assessed how many EMS patients with suspected infection had clinical signs of acute organ failure (i.e. hypotension), received fluids and oxygen, and how many EMS patients without clinical signs of organ failure appeared to have organ failure in the emergency department (ED).
We interrogated an existing database in which consecutive ED patients hospitalized with suspected infection were prospectively collected. Outcomes were 1) number of patients without clinical signs of organ failure in the ambulance who developed clinical signs of organ failure or appeared to have biochemical signs of organ failure (i.e. hyperlactatemia) in the ED, and 2) number of patients who received fluids and oxygen in the ambulance.
Of the 788 analyzed EMS patients, 529 (67.1%) had clinical signs of organ failure, of whom only 161 (30.4%) received fluids and 372 (70.3%) received oxygen. Clinical signs of organ failure were absent in 259 (32.9%) EMS patients, of which 165 patients (63.7%) developed organ failure in the ED.
In patients with suspected infection, acute organ failure is poorly recognized and treated by EMS, partly because of delayed development of organ failure.

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^☆: A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.11.008.

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Clinical paperOpportunities for Emergency Medical Services care of sepsis☆

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Study design and setting

Study population

Results

Discussion

Conclusion

Conflict of interest statement

Funding

Acknowledgements

Injury

Ann Emerg Med

J Chronic Dis

Ann Emerg Med

Epidemiology of sepsis: an update

Crit Care Med

Prehospital endotracheal intubation errors and patient outcome (abstract)

Prehosp Emerg Care

Early goal-directed therapy in the treatment of severe sepsis and septic shock

N Engl J Med

Severe sepsis and septic shock: review of the literature and emergency department management guidelines

Ann Emerg Med

Development of systems of care for ST-elevation myocardial infarction patients: the emergency medical services and emergency department perspective

Circulation

Implementation strategies for emergency medical services within stroke systems of care: a policy statement from the American Heart Association/American Stroke Association Expert Panel on Emergency Medical Services Systems and the Stroke Council

Stroke

Clinical paper
Opportunities for Emergency Medical Services care of sepsis☆