Prehospital sepsis alert notification decreases time to initiation of CMS sepsis core measures

Predicting sepsis at emergency department triage: Implementing clinical and laboratory markers within the first nursing assessment to enhance diagnostic accuracy

BACKGROUND

Early identification of sepsis in the emergency department (ED) triage is both valuable and challenging. Numerous studies have endeavored to pinpoint clinical and biochemical criteria to assist clinicians in the prompt diagnosis of sepsis, but few studies have assessed the efficacy of these criteria in the ED triage setting. The aim of the study was to explore the accuracy of clinical and laboratory markers evaluated at the triage level in identifying patients with sepsis.

METHODS

A prospective study was conducted in a large academic urban hospital, implementing a triage protocol aimed at early identification of septic patients based on clinical and laboratory markers. A multidisciplinary panel of experts reviewed cases to ensure accurate identification of septic patients. Variables analyzed included: Charlson comorbidity index, mean arterial pressure (MAP), partial pressure of carbon dioxide (PetCO2), white cell count, eosinophil count, C-reactive protein to albumin ratio, procalcitonin, and lactate.

RESULTS

A total of 235 patients were included. Multivariable analysis identified procalcitonin ≥1 ng/mL (OR 5.2; p < 0.001); CRP-to-albumin ratio ≥32 (OR 6.6; p < 0.001); PetCO2 ≤ 28 mmHg (OR 2.7; p = 0.031), and MAP <85 mmHg (OR 7.5; p < 0.001) as independent predictors for sepsis. MAP ≥85 mmHg, CRP/albumin ratio <32, and procalcitonin <1 ng/mL demonstrated negative predictive values for sepsis of 90%, 89%, and 88%, respectively.

CONCLUSIONS

Our study underscores the significance of procalcitonin and mean arterial pressure, while introducing CRP/albumin ratio and PetCO2 as important variables to consider in the very initial assessment of patients with suspected sepsis in the ED.

CLINICAL RELEVANCE

Early identification of sepsis since the emergency department (ED) triage is challenging Implementing the ED triage protocol with simple clinical and laboratory markers allows to recognize patients with sepsis with a very good discriminatory power (AUC 0.88).

How consistent are pre-alert guidelines? A review of UK ambulance service guidelines

Aims

Ambulance pre-alerts are used to inform receiving emergency departments (EDs) of the arrival of critically unwell or rapidly deteriorating patients who need time-critical assessment or treatment immediately upon arrival. Inappropriate use of pre-alerts can lead to EDs diverting resources from other critically ill patients. However, there is limited guidance about how pre-alerts should be undertaken, delivered or communicated. We aimed to map existing pre-alert guidance from UK NHS ambulance services to explore consistency and accessibility of existing guidance.

Methods

We contacted all UK ambulance services to request documentation containing guidance about pre-alerts. We reviewed and mapped all guidance to understand which conditions were recommended for a pre-alert and alignment with Association of Ambulance Chief Executives (AACE) and Royal College of Emergency Medicine (RCEM) pre-alert guidance. We reviewed the language and accessibility of guidance using the AGREE II tool.

Results

We received responses from 15/19 UK ambulance services and 10 stated that they had specific pre-alert guidance. We identified noticeable variations in conditions declared suitable for pre-alerts in each service, with a lack of consistency within each ambulance service's own guidance, and a lack of alignment with the AACE/RCEM pre-alert guidance. Services listed between four and 45 different conditions suitable for pre-alert. There were differences in physiological thresholds and terminology, even for conditions with established care pathways (e.g. hyperacute stroke, ST segment elevation myocardial infarction). Pre-alert criteria were typically listed in several short sections in lengthy handover procedure policy documents. Documents appraised were of poor quality with low scores below 35% for applicability and overall.

Implications

There is a clear need for ambulance services to have both policies and tools that complement each other and incorporate the same list of pre-alertable conditions. Clinicians need a single, easily accessible document to refer to in a time-critical situation to reduce the risk of making an incorrect pre-alert decision.

Prehospital early warning scores for adults with suspected sepsis: the PHEWS observational cohort and decision-analytic modelling study

Background

Guidelines for sepsis recommend treating those at highest risk within 1 hour. The emergency care system can only achieve this if sepsis is recognised and prioritised. Ambulance services can use prehospital early warning scores alongside paramedic diagnostic impression to prioritise patients for treatment or early assessment in the emergency department.

Objectives

To determine the accuracy, impact and cost-effectiveness of using early warning scores alongside paramedic diagnostic impression to identify sepsis requiring urgent treatment.

Design

Retrospective diagnostic cohort study and decision-analytic modelling of operational consequences and cost-effectiveness.

Setting

Two ambulance services and four acute hospitals in England.

Participants

Adults transported to hospital by emergency ambulance, excluding episodes with injury, mental health problems, cardiac arrest, direct transfer to specialist services, or no vital signs recorded.

Interventions

Twenty-one early warning scores used alongside paramedic diagnostic impression, categorised as sepsis, infection, non-specific presentation, or other specific presentation.

Main outcome measures

Proportion of cases prioritised at the four hospitals; diagnostic accuracy for the sepsis-3 definition of sepsis and receiving urgent treatment (primary reference standard); daily number of cases with and without sepsis prioritised at a large and a small hospital; the minimum treatment effect associated with prioritisation at which each strategy would be cost-effective, compared to no prioritisation, assuming willingness to pay £20,000 per quality-adjusted life-year gained.

Results

Data from 95,022 episodes involving 71,204 patients across four hospitals showed that most early warning scores operating at their pre-specified thresholds would prioritise more than 10% of cases when applied to non-specific attendances or all attendances. Data from 12,870 episodes at one hospital identified 348 (2.7%) with the primary reference standard. The National Early Warning Score, version 2 (NEWS2), had the highest area under the receiver operating characteristic curve when applied only to patients with a paramedic diagnostic impression of sepsis or infection (0.756, 95% confidence interval 0.729 to 0.783) or sepsis alone (0.655, 95% confidence interval 0.63 to 0.68). None of the strategies provided high sensitivity (> 0.8) with acceptable positive predictive value (> 0.15). NEWS2 provided combinations of sensitivity and specificity that were similar or superior to all other early warning scores. Applying NEWS2 to paramedic diagnostic impression of sepsis or infection with thresholds of > 4, > 6 and > 8 respectively provided sensitivities and positive predictive values (95% confidence interval) of 0.522 (0.469 to 0.574) and 0.216 (0.189 to 0.245), 0.447 (0.395 to 0.499) and 0.274 (0.239 to 0.313), and 0.314 (0.268 to 0.365) and 0.333 (confidence interval 0.284 to 0.386). The mortality relative risk reduction from prioritisation at which each strategy would be cost-effective exceeded 0.975 for all strategies analysed.

Limitations

We estimated accuracy using a sample of older patients at one hospital. Reliable evidence was not available to estimate the effectiveness of prioritisation in the decision-analytic modelling.

Conclusions

No strategy is ideal but using NEWS2, in patients with a paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2. Research is needed to develop better definition, diagnosis and treatments for sepsis.

Study registration

This study is registered as Research Registry (reference: researchregistry5268).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/136/10) and is published in full in Health Technology Assessment; Vol. 28, No. 16. See the NIHR Funding and Awards website for further award information.

Do prehospital sepsis alerts decrease time to complete CMS sepsis measures?

INTRODUCTION

In an effort to improve sepsis outcomes the Centers for Medicare and Medicaid Services (CMS) established a time sensitive sepsis management bundle as a core quality measure that includes blood culture collection, serum lactate collection, initiation of intravenous fluid administration, and initiation of broad-spectrum antibiotics. Few studies examine the effects of a prehospital sepsis alert protocol on decreasing time to complete CMS sepsis core measures.

METHODS

This study was a retrospective cohort study of patients transported via EMS from December 1, 2018 to December 1, 2019 who met the criteria of the Maryland Statewide EMS sepsis protocol and compared outcomes between patients who activated a prehospital sepsis alert and patients who did not activate a prehospital sepsis alert. The Maryland Institute for Emergency Medical Services Systems developed a sepsis protocol that instructs EMS providers to notify the nearest appropriate facility with a sepsis alert if a patient 18 years of age and older is suspected of having an infection and also presents with at least two of the following: temperature >38 °C or <35.5 °C, a heart rate >100 beats per minute, a respiratory rate >25 breaths per minute or end-tidal carbon dioxide less than or equal to 32 mmHg, a systolic blood pressure <90 mmHg, or a point of care lactate reading greater than or equal to 4 mmol/L.

RESULTS

Median time to achieve all four studied CMS sepsis core measures was 103 min [IQR 61-153] for patients who received a prehospital sepsis alert and 106.5 min [IQR 75-189] for patients who did not receive a prehospital sepsis alert (p-value 0.105). Median time to completion was shorter for serum lactate collection (28 min. vs 35 min., p-value 0.019), blood culture collection (28 min. vs 38 min., p-value <0.01), and intravenous fluid administration (54 min. vs 61 min., p-value 0.025) but was not significantly different for antibiotic administration (94 min. vs 103 min., p-value 0.12) among patients who triggered a sepsis alert.

CONCLUSION

This study questions the effectiveness of prehospital sepsis alert protocols on decreasing time to complete CMS sepsis core measures. Future studies should address if these times can be impacted by having EMS providers independently administer antibiotics.

End-tidal carbon dioxide measured at emergency department triage outperforms standard triage vital signs in predicting in-hospital mortality and intensive care unit admission

OBJECTIVES

This study assessed the ability of end-tidal carbon dioxide (ETCO2 ) in predicting in-hospital mortality and intensive care unit (ICU) admission compared to standard vital signs at ED triage as well as comparing to measures of metabolic acidosis.

METHODS

This prospective study enrolled adult patients presenting to the ED of a tertiary care Level I trauma center over 30 months. Patients had standard vital signs measured along with exhaled ETCO2 at triage. Outcome measures included in-hospital mortality; ICU admission; and correlations with lactate, sodium bicarbonate (HCO3 ), and anion gap.

RESULTS

There were 1136 patients enrolled and 1091 patients with outcome data available. There were 26 (2.4%) patients who did not survive to hospital discharge. Mean ETCO2 levels were 34 (33-34) in survivors and 22 (18-26) nonsurvivors (p < 0.001). The area under the curve (AUC) for predicting in-hospital mortality for ETCO2 was 0.82 (0.72-0.91). In comparison the AUC for temperature was 0.55 (0.42-0.68), respiratory rate (RR) 0.59 (0.46-0.73), systolic blood pressure (SBP) 0.77 (0.67-0.86), diastolic blood pressure (DBP) 0.70 (0.59-0.81), heart rate (HR) 0.76 (0.66-0.85), and oxygen saturation (SpO2 ) 0.53 (0.40-0.67). There were 64 (6%) patients admitted to the ICU, and the ETCO2 AUC for predicting ICU admission was 0.75 (0.67-0.80). In comparison the AUC for temperature was 0.51, RR 0.56, SBP 0.64, DBP 0.63, HR 0.66, and SpO2 0.53. Correlations between expired ETCO2 and serum lactate, anion gap, and HCO3 were rho = -0.25 (p < 0.001), rho = -0.20 (p < 0.001), and rho = 0.330 (p < 0.001), respectively.

CONCLUSIONS

ETCO2 was a better predictor of in-hospital mortality and ICU admission than the standard vital signs at ED triage. ETCO2 correlated significantly with measures of metabolic acidosis.

Impact of Prehospital Antibiotics on in-Hospital Mortality in Emergency Medical Service Patients with Sepsis

Background

Sepsis is a life-threatening medical condition that requires early recognition and timely management to improve patient outcomes and reduce mortality rates. Administering antibiotics in the prehospital setting can be effective to reduce the time to antibiotic therapy, which may be crucial for sepsis patients. However, the impact of prehospital antibiotics on mortality in sepsis patients remains uncertain, and the current evidence to support this practice in middle-income countries is particularly limited.

Methods

This was a single-center, retrospective-prospective cohort study aimed at determining the impact of prehospital antibiotics on in-hospital mortality rates among adult patients with sepsis. The study included patients who received care from the advanced level of Emergency Medical Service between June 2020 and October 2022 and compared the mortality rates of patients who received prehospital antibiotics with those of their counterparts who did not.

Results

In this study, 180 patients with a mean age of 71.6 ± 15.7 years were included, of whom 68.9% experienced respiratory infections. The results demonstrated that the prehospital antibiotic group had a significantly lower in-hospital mortality rate (32.2%) than the non-prehospital antibiotic group (47.8%; p=0.034). After adjusting for confounding factors, the odds ratio was 0.304 (95% CI: 0.11, 0.82; p=0.018), indicating a 69.6% lower incidence of in-hospital mortality in the prehospital antibiotic group. Furthermore, the prehospital antibiotic group received antibiotics significantly earlier (16.0 ± 7.4 minutes) than the non-prehospital group (50.9 ± 29.4 minutes; p<0.001).

Conclusion

This study provides evidence to support the administration of antibiotics to sepsis patients in the prehospital setting, as this practice can reduce mortality rates. However, larger, multicenter studies are required to confirm these findings and to further investigate the potential benefits of prehospital antibiotics in improving patient outcomes.

Prehospital Recognition and Management of Pediatric Sepsis: A Qualitative Assessment

BACKGROUND AND PURPOSE

Sepsis is a life-threatening disease in children and is a leading cause of morbidity and mortality. Early prehospital recognition and management of children with sepsis may have significant effects on the timely resuscitation of this high-risk clinical condition. However, the care of acutely ill and injured children in the prehospital setting can be challenging. This study aims to understand barriers, facilitators, and attitudes regarding recognition and management of pediatric sepsis in the prehospital setting.

METHODS

This was a qualitative study of EMS professionals participating in focus groups using a grounded theory-based design to gather information on recognition and management of septic children in the prehospital setting. Focus groups were held for EMS administrators and medical directors. Separate focus groups were held for field clinicians. Focus groups were conducted via video conference until saturation of ideas was reached. Using consensus methodology, transcripts were coded in an iterative process. Data were then organized into positive and negative factors based on the validated PRECEDE-PROCEED model for behavioral change.

RESULTS

Thirty-eight participants in six focus groups identified nine environmental factors, 21 negative factors, and 14 positive factors pertaining to recognition and management of pediatric sepsis. These findings were organized into the PRECEDE-PROCEED planning model. Pediatric sepsis guidelines were identified as positive factors when they did exist and negative factors when they were complicated or did not exist. Six interventions were identified by participants. These include raising awareness of pediatric sepsis, increasing pediatric education, receiving feedback on prehospital encounters, increasing pediatric exposure and skills training, and improving dispatch information.

CONCLUSION

This study fills a gap by examining barriers and facilitators to prehospital diagnosis and management of pediatric sepsis. Using the PRECEDE-PROCEED model, nine environmental factors, 21 negative factors, and 14 positive factors were identified. Participants identified six interventions that could create the foundation to improve prehospital pediatric sepsis care. Policy changes were suggested by the research team based on the results of this study. These interventions and policy changes provide a roadmap for improving care in this population and lay the groundwork for future research.

Association between emergency department sepsis order set design and delay to second dose piperacillin-tazobactam administration

BACKGROUND

Delay to first antibiotic dose in patients with sepsis has been associated with increased mortality. Second dose antibiotic delay has also been linked to worsened patient outcomes. Optimal methods to decrease second dose delay are currently unclear. The primary objective of this study was to evaluate the association between updating an emergency department (ED) sepsis order set design from one-time doses to scheduled antibiotic frequencies and delay to administration of second piperacillin-tazobactam dose.

METHODS

This retrospective cohort study was conducted at eleven hospitals in a large, integrated health system and included adult patients treated in the ED with at least one dose of piperacillin-tazobactam ordered through an ED sepsis order set over a two year period. Patients were excluded if they received less than two doses of piperacillin-tazobactam. Midway through the study period, the enterprise-wide ED sepsis order set was updated to include scheduled antibiotic frequencies. Two patient cohorts receiving piperacillin-tazobactam were compared: those in the year before the order set update and those in the year post-update. The primary outcome was major delay, defined as an administration delay >25% of the recommended dosing interval, which was evaluated with multivariable logistic regression and interrupted time series analysis.

RESULTS

3219 patients were included: 1222 in the pre-update group and 1997 in the post-update group. The proportion of patients who experienced major second dose delay was significantly lower in the post-update group (32.7% vs 25.6%, p < 0.01; adjusted OR 0.64, 95% CI 0.52 to 0.78). No between-group difference was detected in the slope of monthly major delay frequency, but there was a significant level change (post-update change -10%, 95% CI -17.9% to -1.9%).

CONCLUSIONS

Including scheduled antibiotic frequencies in ED sepsis order sets is a pragmatic mechanism to decrease delays in second antibiotic doses.

Utility of Emergency Medical Dispatch (EMD) Telephone Screening in Identifying COVID-19 Positive Patients

Background: In response to the COVID-19 pandemic, Emergency Medical Services (EMS) systems have received guidelines as part of coordinated response efforts aimed at mitigating exposures and ensuring occupational wellbeing, including recommendations of Personal Protective Equipment (PPE) utilization, and modifications of Emergency Medical Dispatch (EMD) caller queries. The aim of the study was to estimate the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of an EMD telephone screening process for the identification of hospital diagnosed COVID-19 positive patients. Methods: A retrospective cohort study was conducted of adult EMS encounters presenting to hospitals within a large health system from March 16-June 30, 2020. EMD telephone screening status was defined as either "positive" or "negative" and was collected from prehospital medical records. COVID-19 positive patients were confirmed via hospital laboratory diagnosis and were matched to their prehospital medical record data. Patient demographics and EMS encounter level data, such as Dispatch Code and Priority level, were also collected. Estimations of sensitivity, specificity, PPV and NPV were made. Emergency telephone screening status was stratified by COVID-19 diagnosis to describe discordant pairs. Results: Of the 3,443 total encounters screened, there were 652 patients who were subsequently COVID-19 positive per hospital diagnosis (18.9%). Approximately 5.0% of all encounters did not screen positive on EMD screening but were later COVID-19 positive. Conversely, 44.2% of encounters screened positive for COVID-19, but were subsequently negative. Sensitivity of the EMD telephonic screening was estimated as 75.0% (95% CI 71.7%, 78.3%) and specificity was 45.5% (95% CI 43.7%, 47.4%). The PPV was 24.3% (95% CI 22.5%, 26.0%), and NPV 88.6% (95% CI 87.0%, 90.3%). Conclusions: The sensitivity of the EMD telephonic screening process was moderately able to identify COVID-19 positive patients. There is a need to reevaluate and revise guidelines and recommendations, specifically modified caller queries, as part of ongoing pandemic emergency response efforts in order to reduce transmissions and maximize patient and provider safety.

Pre-hospital antibiotic therapy preceded by blood cultures in a physician-manned mobile emergency care unit

BACKGROUND

Rapid recognition and antibiotic treatment, preferably preceded by blood cultures (BCs), is a mainstay in sepsis therapy. The objective of this investigation was to determine if pre-hospital BCs were feasible and drawn with an acceptably low level of contamination and to investigate whether pre-hospital antibiotics were administered on correct indications.

METHODS

We performed a register-based study in a pre-hospital physician-manned mobile emergency care unit (MECU) operating in a mixed urban/rural area in Denmark. All patients who received pre-hospital antibiotics by the MECU from November 2013 to October 2018 were reviewed. Outcome measures were characterisation of microbial findings and subsequent in-hospital confirmation of the pre-hospital indication for antibiotics.

RESULTS

One-hundred-and-nineteen patients received antibiotics pre-hospitally. Six were excluded. One-hundred-and-thirteen patients were included in the study. BCs were drawn in 107 of the 113 patients (94.7% [88.8%-98.0%]). We found a true pathogen of sepsis in 29 (27.1% [19.0%-36.6%]) of these 107 patients. Nine (8.4% [3.9%-15.4%]) patients had contaminated pre-hospital BCs. Forty-nine of all patients (36.3% [27.4%-45.9%]) had causative pathogens in either their BCs or other samples confirming the pre-hospital tentative diagnosis. Eighty-two (72.6% [63.4%-80.5%]) patients received antibiotic therapy in-hospitally, while 27 (23.9% [16.4%-32.8%]) were assigned an in-hospital diagnosis not associated with infection. Four (3.5% [1.0%-8.8%]) patients died in hospital before a diagnosis was established.

CONCLUSIONS

Pre-hospital administration of antibiotics preceded by BCs is feasible, although with somewhat high blood culture contamination rates. Antibiotics are administered on reasonable indications.

The Use of Patient Monitoring Systems to Improve Sepsis Recognition and Outcomes: A Systematic Review

Introduction

The aim of this systematic review was to determine the impact of automated patient monitoring systems (PMSs) on sepsis recognition and outcomes.

Methods

Systematic searches were conducted using CINAHL, MEDLINE, and Cochrane, for articles published from 2008 through 2018. English-language, peer-reviewed articles that reported the impact of PMS on sepsis care were included. For selected articles, the authors abstracted information, with the study designed to be compliant with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

Results

Nineteen articles were identified for inclusion: 4 systematic reviews and 15 individual studies. Study design and quality varied, with some randomized controlled trials and quasiexperimental studies, as well as many observational studies. Study results for outcome measures (e.g., mortality, intensive care unit [ICU] length of stay, ICU transfer) were mixed, with more than half of the studies showing a significant improvement in at least one measure. Evidence for process measure (e.g., time to antibiotic administration, lactate measurement, etc.) improvement was of moderate strength across multiple types of hospital units, and evidence was most consistent outside the ICU.

Conclusions

Automated sepsis PMSs have the potential to improve sepsis recognition and outcomes, but current evidence is mixed on their effectiveness. More high-quality studies are needed to understand the effects of PMSs on important sepsis-related process and outcome measures in different hospital units.

Resuscitation Resident Impact in the Treatment of Sepsis

Background The resuscitation of septic patients is a fundamental skill of emergency medicine (EM) training. We developed a required rotation designed to augment resident training in resuscitating critically ill patients in the emergency department (ED). The purpose of this study was to evaluate the successful completion of sepsis core measures alongside clinical outcomes between patients with a resuscitation resident (RR) involved in care versus patients without. Methods This retrospective study was conducted at a single site tertiary care Level 1 trauma center with an ED census of 130,000 visits annually. Data were collected from January 1, 2015, to December 31, 2016, using the electronic medical record (EMR) via an Epic query (Epic Systems Corp., Verona, WI). Patients admitted with severe sepsis or septic shock (Surviving Sepsis Campaign guidelines) were included and separated into two groups, one with RR involvement and one without. Emergency department length of stay, time to initial lactic acid draw, lactic acid value, time to bolus fluid initiation, time to antibiotic initiation, need for medical intensive care unit (ICU) admission, and 30-day mortality were compared between the two groups. Chi-square tests and Fisher's exact tests were used to analyze the categorical variables. Two-sided t-tests and Wilcoxon rank-sum tests were used to examine continuous variables. Results Out of 4,746 patients admitted, 101 patients had an RR participate in their care. The median time to initial lactic acid draw was shorter (0.53 vs 1.05 hours; p < 0. 0001) and the lactic acid level was higher (2.5 vs 1.8 mmol/L; p < 0. 0001) with the presence of an RR. Resuscitation resident was correlated with a decrease in time to antibiotics and appropriate 30 cc/kg bolus, however, these were not statistically significant (p = 0.10 and p = 0.09 respectively). Resuscitation resident involvement was also associated with more medical ICU (45.5% vs 18.8%; p<0.0001) admissions and a higher 30-day mortality (14.9% vs 29.7%; p < 0. 0001). All other variables were not statistically significant. Conclusion Resuscitation residents demonstrate a statistically significant impact on lactic acid-related bundle compliance and help facilitate the care of higher acuity severe sepsis and septic shock patients.

Time to antibiotic administration: Sepsis alerts called in emergency department versus in the field via emergency medical services

INTRODUCTION

The Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) identifies patients with "severe sepsis" and mandates antibiotics within a specific time window. Rapid time to administration of antibiotics may improve patient outcomes. The goal of this investigation was to compare time to antibiotic administration when sepsis alerts are called in the emergency department (ED) with those called in the field by emergency medical services (EMS).

METHODS

This was a multi-center, retrospective review of patients designated as sepsis alerts in ED or via EMS in the field, presenting to four community emergency departments over a six-month period.

RESULTS

507 patients were included, 419 in the ED alert group and 88 in the field alert group. Mean time to antibiotic administration was significantly faster in the field alert group when compared to the ED alert group (48.5 min vs 64.5 min, p < 0.001). Patients were more likely to receive antibiotics within 60 min of ED arrival in the field alert group (59.1% vs 44%, p = 0.01). Secondary outcomes including mortality, hospital length of stay, intensive care unit length of stay, sepsis diagnosis on admission, Clostridioides difficile infection rates, fluid bolus utilization, anti-MRSA antibiotic utilization rates, and anti-Pseudomonal antibiotic utilization rates were not found to be significantly different.

CONCLUSIONS

Sepsis alerts called in the field via EMS may decrease time to antibiotics and increase the likelihood of antibiotic administration occurring within 60 min of arrival when compared to those called in the ED.

Emergency Medical Services Care and Sepsis Trajectories

Objective: Many sepsis patients receive initial care from prehospital Emergency Medical Services (EMS). While earlier sepsis care improves outcomes, the characteristics, care and outcomes of those treated by EMS versus those arriving directly to an emergency department (ED) are currently not detailed. We sought to determine differences in hospital presentation, course and outcomes between EMS and non-EMS patients enrolled in the Protocolized Care of Early Septic Shock (ProCESS) trial. Methods: We performed a secondary analysis of ProCESS, which studied ED patients with septic shock. EMS care was the primary exposure. We determined differences in demographics, clinical features, interventions and hospital course between EMS and non-EMS patients. Using mixed models, we determined the association between EMS care and 60-day mortality. Results: Among 1,341 patients, 826 (61.6%) received initial EMS care. EMS patients were older, more likely to be black (OR 1.49, 95% CI 1.14-1.95) or nursing home residents (5.57, 3.61-8.60), and more likely to have chronic respiratory disease (1.36, 1.04-1.78), cerebral vascular disease (1.56; 1.04-2.33), peripheral vascular disease (2.02; 1.29-3.16), and dementia (3.53; 2.04-6.10). EMS patients were more likely to present with coma (4.48; 2.53-7.96) or elevated lactate (1.30; 1.04-1.63), and to receive mechanical ventilation in the ED (7.16; 4.34-11.79). There were no differences in infection source or total intravenous fluids. Initial differences in vasopressor use (1.66; 1.22-2.26) resolved at 6 hours (1.18; 0.94-1.47). Initial differences in APACHE II (EMS 21.8 vs. non-EMS 19.0) narrowed by 48 hours (17.9 vs. 16.3, [EMS X time] interaction p = 0.003). Although EMS patients exhibited higher 60-day mortality, after adjustment for confounders, this association was not significant (1.09, 95% CI: 0.78-1.55). Conclusions: While EMS sepsis patients presented with worse chronic, nonmodifiable characteristics and higher acuity than non-EMS patients, differences in acuity narrowed after initial hospital care. Despite having higher illness burden, EMS patients did not have worse adjusted short-term mortality.

Characteristics of the prehospital phase of adult emergency department patients with an infection: A prospective pilot study

OBJECTIVE

Research on serious infections/sepsis has focused on the hospital environment, while potentially the most delay, and therefore possibly the best opportunity to improve quality of care, lies in the prehospital setting. In this study we investigated the prehospital phase of adult emergency department (ED) patients with an infection.

METHODS

In this prospective pilot study all adult (≥18y) patients with a suspected/proven infection, based on the notes in the patient's ED chart, were included during a 4-week period in 2017. Prehospital course, ED findings, presence of sepsis and 30-day outcomes were registered.

RESULTS

A total of 440 patients were identified, with a median symptom duration before ED visit of 3 days (IQR 1-7 days). Before arrival in the ED, 23.9% of patients had used antibiotics. Most patients (83.0%) had been referred by a general practitioner (GP), while 41.1% of patients had visited their GP previously during the current disease episode. Patients referred by a GP were triaged as high-urgency less often, while vital parameters were similar. Emergency Medical Services (EMS) transported 268 (60.9%) of patients. Twenty-two patients (5.0%) experienced an adverse outcome (30-day all-cause mortality and/or admission to intensive care).

CONCLUSIONS

Patients with a suspected infection had symptoms for 3 (IQR 1-7) days at the moment of presentation to the ED. During this prehospital phase patients often had consulted, and were treated by, their GP. Many were transported to the ED by EMS. Future research on severe infections should focus on the prehospital phase, targeting patients and primary care professionals.