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Chung YT, Yeh CY, Chen CC, Lai CH, Lin YH, Lin CY, Shu YC, Ko NY. Early changes in skin surface temperature predict body temperature increases in patients with fever: A pilot study. Intensive Crit Care Nurs 2024; 83:103652. [PMID: 38402650 DOI: 10.1016/j.iccn.2024.103652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/28/2024] [Accepted: 02/03/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE To investigate the correlation between body temperature and skin surface temperature in intensive care unit patients and to identify specific indicators of skin surface temperature for early fever detection. RESEARCH METHODOLOGY/DESIGN This pilot study was a prospective, observational investigation conducted at National Cheng Kung University Hospital in Tainan, Taiwan. A total of 54 patients admitted to the Surgical Intensive Care Unit of a tertiary hospital between April and August 2020 were included. Patients utilized the wearable device HEARThremoTM to continuously monitor skin surface temperature and heart rate. Analysis of Variance was applied to identify the association of skin surface temperature with different body temperature groups. The comparison between skin surface temperature and fever over eight time intervals was studied using a generalized estimating equation. RESULTS In 34 patients (63 %) with a fever (≥38 °C), skin surface temperature increased (P < 0.001) when body temperature increased. The maximum skin surface temperature was significantly associated with fever 180-210 min before the fever events occurred (OR: 2.22, 95 % CI: 1.30-3.80). The mean skin surface temperature was associated with fever 120-150 min before the fever events (OR: 8.70, 95 % CI: 2.08-36.36). CONCLUSIONS Skin surface temperature can be an important early predictive sign before the onset of fever. Continuous temperature monitoring can detect fever early and initiate treatment in advance. This study serves as a preliminary exploration in this area, laying the groundwork for future comprehensive research. IMPLICATIONS FOR CLINICAL PRACTICE Continuous monitoring of skin surface temperature empowers nurses to swiftly detect fever, transcending conventional methods. This proactive approach allows for the early identification of physiological abnormalities, facilitating the prompt initiation of further physical assessments and relevant examinations for early treatment commencement.
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Affiliation(s)
- Yi-Ting Chung
- Department of Nursing, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Yin Yeh
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Chang-Chun Chen
- Department of Electrical and Computer Engineering, The University of Arizona, America
| | - Chao-Han Lai
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biochemistry and Molecular Biology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Hsuan Lin
- Office of Geriatric Hospital, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Ying Lin
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Chen Shu
- Department of Mathematics, National Cheng Kung University, Tainan, Taiwan.
| | - Nai-Ying Ko
- Department of Nursing, National Cheng Kung University, Tainan, Taiwan.
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Piedmont S, Goldhahn L, Swart E, Robra BP, Fleischmann-Struzek C, Somasundaram R, Bauer W. Sepsis incidence, suspicion, prediction and mortality in emergency medical services: a cohort study related to the current international sepsis guideline. Infection 2024; 52:1325-1335. [PMID: 38372959 PMCID: PMC11288994 DOI: 10.1007/s15010-024-02181-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/08/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE Sepsis suspicion by Emergency Medical Services (EMS) is associated with improved patient outcomes. This study assessed sepsis incidence and recognition by EMS and analyzed which of the screening tools recommended by the Surviving Sepsis Campaign best facilitates sepsis prediction. METHODS Retrospective cohort study of claims data from health insurances (n = 221,429 EMS cases), and paramedics' and emergency physicians' EMS documentation (n = 110,419); analyzed outcomes were: sepsis incidence and case fatality compared to stroke and myocardial infarction, the extent of documentation for screening-relevant variables and sepsis suspicion, tools' intersections for screening positive in identical EMS cases and their predictive ability for an inpatient sepsis diagnosis. RESULTS Incidence of sepsis (1.6%) was similar to myocardial infarction (2.6%) and stroke (2.7%); however, 30-day case fatality rate was almost threefold higher (31.7% vs. 13.4%; 11.8%). Complete vital sign documentation was achieved in 8.2% of all cases. Paramedics never, emergency physicians rarely (0.1%) documented a sepsis suspicion, respectively septic shock. NEWS2 had the highest sensitivity (73.1%; Specificity:81.6%) compared to qSOFA (23.1%; Sp:96.6%), SIRS (28.2%; Sp:94.3%) and MEWS (48.7%; Sp:88.1%). Depending on the tool, 3.7% to 19.4% of all cases screened positive; only 0.8% in all tools simultaneously. CONCLUSION Incidence and mortality underline the need for better sepsis awareness, documentation of vital signs and use of screening tools. Guidelines may omit MEWS and SIRS as recommendations for prehospital providers since they were inferior in all accuracy measures. Though no tool performed ideally, NEWS2 qualifies as the best tool to predict the highest proportion of septic patients and to rule out cases that are likely non-septic.
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Affiliation(s)
- Silke Piedmont
- Charité - Universitätsmedizin Berlin, Zentrale Notaufnahme Campus Benjamin Franklin, Berlin, Germany.
- Institut für Sozialmedizin und Gesundheitssystemforschung, Otto-von-Guericke-Universität Magdeburg, Magdeburg, Germany.
| | - Ludwig Goldhahn
- Institut für Sozialmedizin und Gesundheitssystemforschung, Otto-von-Guericke-Universität Magdeburg, Magdeburg, Germany
| | - Enno Swart
- Institut für Sozialmedizin und Gesundheitssystemforschung, Otto-von-Guericke-Universität Magdeburg, Magdeburg, Germany
| | - Bernt-Peter Robra
- Institut für Sozialmedizin und Gesundheitssystemforschung, Otto-von-Guericke-Universität Magdeburg, Magdeburg, Germany
| | | | - Rajan Somasundaram
- Charité - Universitätsmedizin Berlin, Zentrale Notaufnahme Campus Benjamin Franklin, Berlin, Germany
| | - Wolfgang Bauer
- Charité - Universitätsmedizin Berlin, Zentrale Notaufnahme Campus Benjamin Franklin, Berlin, Germany
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Piedmont S, Baier L, Ullrich N, Fitz I, Sprünken E, Toubekis E, Albrecht V, Neugebauer E. [Factors that influence the use of sepsis-related competencies in health professionals and how they promote their patients' sepsis knowledge: Results of a mixed methods study with health professionals]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2024:S1865-9217(24)00085-0. [PMID: 38834485 DOI: 10.1016/j.zefq.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 04/22/2024] [Accepted: 04/27/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Sepsis is a life-threatening and relatively common emergency which is often recognized too late or not at all. Therefore, the "SepsisWissen" (SepsisKnowledge) project aimed to bring about changes in health care professionals' behavior in the area of sepsis prevention and early detection. It addressed the health care professionals themselves (e. g., their own vaccination, hygiene and early detection behavior) and their patient counseling behavior. To promote this behavior, the SepsisWissen campaign included offers such as trainings or print products. The subsequent core question is: From the health professionals' perspective, which barriers and facilitators affect their own application of sepsis competence and their promotion of their patients' sepsis competence? METHODS This paper was based on a cross-sectional mixed-methods study part of "SepsisWissen" withPart a) was analyzed using qualitative oriented content analysis based on Mayring, part b) was analyzed descriptively. The interviewees included physicians, nurses, pharmacists, assistants to physicians and pharmacists and, additionally, one paramedic in the quantitative sample. Some of them had attended "SepsisWissen" trainings. RESULTS The qualitative data analysis identified 41 conducive and hindering factors, which can be assigned to the following eight major topics: 1) syndrome sepsis; 2) predisposing factors for health professionals' own acquisition and application of sepsis competence; 3) enabling factors for health professionals themselves; 4) behavior and lifestyle of patients; 5) reinforcing factors for patients; 6) public health education; 7) political, administrative, and organizational context; 8) environmental factors. In the qualitative and quantitative surveys, the suggestion to improve the sepsis competence of the population and to reduce misinformation, respectively, through public education (e.g., via schools or the media). DISCUSSION Sepsis training for health professionals was considered as a facilitating factor for taking potential sepsis symptoms and patients' respective statements more seriously. Future training formats should convey more explicitly how health professionals can better communicate their own sepsis knowledge to their patients. They request instruments to support their communication, such as checklists for lay persons. According to the interviews, health workers themselves need recurring external reminders for the topic of sepsis. Organizational and political conditions should be improved. From the health professionals' point of view, it is essential to offer better reimbursement for prevention and counseling services and to allocate adequate time resources for both. CONCLUSION Health professionals could increase their potential to apply and promote sepsis competence if general conditions were optimized. From their perspective, it is most important to relieve them of some of their patient counselling burden by initiating more public education.
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Affiliation(s)
- Silke Piedmont
- Brandenburg Medical School, Zentrum für Versorgungsforschung, Neuruppin, Deutschland.
| | - Luisa Baier
- Brandenburg Medical School, Zentrum für Versorgungsforschung, Neuruppin, Deutschland
| | - Nastja Ullrich
- Brandenburg Medical School, Zentrum für Versorgungsforschung, Neuruppin, Deutschland
| | - Isabell Fitz
- Brandenburg Medical School, Zentrum für Versorgungsforschung, Neuruppin, Deutschland
| | - Erin Sprünken
- Charité - Universitätsmedizin Berlin, Institut für Biometrie und klinische Epidemiologie, Campus Charité Mitte, Berlin, Deutschland
| | - Evjenia Toubekis
- Charité - Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Charité Mitte, Berlin, Deutschland
| | - Valentina Albrecht
- Charité - Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Charité Mitte, Berlin, Deutschland
| | - Edmund Neugebauer
- Brandenburg Medical School, Zentrum für Versorgungsforschung, Neuruppin, Deutschland
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MacAllister SA, Fernandez AR, Smith MJ, Myers JB, Crowe RP. Prehospital Sepsis Recognition and Outcomes for Patients with Sepsis by Race and Ethnicity. PREHOSP EMERG CARE 2023:1-7. [PMID: 38095600 DOI: 10.1080/10903127.2023.2294269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND First medical contact for patients with sepsis often initiates in the prehospital setting, yet limited studies have explored the EMS sepsis recognition-mortality relationship. Racial and ethnic minority patients often have worse sepsis outcomes, yet the role of prehospital recognition in this inequity has not been explored. Our objective was to describe prehospital sepsis recognition and hospital mortality, with analysis by patient race and ethnicity. METHODS Using linked EMS and hospital records from the 2021 ESO Data Collaborative, we retrospectively analyzed 9-1-1 EMS transports for adult patients with emergency department ICD-10 sepsis diagnosis codes. EMS sepsis recognition was defined as a primary or secondary sepsis impression, use of an electronic health record specialty sepsis form, or a prehospital sepsis alert. We used multivariable logistic regression to assess the association between EMS sepsis recognition and hospital mortality, adjusting for age, sex, race and ethnicity, scene socioeconomic status, and documented clinical characteristics: altered mental status, hypotension, tachypnea, tachycardia, fever. We conducted a secondary analysis of patients who were positive for the quick sequential organ failure assessment (qSOFA) using first prehospital vital signs. RESULTS We analyzed 20,172 records for EMS-transported patients with diagnosed sepsis. Overall, 8% of patients were Black, 8% were Hispanic, and 72% were White. Prehospital sepsis recognition was 18%. Prehospital sepsis recognition was similar across racial and ethnic groups (Black: 17.2%, Hispanic: 17.4%, White: 18.1%) and adjusted odds of sepsis recognition did not differ between racial and ethnic groups. Overall mortality was 11% (2,186). Prehospital sepsis recognition was associated with a 18% reduction in adjusted odds of mortality (OR: 0.82, 95% CI: 0.70-0.94). Of patients who were qSOFA positive in the field (n = 2,168), EMS sepsis recognition was 32% and was similar across race and ethnicities. Adjusted odds of mortality were 0.68 (95% CI: 0.53-0.88) when sepsis was recognized in the prehospital setting. CONCLUSION EMS identified sepsis in fewer than one in three patients even after limiting to those positive for qSOFA, without differences by race and ethnicity. EMS sepsis recognition was associated with reduced odds of mortality; however, Black patients remained at greater odds of death suggesting additional factors that warrant investigation.
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Dankert A, Kraxner J, Breitfeld P, Bopp C, Issleib M, Doehn C, Bathe J, Krause L, Zöllner C, Petzoldt M. Is Prehospital Assessment of qSOFA Parameters Associated with Earlier Targeted Sepsis Therapy? A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11123501. [PMID: 35743570 PMCID: PMC9224632 DOI: 10.3390/jcm11123501] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/07/2022] [Accepted: 06/15/2022] [Indexed: 12/10/2022] Open
Abstract
BACKGROUND This study aimed to determine whether prehospital qSOFA (quick sequential organ failure assessment) assessment was associated with a shortened 'time to antibiotics' and 'time to intravenous fluid resuscitation' compared with standard assessment. METHODS This retrospective study included patients who were referred to our Emergency Department between 2014 and 2018 by emergency medical services, in whom sepsis was diagnosed during hospitalization. Two multivariable regression models were fitted, with and without qSOFA parameters, for 'time to antibiotics' (primary endpoint) and 'time to intravenous fluid resuscitation'. RESULTS In total, 702 patients were included. Multiple linear regression analysis showed that antibiotics and intravenous fluids were initiated earlier if infections were suspected and emergency medical services involved emergency physicians. A heart rate above 90/min was associated with a shortened time to antibiotics. If qSOFA parameters were added to the models, a respiratory rate ≥ 22/min and altered mentation were independent predictors for earlier antibiotics. A systolic blood pressure ≤ 100 mmHg and altered mentation were independent predictors for earlier fluids. When qSOFA parameters were added, the explained variability of the model increased by 24% and 38%, respectively (adjusted R² 0.106 versus 0.131 for antibiotics and 0.117 versus 0.162 for fluids). CONCLUSION Prehospital assessment of qSOFA parameters was associated with a shortened time to a targeted sepsis therapy.
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Affiliation(s)
- André Dankert
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany; (J.K.); (P.B.); (M.I.); (C.D.); (J.B.); (C.Z.); (M.P.)
- Correspondence:
| | - Jochen Kraxner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany; (J.K.); (P.B.); (M.I.); (C.D.); (J.B.); (C.Z.); (M.P.)
| | - Philipp Breitfeld
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany; (J.K.); (P.B.); (M.I.); (C.D.); (J.B.); (C.Z.); (M.P.)
| | - Clemens Bopp
- Department of Anesthesiology and Intensive Care Medicine, German Military Hospital Hamburg, Lesserstrasse 180, 22049 Hamburg, Germany;
| | - Malte Issleib
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany; (J.K.); (P.B.); (M.I.); (C.D.); (J.B.); (C.Z.); (M.P.)
| | - Christoph Doehn
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany; (J.K.); (P.B.); (M.I.); (C.D.); (J.B.); (C.Z.); (M.P.)
| | - Janina Bathe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany; (J.K.); (P.B.); (M.I.); (C.D.); (J.B.); (C.Z.); (M.P.)
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany;
| | - Christian Zöllner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany; (J.K.); (P.B.); (M.I.); (C.D.); (J.B.); (C.Z.); (M.P.)
| | - Martin Petzoldt
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany; (J.K.); (P.B.); (M.I.); (C.D.); (J.B.); (C.Z.); (M.P.)
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The new 2021 Surviving Sepsis Guidelines: an emergency department perspective may be more effective. Eur J Emerg Med 2022; 29:5-6. [PMID: 34932027 DOI: 10.1097/mej.0000000000000898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Veldhuis LI, Ridderikhof ML, Nanayakkara PWB, Hollmann MW. Recognition of sepsis in the pre-hospital environment one year after intensive traineeship. Eur J Intern Med 2021; 92:115-116. [PMID: 34175180 DOI: 10.1016/j.ejim.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/05/2021] [Indexed: 11/19/2022]
Affiliation(s)
- L I Veldhuis
- Emergency Department, Amsterdam UMC, Location Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Amsterdam, Netherlands; Department of Anesthesiology, Amsterdam UMC, Location Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Amsterdam, Netherlands
| | - M L Ridderikhof
- Emergency Department, Amsterdam UMC, Location Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Amsterdam, Netherlands.
| | - P W B Nanayakkara
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, Location VU University Medical Center, De Boelelaan 1118, 1081HZ, Amsterdam, Netherlands
| | - M W Hollmann
- Department of Anesthesiology, Amsterdam UMC, Location Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Amsterdam, Netherlands
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Mulders MCF, Loots FJ, van Nieuwenhoven J, Ter Maaten JC, Bouma HR. Use of sepsis-related diagnostic criteria in primary care: a survey among general practitioners. Fam Pract 2021; 38:617-622. [PMID: 33755106 PMCID: PMC8527837 DOI: 10.1093/fampra/cmab020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Use of sepsis-criteria in hospital settings is effective in realizing early recognition, adequate treatment and reduction of sepsis-associated morbidity and mortality. Whether general practitioners (GPs) use these diagnostic criteria is unknown. OBJECTIVE To gauge the knowledge and use of various diagnostic criteria. To determine which parameters GPs associate with an increased likelihood of sepsis. METHODS Two thousand five hundred and sixty GPs were invited and 229 agreed to participate in a survey, reached out to through e-mail and WhatsApp groups. The survey consisted of two parts: the first part aimed to obtain information about the GP, training and knowledge about sepsis recognition, and the second part tested specific knowledge using six realistic cases. RESULTS Two hundred and six questionnaires, representing a response rate of 8.1%, were eligible for analysis. Gut feeling (98.1%) was the most used diagnostic method, while systemic inflammatory response syndrome (37.9%), quick Sequential Organ Failure Assessment (qSOFA) (7.8%) and UK Sepsis Trust criteria (UKSTc) (1.5%) were used by the minority of the GPs. Few of the responding GPs had heard of either the qSOFA (27.7%) or the UKSTc (11.7%). Recognition of sepsis varied greatly between GPs. GPs most strongly associated the individual signs of the qSOFA (mental status, systolic blood pressure, capillary refill time and respiratory rate) with diagnosing sepsis in the test cases. CONCLUSIONS GPs mostly use gut feeling to diagnose sepsis and are frequently not familiar with the 'sepsis-criteria' used in hospital settings, although clinical reasoning was mostly in line with the qSOFA score. In order to improve sepsis recognition in primary care, GPs should be educated in the use of available screening tools.
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Affiliation(s)
- Merijn C F Mulders
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Feike J Loots
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Jan C Ter Maaten
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hjalmar R Bouma
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Kang S, Ahn TK, Seo YH, Suh YJ, Paik JH. Comparison of emergency department utilization trends between the COVID-19 pandemic and control period. Medicine (Baltimore) 2021; 100:e26847. [PMID: 34397892 PMCID: PMC8360451 DOI: 10.1097/md.0000000000026847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 06/15/2021] [Accepted: 07/12/2021] [Indexed: 02/07/2023] Open
Abstract
ABSTRACT Infectious disease pandemics has a great impact on the use of medical facilities. The purpose of this study was to analyze the effects of coronavirus disease 2019 (COVID-19) on the use of emergency medical facilities in the Republic of Korea. This single-center, retrospective observational study was conducted in a tertiary teaching hospital located in Incheon Metropolitan City, Republic of Korea. We set the pandemic period as February 19, 2020 to April 18, 2020, and the control period was set to the same period in 2018 and 2019. All consecutive patients who visited the emergency department (ED) during the study period were included. Patients were divided into 3 groups according to age (pediatric patients, younger adult patients and older adult patients). The total number, demographics, clinical data, and diagnostic codes of ED patients were analyzed. The total number of ED patients in the pandemic period was lower than that in the control period, which was particularly pronounced for pediatric patients. The proportion of patients who used the 119 ambulances increased in all 3 groups (P = .002, P < .001, and P = .001), whereas the proportion of patients who visited on foot was decreased (P = .006, P < .001, and P = .027). In terms of diagnostic codes, a significant decrease was observed in the proportion of certain infectious or parasitic diseases (A00-B99), and respiratory diseases (J00-J99) in the pediatric and younger adult patient groups (P < .001 and P < .001, respectively). The COVID-19 pandemic reduced the number of ED patients; however, the proportion of patients using ambulances increased. In particular, the proportion of patients with diagnostic codes for infectious and respiratory diseases significantly decreased during the pandemic period.
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Affiliation(s)
- Soo Kang
- Department of Emergency Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Tae Kyu Ahn
- Department of Emergency Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Young Ho Seo
- Department of Emergency Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Young Ju Suh
- Department of Biomedical Sciences, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jin Hui Paik
- Department of Emergency Medicine, Inha University School of Medicine, Incheon, Republic of Korea
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Lane DJ, Wunsch H, Saskin R, Cheskes S, Lin S, Morrison LJ, Scales DC. Screening strategies to identify sepsis in the prehospital setting: a validation study. CMAJ 2020; 192:E230-E239. [PMID: 32152051 DOI: 10.1503/cmaj.190966] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In the prehospital setting, differentiating patients who have sepsis from those who have infection but no organ dysfunction is important to initiate sepsis treatments appropriately. We aimed to identify which published screening strategies for paramedics to use in identifying patients with sepsis provide the most certainty for prehospital diagnosis. METHODS We identified published strategies for screening by paramedics through a literature search. We then conducted a validation study in Alberta, Canada, from April 2015 to March 2016. For adult patients (≥ 18 yr) who were transferred by ambulance, we linked records to an administrative database and then restricted the search to patients with infection diagnosed in the emergency department. For each patient, the classification from each strategy was determined and compared with the diagnosis recorded in the emergency department. For all strategies that generated numeric scores, we constructed diagnostic prediction models to estimate the probability of sepsis being diagnosed in the emergency department. RESULTS We identified 21 unique prehospital screening strategies, 14 of which had numeric scores. We linked a total of 131 745 eligible patients to hospital databases. No single strategy had both high sensitivity (overall range 0.02-0.85) and high specificity (overall range 0.38-0.99) for classifying sepsis. However, the Critical Illness Prediction (CIP) score, the National Early Warning Score (NEWS) and the Quick Sepsis-Related Organ Failure Assessment (qSOFA) score predicted a low to high probability of a sepsis diagnosis at different scores. The qSOFA identified patients with a 7% (lowest score) to 87% (highest score) probability of sepsis diagnosis. INTERPRETATION The CIP, NEWS and qSOFA scores are tools with good predictive ability for sepsis diagnosis in the prehospital setting. The qSOFA score is simple to calculate and may be useful to paramedics in screening patients with possible sepsis.
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Affiliation(s)
- Daniel J Lane
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont.
| | - Hannah Wunsch
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Refik Saskin
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Sheldon Cheskes
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Steve Lin
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Laurie J Morrison
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Damon C Scales
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
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Latten G, Hensgens K, de Bont EGPM, Muris JWM, Cals JWL, Stassen P. How well are sepsis and a sense of urgency documented throughout the acute care chain in the Netherlands? A prospective, observational study. BMJ Open 2020; 10:e036276. [PMID: 32690518 PMCID: PMC7371221 DOI: 10.1136/bmjopen-2019-036276] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To investigate the documentation of sepsis and a sense of urgency throughout the acute care chain. DESIGN Prospective cohort study. SETTING Emergency department (ED) in a large district hospital in Heerlen, The Netherlands. PARTICIPANTS Participants included patients ≥18 years with suspected sepsis who visited the ED during out-of-hours between September 2017 and January 2018 (n=339) and had been referred by a general practitioner and/or transported by ambulance. We defined suspected sepsis as suspected or proven infection and the presence of ≥2 quick Sepsis-related Organ Failure Assessment and/or ≥2 Systemic Inflammatory Response Syndrome criteria. OUTCOME MEASURES We analysed how often sepsis and a sense of urgency were documented in the prehospital and ED medical records. A sense of urgency was considered documented when a medical record suggested the need of immediate assessment by a physician in the ED. We described documentation patterns throughout the acute care chain and investigated whether documentation of sepsis or a sense of urgency is associated with adverse outcomes (intensive care admission/30-day all-cause mortality). RESULTS Sepsis was documented in 16.8% of medical records and a sense of urgency in 22.4%. In 4.1% and 7.7%, respectively, sepsis and a sense of urgency were documented by all involved professionals. In patients with an adverse outcome, sepsis was documented more often in the ED than in patients without an adverse outcome (47.9% vs 13.7%, p<0.001). CONCLUSIONS Our study shows that in prehospital and ED medical records, sepsis and a sense of urgency are documented in one out of five patients. In only 1 out of 20 patients sepsis or a sense of urgency is documented by all involved professionals. It is possible that poor documentation causes harm, due to delayed diagnosis or treatment. Hence, it could be important to raise awareness among professionals regarding the importance of their documentation.
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Affiliation(s)
- Gideon Latten
- Emergency Department, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Kirsten Hensgens
- Emergency Department, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Eefje G P M de Bont
- Family Medicine, Maastricht University, Research Institute CAPHRI, Maastricht, Limburg, The Netherlands
| | - Jean W M Muris
- Family Medicine, Maastricht University, Research Institute CAPHRI, Maastricht, Limburg, The Netherlands
| | - Jochen W L Cals
- Family Medicine, Maastricht University, Research Institute CAPHRI, Maastricht, Limburg, The Netherlands
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Prognostic value of prehospital quick sequential organ failure assessment score among patients with suspected infection. Eur J Emerg Med 2020; 26:329-333. [PMID: 30138252 DOI: 10.1097/mej.0000000000000570] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE After the third international consensus on sepsis released its new definitions, the prognostic value of quick sequential organ failure assessment (qSOFA) score has been confirmed in the emergency department. However, its validity in the prehospital setting remains unknown. The objective of the study was to assess its accuracy for prehospital patients cared by emergency physician-staffed ambulances (services mobiles d'urgence et de réanimation SMUR). PATIENTS AND METHODS This was a prospective observational multicenter cohort study (N = 6). All consecutive patients with prehospital clinical suspicion of infection by the emergency physician of the SMUR emergency medical service were included. Components of qSOFA were collected, and the patients were followed until hospital discharge. The primary end point was in-hospital mortality, censored at 28 days. Secondary end points included ICU admission longer than 72 h and a composite of 'death or ICU stay more than 72 h'. RESULTS We screened 342 patients and included 332 in the analysis. Their mean age was 73 years, 159 (48%) were women, and the most common site of infection was respiratory (73% of cases). qSOFA was at least 2 in 133 (40%) patients. The overall in-hospital mortality was 27%: 41% in patients with qSOFA of at least 2 versus 18% for qSOFA less than 2 (absolute difference 23%; 95% confidence interval: 13-33%, P < 0.001). The overall discrimination for qSOFA was poor, with an area under the receiver operating characteristic curve of 0.69 (95% confidence interval: 0.62-0.74). CONCLUSION In this large multicenter study, prehospital qSOFA presents a strong association with mortality in infected patient, though with poor prognostic performances in our severely ill sample.
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Coeckelenbergh S, Van Nuffelen M, Mélot C. Sepsis is frequent in initially non-critical hypotensive emergency department patients and is associated with increased mortality. Am J Emerg Med 2019; 37:2242-2245. [PMID: 31466913 DOI: 10.1016/j.ajem.2019.158360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 07/08/2019] [Accepted: 07/21/2019] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Hypotension, defined as a mean arterial pressure of maximum 70 mmHg, is associated with significant morbidity and mortality. The objective of this study was to determine in initially non-critical hypotensive adult patients the proportion of sepsis and if septic patients had different outcome and clinical factors than non-septic patients. METHODS This retrospective observational study was conducted over a year on adult hypotensive emergency department patients initially considered by triage as non-critical. Patients were separated into three groups: hypotensive septic patients (HSP), hypotensive non-septic infected patients (HNSIP), and other hypotensive patients (OHP). Clinical scores, signs, length of stay (LOS), and mortality were compared using analysis of variance for continuous variables and chi-square analysis for categorical variables. RESULTS There were 136 (35.5%) septic patients, 37 (9.7%) with non-septic infection, and 210 (54.8%) with another cause of hypotension. Overall in-hospital mortality was 12.0% and total mortality was greater in HSP than in HNSIP (20.6% vs. 5.4%, p = 0.031) or OHP (20.6 vs. 7.6%, p < 0.001). LOS was greater for HSP when compared to HNSIP (median(IQR): 9(6-17) vs. 6(1-13), p = 0.004) and OHP (median(IQR): 9(6-17) vs. 3(1-8) days, p < 0.0001). CONCLUSION Sepsis in a priori non-critical hypotensive adult patients, when compared with other causes of hypotension, is associated with significantly higher mortality and increased LOS. Patients that present to the emergency department and have a MAP of 70mmHg or less must be rigorously evaluated and have consistent follow-up.
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Affiliation(s)
- Sean Coeckelenbergh
- Anesthesia Department, Erasme University Hospital, Lennik street 808, B-1070 Brussels, Belgium
| | - Marc Van Nuffelen
- Emergency Department, Erasme University Hospital, Lennik street 808, B-1070 Brussels, Belgium
| | - Christian Mélot
- Emergency Department, Erasme University Hospital, Lennik street 808, B-1070 Brussels, Belgium.
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14
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Smyth MA, Gallacher D, Kimani PK, Ragoo M, Ward M, Perkins GD. Derivation and internal validation of the screening to enhance prehospital identification of sepsis (SEPSIS) score in adults on arrival at the emergency department. Scand J Trauma Resusc Emerg Med 2019; 27:67. [PMID: 31311608 PMCID: PMC6636043 DOI: 10.1186/s13049-019-0642-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/03/2019] [Indexed: 12/29/2022] Open
Abstract
Background Prehospital recognition of sepsis may inform case management by ambulance clinicians, as well as inform transport decisions. The objective of this study was to develop a prehospital sepsis screening tool for use by ambulance clinicians. Methods We derived and validated a sepsis screening tool, utilising univariable logistic regression models to identify predictors for inclusion, and multivariable logistic regression to generate the SEPSIS score. We utilised a retrospective cohort of adult patients transported by ambulance (n = 38483) to hospital between 01 July 2013 and 30 June 2014. Records were linked using LinkPlus® software. Successful linkage was achieved in 33289 cases (86%). Eligible patients included adult, non-trauma, non-mental health, non-cardiac arrest cases. Of 33289 linked cases, 22945 cases were eligible. Eligible cases were divided into derivation (n = 16063, 70%) and validation (n = 6882, 30%) cohorts. The primary outcome measure was high risk of severe illness or death from sepsis, as defined by the National Institute for Health and Care Excellence Sepsis guideline. Results ‘High risk of severe illness or death from sepsis’ was present in 3.7% of derivation (n = 593) and validation (n = 254) cohorts. The SEPSIS score comprises the following variables: age, respiratory rate, peripheral oxygen saturations, heart rate, systolic blood pressure, temperature and level of consciousness (p < 0.001 for all variables). Area under the curve was 0.87 (95%CI 0.85–0.88) for the derivation cohort, and 0.86 (95%CI 0.84–0.88) for the validation cohort. In an undifferentiated adult medical population, for a SEPSIS score ≥ 5, sensitivity was 0.37 (0.31–0.44), specificity was 0.96 (0.96–0.97), positive predictive value was 0.27 (0.23–0.32), negative predictive value was 0.97 (0.96–0.97), positive likelihood value was 13.5 (9.7–18.73) and the negative likelihood value was 0.83 (0.78–0.88). Conclusion This is the first screening tool developed to identify NICE high risk of severe illness or death from sepsis. The SEPSIS score is significantly associated with high risk of severe illness or death from sepsis on arrival at the Emergency Department. It may assist ambulance clinicians to identify those patients with sepsis in need of antibiotic therapy. However, it requires external validation, in clinical practice by ambulance clinicians, in an independent population. Electronic supplementary material The online version of this article (10.1186/s13049-019-0642-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael A Smyth
- Clinical Trials Unit, University of Warwick, Coventry, UK. .,West Midlands Ambulance Service NHS Foundation Trust, Dudley, UK. .,Midlands Air Ambulance, Dudley, UK.
| | | | - Peter K Kimani
- Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Mark Ragoo
- Royal Stoke University Hospital, Stoke on Trent, UK
| | - Matthew Ward
- West Midlands Ambulance Service NHS Foundation Trust, Dudley, UK
| | - Gavin D Perkins
- Clinical Trials Unit, University of Warwick, Coventry, UK.,Heart of England NHS Foundation Trust, Birmingham, UK
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Amesz AL, de Visser M, de Groot B. Recognition of acute organ failure and associated fluid and oxygen resuscitation by emergency medical services of emergency department patients with a suspected infection. Int Emerg Nurs 2019; 43:92-98. [DOI: 10.1016/j.ienj.2018.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/18/2018] [Accepted: 11/22/2018] [Indexed: 11/25/2022]
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16
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The early chain of care in bacteraemia patients: Early suspicion, treatment and survival in prehospital emergency care. Am J Emerg Med 2018; 36:2211-2218. [DOI: 10.1016/j.ajem.2018.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/02/2018] [Accepted: 04/03/2018] [Indexed: 12/31/2022] Open
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Loots FJ, Smits M, van Steensel C, Giesen P, Hopstaken RM, van Zanten ARH. Management of sepsis in out-of-hours primary care: a retrospective study of patients admitted to the intensive care unit. BMJ Open 2018; 8:e022832. [PMID: 30224394 PMCID: PMC6144400 DOI: 10.1136/bmjopen-2018-022832] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/27/2018] [Accepted: 08/04/2018] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES Timely recognition and treatment of sepsis is essential to reduce mortality and morbidity. Acutely ill patients often consult a general practitioner (GP) as the first healthcare provider. During out-of-hours, GP cooperatives deliver this care in the Netherlands. The aim of this study is to explore the role of these GP cooperatives in the care for patients with sepsis. DESIGN Retrospective study of patient records from both the hospital and the GP cooperative. SETTING An intensive care unit (ICU) of a general hospital in the Netherlands, and the colocated GP cooperative serving 260 000 inhabitants. PARTICIPANTS We used data from 263 patients who were admitted to the ICU due to community-acquired sepsis between January 2011 and December 2015. MAIN OUTCOME MEASURES Contact with the GP cooperative within 72 hours prior to hospital admission, type of contact, delay from the contact until hospital arrival, GP diagnosis, initial vital signs and laboratory values, and hospital mortality. RESULTS Of 263 patients admitted to the ICU, 127 (48.3%) had prior GP cooperative contacts. These contacts concerned home visits (59.1%), clinic consultations (18.1%), direct ambulance deployment (12.6%) or telephone advice (10.2%). Patients assessed by a GP were referred in 64% after the first contact. The median delay to hospital arrival was 1.7 hours. The GP had not suspected an infection in 43% of the patients. In this group, the in-hospital mortality rate was significantly higher compared with patients with suspected infections (41.9% vs 17.6%). Mortality difference remained significant after correction for confounders. CONCLUSION GP cooperatives play an important role in prehospital management of sepsis and recognition of sepsis in this setting proved difficult. Efforts to improve management of sepsis in out-of-hours primary care should not be limited to patients with a suspected infection, but also include severely ill patients without clear signs of infection.
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Affiliation(s)
- Feike J Loots
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- Emergency Department, Gelderse Vallei Hospital, Ede, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marleen Smits
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carlijn van Steensel
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Paul Giesen
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rogier M Hopstaken
- STAR-SHL, Etten-Leur, The Netherlands
- Department of General Practice, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Arthur R H van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
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18
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Alam N, Oskam E, Stassen PM, Exter PV, van de Ven PM, Haak HR, Holleman F, Zanten AV, Leeuwen-Nguyen HV, Bon V, Duineveld BAM, Nannan Panday RS, Kramer MHH, Nanayakkara PWB, Alam N, Nanayakkara P, Oskam E, Stassen P, Haak H, Holleman F, Nannan Panday R, Duineveld B, van Exter P, van de Ven P, Bon V, Goselink J, De Kreek A, van Grunsven P, Biekart M, Deddens G, Weijschede F, Rijntjes N, Franschman G, Janssen J, Frenken J, Versluis J, Boomars R, de Vries G, den Boer E, van Gent A, Willeboer M, Buunk G, Timmers G, Snijders F, Posthuma N, Stoffelen S, Claassens S, Ammerlaan H, Sankatsing S, Frenken J, Alsma J, van Zanten A, Slobbe L, de Melo M, Dees A, Carels G, Wabbijn M, van Leeuwen-Nguyen T, Assink J, van der Honing A, Luik P, Poortvliet W, Schouten W, Veenstra J, Holkenborg J, Cheung T, van Bokhorst J, Kors B, Louis- Wattel G, Roeleveld T, Toorians A, Jellema W, Govers A, Kaasjager H, Dekker D, Verhoeven M, Kramer M, Flietstra T, Roest L, Peters E, Hekker T, Ang W, van der Wekken W, Ghaem Maghami P, Kanen B, Wesselius H, Heesterman L, Zwietering A, Stoffers J. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. THE LANCET RESPIRATORY MEDICINE 2018; 6:40-50. [DOI: 10.1016/s2213-2600(17)30469-1] [Citation(s) in RCA: 170] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/22/2017] [Accepted: 10/25/2017] [Indexed: 11/29/2022]
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Abstract
Background Early recognition and treatment of sepsis are important to reduce morbidity and mortality. Screening tools using vital signs are effective in emergency departments. It is not known how the decision to refer a patient to the hospital with a possible serious infection is made in primary care. Aim To gain insight into the clinical decision-making process of GPs in patients with possible sepsis infections. Design & setting Survey among a random sample of 800 GPs in the Netherlands. Method Quantitative questionnaire using Likert scales. Results One hundred and sixty (20.3%) of questionnaires were eligible for analysis. Based on self-reported cases of possible serious infections, the factors most often indicated as important for the decision to refer patients to the hospital were: general appearance (94.1%), gut feeling (92.1%), history (92.0%), and physical examination (89.3%). Temperature (88.7%), heart rate (88.7%), and blood pressure (82.1%), were the most frequently measured vital signs. In general, GPs more likely referred patients in case of: altered mental status (98.7%), systolic blood pressure <100 mmHg (93.7%), unable to stand (89.3%), insufficient effect of previous antibiotic treatment (87.4%), and respiratory rate ≥22/minute (86.1%). Conclusion The GPs' assessment of patients with possible serious infection is a complex process, in which besides checking vital signs, many other aspects of the consultation guide the decision to refer a patient to the hospital. To improve care for patients with sepsis, the diagnostic and prognostic value of assessing the vital signs and symptoms, GPs' gut feeling, and additional diagnostic tests, should be prospectively studied in the primary care setting.
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Abstract
OBJECTIVE Early identification of sepsis could enable prompt delivery of key interventions such as fluid resuscitation and antibiotic administration which, in turn, may lead to improved patient outcomes. Limited data indicate that recognition of sepsis by paramedics is often poor. We systematically reviewed the literature on prehospital sepsis screening tools to determine whether they improved sepsis recognition. DESIGN Systematic review. The electronic databases MEDLINE, EMBASE, CINAHL, the Cochrane Library and PubMed were systematically searched up to June 2015. In addition, subject experts were contacted. SETTING Prehospital/emergency medical services (EMS). STUDY SELECTION All studies addressing identification of sepsis (including severe sepsis and septic shock) among adult patients managed by EMS. OUTCOME MEASURES Recognition of sepsis by EMS clinicians. RESULTS Owing to considerable variation in the methodological approach adopted and outcome measures reported, a narrative approach to data synthesis was adopted. Three studies addressed development of prehospital sepsis screening tools. Six studies addressed paramedic diagnosis of sepsis with or without use of a prehospital sepsis screening tool. CONCLUSIONS Recognition of sepsis by ambulance clinicians is poor. The use of screening tools, based on the Surviving Sepsis Campaign diagnostic criteria, improves prehospital sepsis recognition. Screening tools derived from EMS data have been developed, but they have not yet been validated in clinical practice. There is a need to undertake validation studies to determine whether prehospital sepsis screening tools confer any clinical benefit.
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Affiliation(s)
- Michael A Smyth
- Clinical Trials Unit, University of Warwick, Coventry, UK
- Midlands Air Ambulance, Stourbridge, UK
- West Midlands Ambulance Service NHS Foundation Trust, Dudley, UK
| | - Samantha J Brace-McDonnell
- Clinical Trials Unit, University of Warwick, Coventry, UK
- Heart of England Hospital NHS Foundation Trust, Birmingham, UK
| | - Gavin D Perkins
- Clinical Trials Unit, University of Warwick, Coventry, UK
- Heart of England Hospital NHS Foundation Trust, Birmingham, UK
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Smyth MA, Brace-McDonnell SJ, Perkins GD. Identification of adults with sepsis in the prehospital environment: a systematic review. BMJ Open 2016. [PMID: 27496231 DOI: 10.1136/bmjo-pen-2016-011218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Early identification of sepsis could enable prompt delivery of key interventions such as fluid resuscitation and antibiotic administration which, in turn, may lead to improved patient outcomes. Limited data indicate that recognition of sepsis by paramedics is often poor. We systematically reviewed the literature on prehospital sepsis screening tools to determine whether they improved sepsis recognition. DESIGN Systematic review. The electronic databases MEDLINE, EMBASE, CINAHL, the Cochrane Library and PubMed were systematically searched up to June 2015. In addition, subject experts were contacted. SETTING Prehospital/emergency medical services (EMS). STUDY SELECTION All studies addressing identification of sepsis (including severe sepsis and septic shock) among adult patients managed by EMS. OUTCOME MEASURES Recognition of sepsis by EMS clinicians. RESULTS Owing to considerable variation in the methodological approach adopted and outcome measures reported, a narrative approach to data synthesis was adopted. Three studies addressed development of prehospital sepsis screening tools. Six studies addressed paramedic diagnosis of sepsis with or without use of a prehospital sepsis screening tool. CONCLUSIONS Recognition of sepsis by ambulance clinicians is poor. The use of screening tools, based on the Surviving Sepsis Campaign diagnostic criteria, improves prehospital sepsis recognition. Screening tools derived from EMS data have been developed, but they have not yet been validated in clinical practice. There is a need to undertake validation studies to determine whether prehospital sepsis screening tools confer any clinical benefit.
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Affiliation(s)
- Michael A Smyth
- Clinical Trials Unit, University of Warwick, Coventry, UK Midlands Air Ambulance, Stourbridge, UK West Midlands Ambulance Service NHS Foundation Trust, Dudley, UK
| | - Samantha J Brace-McDonnell
- Clinical Trials Unit, University of Warwick, Coventry, UK Heart of England Hospital NHS Foundation Trust, Birmingham, UK
| | - Gavin D Perkins
- Clinical Trials Unit, University of Warwick, Coventry, UK Heart of England Hospital NHS Foundation Trust, Birmingham, UK
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Smyth MA, Brace-McDonnell SJ, Perkins GD. Impact of Prehospital Care on Outcomes in Sepsis: A Systematic Review. West J Emerg Med 2016; 17:427-37. [PMID: 27429693 PMCID: PMC4944799 DOI: 10.5811/westjem.2016.5.30172] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 04/14/2016] [Accepted: 05/03/2016] [Indexed: 12/29/2022] Open
Abstract
Introduction Sepsis is a common and potentially life-threatening response to an infection. International treatment guidelines for sepsis advocate that treatment be initiated at the earliest possible opportunity. It is not yet clear if very early intervention by ambulance clinicians prior to arrival at hospital leads to improved clinical outcomes among sepsis patients. Methoda We systematically searched the electronic databases MEDLINE, EMBASE, CINAHL, the Cochrane Library and PubMed up to June 2015. In addition, subject experts were contacted. We adopted the GRADE (grading recommendations assessment, development and evaluation) methodology to conduct the review and follow PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations to report findings. Results Nine studies met the eligibility criteria – one study was a randomized controlled trial while the remaining studies were observational in nature. There was considerable variation in the methodological approaches adopted and outcome measures reported across the studies. Because of these differences, the studies did not answer a unique research question and meta-analysis was not appropriate. A narrative approach to data synthesis was adopted. Conclusion There is little robust evidence addressing the impact of prehospital interventions on outcomes in sepsis. That which is available is of low quality and indicates that prehospital interventions have limited impact on outcomes in sepsis beyond improving process outcomes and expediting the patient’s passage through the emergency care pathway. Evidence indicating that prehospital antibiotic therapy and fluid resuscitation improve patient outcomes is currently lacking.
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Affiliation(s)
- Michael A Smyth
- University of Warwick, Clinical Trials Unit, Coventry, England
| | | | - Gavin D Perkins
- University of Warwick, Clinical Trials Unit, Coventry, England
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