Identification of adults with sepsis in the prehospital environment: a systematic review

The performance of screening tools and use of blood analyses in prehospital identification of sepsis patients and patients suitable for non-conveyance - an observational study

BACKGROUND

Early recognition of sepsis by the EMS (Emergency Medical Services), along with communicating this concern to the emergency department, could improve patient prognosis and outcome. Knowledge is limited about the performance of sepsis identification screening tools in the EMS setting. Research is also limited on the effectiveness of prehospital use of blood tests for sepsis identification. Integrating blood analyses with screening tools could improve sepsis identification, leading to prompt interventions and improved patient outcomes.

AIM

The aim of the present study is firstly to evaluate the performance of various screening tools for sepsis identification in the EMS setting and secondly to assess the potential improvement in accuracy by incorporating blood analyses.

METHODS

This is a retrospective observational cohort study. The data were collected from prehospital and hospital medical records in Region Halland. Data on demographics, vital signs, blood tests, treatment, and outcomes were collected from patients suspected by EMS personnel of having infection. The data were analysed using Student's t-test. Sensitivity, specificity, positive predictive value, negative predictive value and odds ratio were used to indicate accuracy and predictive value.

RESULTS

In total, 5,405 EMS missions concerning 3,225 unique patients were included. The incidence of sepsis was 9.8%. None of the eleven tools included had both high sensitivity and specificity for sepsis identification. White blood cell (WBC) count was the blood analysis with the highest sensitivity but the lowest specificity for identifying sepsis. Adding WBC, C-reactive protein (CRP) or lactate to the National Early Warning Score (NEWS) increased the specificity to > 80% but substantially lowered the sensitivity.

CONCLUSIONS

Identifying sepsis in EMS settings remains challenging, with existing screening tools offering limited accuracy. CRP, WBC, and lactate blood tests add minimal predictive value in distinguishing sepsis or determining non-conveyance eligibility.

Sepsis incidence, suspicion, prediction and mortality in emergency medical services: a cohort study related to the current international sepsis guideline

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.

Nurses' experience of prehospital sepsis assessment: a qualitative study

BACKGROUND

Sepsis is a frequent cause of global deaths with time critical diagnosis and treatment impacting outcomes. Prehospital emergency nurses are pivotal in assessment that influences timely diagnosis.

AIM

To gain a deep understanding of nurse's experiences when caring for those with suspected sepsis.

DESIGN AND METHODS

A qualitative study using semi-structured interviews and inductive content analysis according to the Elo Kyngäs method.

FINDINGS

Early identification of sepsis by prehospital emergency nurses (n = 13) was augmented through a combination of clinical experience and the implementation of practice guidelines. There were three key components to practice improvement a) clinical experience, b) continuous education and c) explicit guidelines.

CONCLUSIONS

Identification of sepsis in the prehospital environment can shorten the time to treatment for patients with sepsis. Early identification can be achieved by continuous education in the Emergency Medical Service (EMS), ensuring experienced personnel and including the EMS in medical guidelines.

Recognition and Awareness of Sepsis by First-Aid Providers in Adults With Suspected Infection: A Scoping Review

Sepsis accounts for a significant proportion of preventable deaths worldwide and early treatment has been found to be a mainstay of decreasing mortality. Early identification of sepsis in the first-aid setting is critical as this results in a shorter time to hospital presentation and management with antibiotics and initial resuscitation. Our aim was to explore the existing literature related to either sepsis recognition or awareness of sepsis by first-aid providers who are evaluating an adult suspected of an acute infection. Our scoping review was performed as part of the International Liaison Committee on Resuscitation's (ILCOR) continuous evidence evaluation process to update the 2024 ILCOR Consensus on Science with Treatment Recommendations. We searched Embase, Medline, and Cochrane databases from their inception to January 17, 2023, with updated searches performed on November 21, 2023, and December 2, 2023. The gray literature search was conducted on August 29, 2023. The population included adults presenting with an acute illness exhibiting signs and symptoms of a severe infection. Outcomes included sepsis recognition or awareness of sepsis by a lay first-aid provider. After reviewing 4380 potential sources, four reviews (three systematic reviews and one scoping review), 11 observational studies, and 27 websites met the inclusion criteria. No study directly addressed our PICOST (Population, Intervention, Comparator, Outcomes, Study Design, and Timeframe) question as none were performed in the first-aid setting. Three systematic reviews and nine observational studies that assessed the ability of early warning scores to detect sepsis and predict adverse outcomes secondary to sepsis had inconsistent results, but many found the screening tools to be useful. One scoping review and one observational study found public knowledge and awareness of sepsis to be variable and dependent upon healthcare employment, location, education level, ethnicity, sex, and age. Signs and symptoms associated with sepsis as listed by gray literature sources fell primarily under nine general categories as a means of educating the public on sepsis recognition. Although this scoping review did not identify any studies that directly addressed our outcomes, it highlights the need for future research to better understand the recognition of sepsis in first-aid settings.

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.

Prehospital Sepsis Recognition and Outcomes for Patients with Sepsis by Race and Ethnicity

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.

Ciclopirox mitigates inflammatory response in LPS-induced septic shock via inactivation of SORT1-mediated wnt/β-Catenin signaling pathway

OBJECTIVE

Septic shock, the most severe stage of sepsis, is a deadly inflammatory disorder with high mortality. Ciclopirox (CPX) is a broad-spectrum antimycotic agent which also exerts anti-inflammatory effects in human diseases. However, whether CPX can relieve inflammatory response in LPS-induced septic shock remains unclear.

MATERIALS AND METHODS

Male C57BL/6 mice LPS were injected intraperitoneally with LPS to simulate septic shock in vivo. RAW264.7 cells and bone marrow-derived macrophages (BMDMs) were subject to LPS treatment to simulate septic shock in vitro. ELISA was applied to detect the level of pro-inflammatory cytokines. Cell viability was assessed by CCK-8 assay. Protein levels was detected by western blotting.

RESULTS

CPX enhanced the survival rate and attenuated inflammation in mice with LPS-induced septic shock. Similarly, CPX dose-dependently mitigated LPS-induced inflammation in BMDMs. It was also found that Sortilin 1 (SORT1) was upregulated in both in vivo and in vitro models of LPS-induced septic shock. In addition, SORT1 overexpression counteracted the alleviative effects of CPX on the inflammation response of LPS-challenged BMDMs by activating the Wnt/β-Catenin signaling. Furthermore, BML-284 (a Wnt/β-Catenin agonist) treatment also abrogated CPX-mediated moderation of LPS-triggered inflammatory reaction in BMDMs.

CONCLUSIONS

In sum, we found that CPX protected against LPS-induced septic shock by mitigating inflammation via SORT1-mediated Wnt/β-Catenin signaling pathway.

A comparative study on specialized services in pre-hospital emergencies in Iran and selected countries

The quality of emergency services is one of the indicators describing the health status of countries. Moreover, the specialization of services and targeted response to any accident or disease has been the priority of pre-hospital emergency operations in some leading countries. This study aimed to compare the special services provided in the emergency department of several selected countries. This was a comparative study that was done in Isfahan in 2022. Data were collected by reviewing the literature provided by libraries and emergency websites of selected countries. We selected countries based on the accessibility of information in two groups of developed countries and countries with the same income and population as Iran including Germany, France, The United States, Australia, Britain, Malaysia, and Turkey. Data were classified and compared based on staff, vehicles, and specialized services. Emergency staffs in most countries were of different skill and training levels. Ambulances varied in equipment types in various land, air, and sea forms and dimensions. Developed countries had more modern ambulances and equipment. France and Germany were operating more especially. Specialized teams are dispatched only in the United States and Germany. Existing studies have shown the adequacy and effectiveness of these teams in reducing complications and mortality and improving the prognosis of patients. The use of specialized teams appropriate to each emergency based on the specific and targeted response is effective in improving the prognosis of patients. The results of this study are suggested to beneficiaries to improve the quality of emergency care and reduce complications and potential causalities.

Prehospital early warning scores for adults with suspected sepsis: retrospective diagnostic cohort study

BACKGROUND

Ambulance services need to identify and prioritise patients with sepsis for early hospital assessment. We aimed to determine the accuracy of early warning scores alongside paramedic diagnostic impression to identify sepsis that required urgent treatment.

METHODS

We undertook a retrospective diagnostic cohort study involving adult emergency medical cases transported to Sheffield Teaching Hospitals ED by Yorkshire Ambulance Service in 2019. We used routine ambulance service data to calculate 21 early warning scores and categorise paramedic diagnostic impressions as sepsis, infection, non-specific presentation or other presentation. We linked cases to hospital records and identified those meeting the sepsis-3 definition who received urgent hospital treatment for sepsis (reference standard). Analysis determined the accuracy of strategies that combined early warning scores at varying thresholds for positivity with paramedic diagnostic impression.

RESULTS

We linked 12 870/24 955 (51.6%) cases and identified 348/12 870 (2.7%) with a positive reference standard. None of the strategies provided sensitivity greater than 0.80 with positive predictive value greater than 0.15. The area under the receiver operating characteristic curve for the National Early Warning Score, version 2 (NEWS2) applied to patients with a diagnostic impression of sepsis or infection was 0.756 (95% CI 0.729, 0.783). No other early warning score provided clearly superior accuracy to NEWS2. Paramedic impression of sepsis or infection had sensitivity of 0.572 (0.519, 0.623) and positive predictive value of 0.156 (0.137, 0.176). NEWS2 thresholds of >4, >6 and >8 applied to patients with a diagnostic impression of sepsis or infection, respectively, provided sensitivities and positive predictive values of 0.522 (0.469, 0.574) and 0.216 (0.189, 0.245), 0.447 (0.395, 0.499) and 0.274 (0.239, 0.313), and 0.314 (0.268, 0.365) and 0.333 (0.284, 0.386).

CONCLUSION

No strategy is ideal but using NEWS2 alongside 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.

TRIAL REGISTRATION NUMBER

researchregistry5268, https://www.researchregistry.com/browse-the-registry%23home/registrationdetails/5de7bbd97ca5b50015041c33/.

Predicting sepsis using a combination of clinical information and molecular immune markers sampled in the ambulance

Sepsis is a time dependent condition. Screening tools based on clinical parameters have been shown to increase the identification of sepsis. The aim of current study was to evaluate the additional predictive value of immunological molecular markers to our previously developed prehospital screening tools. This is a prospective cohort study of 551 adult patients with suspected infection in the ambulance setting of Stockholm, Sweden between 2017 and 2018. Initially, 74 molecules and 15 genes related to inflammation were evaluated in a screening cohort of 46 patients with outcome sepsis and 50 patients with outcome infection no sepsis. Next, 12 selected molecules, as potentially synergistic predictors, were evaluated in combination with our previously developed screening tools based on clinical parameters in a prediction cohort (n = 455). Seven different algorithms with nested cross-validation were used in the machine learning of the prediction models. Model performances were compared using posterior distributions of average area under the receiver operating characteristic (ROC) curve (AUC) and difference in AUCs. Model variable importance was assessed by permutation of variable values, scoring loss of classification as metric and with model-specific weights when applicable. When comparing the screening tools with and without added molecular variables, and their interactions, the molecules per se did not increase the predictive values. Prediction models based on the molecular variables alone showed a performance in terms of AUCs between 0.65 and 0.70. Among the molecular variables, IL-1Ra, IL-17A, CCL19, CX3CL1 and TNF were significantly higher in septic patients compared to the infection non-sepsis group. Combing immunological molecular markers with clinical parameters did not increase the predictive values of the screening tools, most likely due to the high multicollinearity of temperature and some of the markers. A group of sepsis patients was consistently miss-classified in our prediction models, due to milder symptoms as well as lower expression levels of the investigated immune mediators. This indicates a need of stratifying septic patients with a priori knowledge of certain clinical and molecular parameters in order to improve prediction for early sepsis diagnosis.Trial registration: NCT03249597. Registered 15 August 2017.

Rethinking non-urgent EMS conveyance to ED during night-time - a pilot study in Southwest Finland

BACKGROUND

The amount of emergency medical service missions has increased internationally in recent years, and emergency departments are overcrowded globally. Previous evidence has shown that patients arriving at the emergency department during nighttime (20 - 08) have to wait longer, are more likely to leave without being seen, and often have non-urgent conditions compared to patients arriving during the day. The objective of this pilot study was to examine what kind of patient groups are conveyed as non-urgent to the hospital by emergency medical service during nighttime and what kind of diagnostic tests and medical interventions those patients receive before morning to identify patient groups that could be non-conveyed or directed to alternative points of care.

METHODS

This was a retrospective register study where the information of patients conveyed to university hospital during nighttime (20 - 08) were analyzed. Frequencies of the dispatch codes presenting complaints, medical treatments, and diagnostic tests were calculated. Age significance (under/over 70 years) was also tested.

RESULTS

73.5% of the patients received neither medical treatment nor had diagnostic tests taken before morning. Most of these were patients with mental disorder(s), hip pain/complaint, or laceration/cut. Almost half of the patients with abdominal pain or fever had laboratory tests taken. Patients over 70 years old received more medications and had more diagnostic tests taken than younger patients.

CONCLUSIONS

Some of the low-acuity patients could be non-conveyed or referred to alternative pathways of care to avoid impolitic use of emergency medical service and to reduce the workload of emergency departments. Further research is needed to ensure patient safety for patients who are not conveyed at night.

Evidence for Use of Validated Sepsis Screening Tools in the Prehospital Population: A Scoping Review

INTRODUCTION

Early detection and treatment of sepsis improves chances of survival; however, sepsis is often difficult to diagnose initially. This is especially true in the prehospital setting, where resources are scarce, yet time is of great significance. Early warning scores (EWS) based on vital signs were originally developed to guide medical practitioners in determining the degree of illness of a patient in the in-patient setting. These EWS were adapted for use in the prehospital setting to predict critical illness and sepsis. We performed a scoping review to evaluate the existing evidence for use of validated EWS to identify prehospital sepsis.

METHODS

We performed a systematic search using the CINAHL, Embase, Ovid-MEDLINE, and PubMed databases on September 1, 2022. Articles that examined the use of EWS to identify prehospital sepsis were included and assessed.

RESULTS

Twenty-three studies were included in this review: one validation study, two prospective studies, two systematic reviews, and 18 retrospective studies. Study characteristics, classification statistics, and primary conclusions of each article were extracted and tabulated. Classification statistics varied markedly for prehospital sepsis identification across all included EWS: sensitivities ranged from 0.02-1.00, specificities from 0.07-1.00, and PPV and NPV from 0.19-0.98 and 0.32-1.00, respectively.

CONCLUSIONS

All studies demonstrated inconsistency for the identification of prehospital sepsis. The variety of available EWS and study design heterogeneity suggest it is unlikely that new research can identify a single gold standard score. Based on our findings in this scoping review, we recommend future efforts focus on combining standardized prehospital care with clinical judgment to provide timely interventions for unstable patients where infection is considered a likely etiology, in addition to improving sepsis education for prehospital clinicians. At most, EWS can be used as an adjunct to these efforts, but they should not be relied on alone for prehospital sepsis identification.

Evaluation of the PRESEP Score and the Miami Sepsis Score for Prehospital Sepsis Screening

INTRODUCTION

Sepsis is a life-threatening organ dysfunction caused by a dysregulated response to an infection that requires early intervention. Prehospital sepsis screening tools have not yet been widely evaluated for their performance in clinical practice.

OBJECTIVE

To evaluate the ability of the Prehospital Early Sepsis Detection (PRESEP) score and the Miami Sepsis Score to predict sepsis in prehospital settings.

METHOD

This retrospective analysis included patients with diseases of internal cause who were transported by emergency medical services (EMS) to the hospital and hospitalized between January and June 2020. Data were extracted from the medical and EMS records. The primary outcome was sepsis diagnosis within 48 h of admission. The predictive abilities of the scores were assessed using the area under the receiver operating characteristic curve (AUC). Sensitivity, specificity, and positive and negative likelihood ratios (LRs) were calculated at cutoff values derived using Youden's index.

RESULTS

Data from 354 patients were analyzed. The AUC for the PRESEP score was 0.83 (95% confidence interval [CI] 0.79-0.88) while that for the Miami Sepsis Score was 0.80 (0.75-0.85). The sensitivity, specificity, positive LR, and negative LR for the PRESEP score (cutoff was 5) were 0.83 (0.73-0.90), 0.68 (0.62-0.73), 2.59 (2.12-3.16), and 0.25 (0.15-0.40), respectively, and those for the Miami Sepsis Score (cu-off was 3) were 0.81 (0.71-0.89), 0.65 (0.59-0.71), 2.33 (1.93-2.83), and 0.30 (0.19-0.46), respectively.

CONCLUSION

Due to their relatively good predictive abilities to detect septic patients and simplicities, the PRESEP and Miami Sepsis Scores could be used for screening patients for sepsis in prehospital settings. Further prospective validation and evaluation of effect on clinical outcomes are needed.

A Comparative Study on Predictive Validity of Modified Shock Index, Shock Index, and Age Shock Index in Predicting the Need for Mechanical Ventilation among Sepsis Patients in a Tertiary Care Hospital

Introduction

The shock index (SI), modified shock index (MSI), and age multiplied by SI (ASI) are used to assess the severity of shock. They are also used to predict the mortality of trauma patients, but their validity for sepsis patients is controversial. The aim of this study is to assess the predictive value of the SI, MSI, and ASI in predicting the need for mechanical ventilation after 24 h of admission among sepsis patients.

Methods

A prospective observational study was conducted in a tertiary care teaching hospital. Patients with sepsis (235) diagnosed based on systemic inflammatory response syndrome criteria and quick sequential organ failure assessment were included in the study. The need for mechanical ventilation after 24 h is the outcome variables MSI, SI, and ASI were considered as predictor variables. The utility of MSI, SI, and ASI in predicting mechanical ventilation was assessed by receiver operative curve analysis. Data were analyzed using coGuide.

Results

Among the study population, the mean age was 56.12 ± 17.28 years. MSI value at the time of disposition from the emergency room had good predictive validity in predicting mechanical ventilation after 24 h, as indicated by the area under the curve (AUC) of 0.81 (P < 0.001), SI and ASI had fair predictive validity for mechanical ventilation as indicated by AUC (0.78, P < 0.001) and (0.802, P < 0.001), respectively.

Conclusion

SI had better sensitivity (78.57%) and specificity (77.07%) compared to ASI and MSI in predicting the need for mechanical ventilation after 24 h in sepsis patients admitted to intensive care units.

Automated digital technologies for supporting sepsis prediction in children: a scoping review protocol

INTRODUCTION

While there have been several literature reviews on the performance of digital sepsis prediction technologies and clinical decision-support algorithms for adults, there remains a knowledge gap in examining the development of automated technologies for sepsis prediction in children. This scoping review will critically analyse the current evidence on the design and performance of automated digital technologies to predict paediatric sepsis, to advance their development and integration within clinical settings.

METHODS AND ANALYSIS

This scoping review will follow Arksey and O'Malley's framework, conducted between February and December 2022. We will further develop the protocol using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. We plan to search the following databases: Association of Computing Machinery (ACM) Digital Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Google Scholar, Institute of Electric and Electronic Engineers (IEEE), PubMed, Scopus and Web of Science. Studies will be included on children >90 days postnatal to <21 years old, predicted to have or be at risk of developing sepsis by a digitalised model or algorithm designed for a clinical setting. Two independent reviewers will complete the abstract and full-text screening and the data extraction. Thematic analysis will be used to develop overarching concepts and present the narrative findings with quantitative results and descriptive statistics displayed in data tables.

ETHICS AND DISSEMINATION

Ethics approval for this scoping review study of the available literature is not required. We anticipate that the scoping review will identify the current evidence and design characteristics of digital prediction technologies for the timely and accurate prediction of paediatric sepsis and factors influencing clinical integration. We plan to disseminate the preliminary findings from this review at national and international research conferences in global and digital health, gathering critical feedback from multidisciplinary stakeholders. SCOPING REVIEW REGISTRATION: https://osf.io/veqha/?view_only=f560d4892d7c459ea4cff6dcdfacb086.

Biomarkers of sepsis in pigs, horses and cattle: from acute phase proteins to procalcitonin

Sepsis is a complex clinical syndrome triggered by an inflammatory host response to an infection. It is usually complicated to detect and diagnose, and has severe consequences in human and veterinary health, especially when treatment is not started early. Therefore, efforts to detect sepsis accurately are needed. In addition, its proper diagnosis could reduce the misuse of antibiotics, which is essential fighting against antimicrobial resistance. This case is a particular issue in farm animals, as antibiotics have been traditionally given massively, but now they are becoming increasingly restricted. When sepsis is suspected in animals, the most frequently used biomarkers are acute phase proteins such as C-reactive protein, serum amyloid A and haptoglobin, but their concentrations can increase in other inflammatory conditions. In human patients, the most promising biomarkers to detect sepsis are currently procalcitonin and presepsin, and there is a wide range of other biomarkers under study. However, there is little information on the application of these biomarkers in veterinary species. This review aims to describe the general concepts of sepsis and the current knowledge about the biomarkers of sepsis in pigs, horses, and cattle and to discuss possible advances in the field.

Is Prehospital Assessment of qSOFA Parameters Associated with Earlier Targeted Sepsis Therapy? A Retrospective Cohort Study

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.

A Proteomic Approach to Elucidate the Changes in Saliva and Serum Proteins of Pigs with Septic and Non-Septic Inflammation

Sepsis is a systemic inflammatory response triggered by an infectious agent and is recognized by the World Health Organization as a global concern, since it is one of the major causes of severe illness in humans and animals. The study of the changes that can occur in saliva and serum in sepsis can contribute to a better understanding of the pathophysiological mechanisms involved in the process and also to discover potential biomarkers that can help in its diagnosis and monitoring. The objective of this study was to characterize the changes that occur in the salivary and serum proteome of pigs with experimentally-induced sepsis. The study included five pigs with sepsis induced by LPS administration and five pigs with non-septic inflammation induced by turpentine for comparative purposes. In saliva, there were eighteen salivary proteins differentially expressed in the sepsis condition and nine in non-septic inflammation. Among these, significant increments in aldolase A and serpin B12 only occurred in the sepsis model. Changes in aldolase A were validated in a larger population of pigs with sepsis due to Streptococcus suis infection. In serum, there were 30 proteins differentially expressed in sepsis group and 26 proteins in the non-septic group, and most of the proteins that changed in both groups were related to non-specific inflammation. In the saliva of the septic animals there were some specific pathways activated, such as the organonitrogen compound metabolic process and lipid transport, whereas, in the serum, one of the main activated pathways was the regulation of protein secretion. Overall, saliva and serum showed different proteome variations in response to septic inflammation and could provide complementary information about the pathophysiological mechanisms occurring in this condition. Additionally, salivary aldolase A could be a potential biomarker of sepsis in pigs that should be confirmed in a larger population.

Implementing a new emergency medical triage tool in one health region in Norway: some lessons learned

BACKGROUND

Acutely sick or injured patients depend on ambulance and emergency department personnel performing an accurate initial assessment and prioritisation (triage) to effectively identify patients in need of immediate treatment. Triage also ensures that each patient receives fair initial assessment. To improve the patient safety, quality of care, and communication about a patient's medical condition, we implemented a new triage tool (the South African Triage Scale Norway (SATS-N) in all the ambulance services and emergency departments in one health region in Norway. This article describes the lessons we learnt during this implementation process.

METHODS

The main framework in this quality improvement (QI) work was the plan-do-study-act cycle. Additional process sources were 'The Institute for Healthcare Improvement Model for improvement' and the Norwegian Patient Safety Programme.

RESULTS

Based on the QI process as a whole, we defined subjects influencing this work to be successful, such as identifying areas for improvement, establishing multidisciplinary teams, coaching, implementing measurements and securing sustainability. After these subjects were connected to the relevant challenges and desired effects, we described the lessons we learnt during this comprehensive QI process.

CONCLUSION

We learnt the importance of following a structured framework for QI process during the implementation of the SATS-N triage tool. Furthermore, securing anchoring at all levels, from the managements to the medical professionals in direct patient-orientated work, was relevant important. Moreover, establishing multidisciplinary teams with ambulance personnel, emergency department nurses and doctors with various medical specialties provided ownership to the participants. Meanwhile, coaching provided necessary security for the staff directly involved in caring for patients. Keeping the spirit and perseverance high were important factors in completing the implementation. Establishment of the regional network group was found to be important for sustainability and further improvements.

Combination of Prehospital NT-proBNP with qSOFA and NEWS to Predict Sepsis and Sepsis-Related Mortality

Background. The aim of this study was to assess the role of prehospital point-of-care N-terminal probrain natriuretic peptide to predict sepsis, septic shock, or in-hospital sepsis-related mortality. Methods. A prospective, emergency medical service-delivered, prognostic, cohort study of adults evacuated by ambulance and admitted to emergency department between January 2020 and May 2021. The discriminative power of the predictive variable was assessed through a prediction model trained using the derivation cohort and evaluated by the area under the curve of the receiver operating characteristic on the validation cohort. Results. A total of 1,360 patients were enrolled with medical disease in the study. The occurrence of sepsis, septic shock, and in-hospital sepsis-related mortality was 6.4% (67 cases), 4.2% (44 cases), and 6.1% (64 cases). Prehospital National Early Warning Score 2 had superior predictive validity than quick Sequential Organ Failure Assessment and N-terminal probrain natriuretic peptide for detecting sepsis and septic shock, but N-terminal probrain natriuretic peptide outperformed both scores in in-hospital sepsis-related mortality estimation. Application of N-terminal probrain natriuretic peptide to subgroups of the other two scores improved the identification of sepsis, septic shock, and sepsis-related mortality in the group of patients with low-risk scoring. Conclusions. The incorporation of N-terminal probrain natriuretic peptide in prehospital care combined with already existing scores could improve the identification of sepsis, septic shock, and sepsis-related mortality.

Prehospital delay is an important risk factor for mortality in community-acquired bloodstream infection (CA-BSI): a matched case-control study

OBJECTIVES

The aim of this study was to identify prehospital and early hospital risk factors associated with 30-day mortality in patients with blood culture-confirmed community-acquired bloodstream infection (CA-BSI) in Sweden.

METHODS

A retrospective case-control study of 1624 patients with CA-BSI (2015-2016), 195 non-survivors satisfying the inclusion criteria were matched 1:1 with 195 survivors for age, gender and microorganism. All forms of contact with a healthcare provider for symptoms of infection within 7 days prior CA-BSI episode were registered. Logistic regression was used to analyse risk factors for 30-day all-cause mortality.

RESULTS

Of the 390 patients, 61% (115 non-survivors and 121 survivors) sought prehospital contact. The median time from first prehospital contact till hospital admission was 13 hours (6-52) for non-survivors and 7 hours (3-24) for survivors (p<0.01). Several risk factors for 30-day all-cause mortality were identified: prehospital delay OR=1.26 (95% CI: 1.07 to 1.47), p<0.01; severity of illness (Sequential Organ Failure Assessment score) OR=1.60 (95% CI: 1.40 to 1.83), p<0.01; comorbidity score (updated Charlson Index) OR=1.13 (95% CI: 1.05 to 1.22), p<0.01 and inadequate empirical antimicrobial therapy OR=3.92 (95% CI: 1.64 to 9.33), p<0.01. In a multivariable model, prehospital delay >24 hours from first contact remained an important risk factor for 30-day all-cause mortality due to CA-BSI OR=6.17 (95% CI: 2.19 to 17.38), p<0.01.

CONCLUSION

Prehospital delay and inappropriate empirical antibiotic therapy were found to be important risk factors for 30-day all-cause mortality associated with CA-BSI. Increased awareness and earlier detection of BSI in prehospital and early hospital care is critical for rapid initiation of adequate management and antibiotic treatment.

Use of sepsis-related diagnostic criteria in primary care: a survey among general practitioners

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.

Comparison of children receiving emergent sepsis care by mode of arrival

OBJECTIVE

To determine if differences in patient characteristics, treatments, and outcomes exist between children with sepsis who arrive by emergency medical services (EMS) versus their own mode of transport (self-transport).

METHODS

Retrospective cohort study of patients who presented to the Emergency Department (ED) of two large children's hospitals and treated for sepsis from November 2013 to June 2017. Presentation, ED treatment, and outcomes, primarily time to first bolus and first parental antibiotic, were compared between those transported via EMS versus patients who were self-transported.

RESULTS

Of the 1813 children treated in the ED for sepsis, 1452 were self-transported and 361 were transported via EMS. The EMS group were more frequently male, of black race, and publicly insured than the self-transport group. The EMS group was more likely to have a critical triage category, receive initial care in the resuscitation suite (51.9 vs. 22%), have hypotension at ED presentation (14.4 vs. 5.4%), lactate >2.0 mmol/L (60.6 vs. 40.8%), vasoactive agents initiated in the ED (8.9 vs. 4.9%), and to be intubated in the ED (14.4 vs. 2.8%). The median time to first IV fluid bolus was faster in the EMS group (36 vs. 57 min). Using Cox LASSO to adjust for potential covariates, time to fluids remained faster for the EMS group (HR 1.26, 95% CI 1.12, 1.42). Time to antibiotics, ICU LOS, 3- or 30-day mortality rates did not differ, yet median hospital LOS was significantly longer in those transported by EMS versus self-transported (6.5 vs. 5.3 days).

CONCLUSIONS

Children with sepsis transported by EMS are a sicker population of children than those self-transported on arrival and had longer hospital stays. EMS transport was associated with earlier in-hospital fluid resuscitation but no difference in time to first antibiotic. Improved prehospital recognition and care is needed to promote adherence to both prehospital and hospital-based sepsis resuscitation benchmarks.

Assessment of patients with suspected sepsis in ambulance services: a qualitative interview study

Background

The initial care of patients with sepsis is commonly performed by ambulance clinicians (ACs). Early identification, care and treatment are vital for patients with sepsis to avoid adverse outcomes. However, knowledge about how patients with sepsis are assessed in ambulance services (AS) by AC is limited. Therefore, the aim of this study was to explore the meaning of ACs’ lived experiences in assessing patients suspected of having sepsis.

Methods

A descriptive design with a qualitative approach was used. Fourteen ACs from three Swedish ambulance organizations participated in dyadic and individual semistructured interviews. A thematic analysis based on descriptive phenomenology was performed.

Results

AC experiences were grouped into four themes: (1) being influenced by previous experience; (2) searching for clues to the severity of the patient’s condition; (3) feeling confident when signs and symptoms were obvious; and (4) needing health-care professionals for support and consultation.

Conclusions

This study indicates that several factors are important to assessments. ACs needed to engage in an ongoing search for information, discuss the cases with colleagues and reconsider the assessment throughout the entire ambulance mission. A reflective and open stance based on professional knowledge could contribute to recognizing patients with sepsis.

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.

National Early Warning Score (NEWS) as Prognostic Triage Tool for Septic Patients

Purpose

We assessed the National Early Warning Score (NEWS) in emergency triage for predicting sepsis-related outcomes.

Methods

A retrospective chart review of all cases enrolled in the sepsis management protocol for a one-year duration. The protocol utilized the NEWS as a screening tool for sepsis in the triage area. Primary outcomes of interest were hyperlactatemia, admission to ICU and intrahospital mortality. Sensitivity, specificity, and area under the curve (AUC) were calculated for a given NEWS.

Results

A total of 444 patients were reviewed from July 2018 to June 2019, with a mean age of 58.7 years. A NEWS ≥5 was more than 88% sensitive in predicting hyperlactatemia, ICU admission, and/or mortality. Specificity, on the other hand, was as low as 12%. The AUC for the NEWS was 0.667 for predicting hyperlactatemia and 0.602 for predicting ICU admission or mortality.

Conclusion

The NEWS was a sensitive screening tool for predicting sepsis-related outcomes. However, it was not specific, and further studies are recommended to assess the integration of other factors to improve specificity.

Severe sepsis and septic shock in patients transported by prehospital services versus walk in patients to the emergency department

BACKGROUND

Sepsis is a leading cause of death in the hospital for which aggressive treatment is recommended to improve patient outcomes. It is possible that sepsis patients brought in by emergency medical services (EMS) have a unique advantage in the emergency department (ED) which could improve sepsis bundle compliance.

OBJECTIVE

To evaluate patient care processes and outcome differences between severe sepsis and septic shock patients in the emergency department who were brought in by EMS compared to non-EMS patients.

METHODS

We performed a retrospective chart review of all severe sepsis and septic shock patients who declared in the ED during January 2012 thru December 2014. We compared differences in patient characteristics, patient care processes, sepsis bundle compliance metrics, and outcomes between both groups.

RESULTS

Of the 1066 patients included in the study, 387 (36.6%) were brought in by EMS and 679 (63.7%) patients arrived via non-EMS transport. In the multivariate regression model, time of triage to sepsis declaration (coeff = -0.406; 95% CI = -0.809, -0.003; p = 0.048) and time of triage to physician (coeff = -0.543; 95% CI = -0.864, -0.221; p = 0.001) was significantly shorter for EMS patients. We found no statistical difference in adjusted individual sepsis compliance metrics, overall bundle compliance, or mortality between both groups.

CONCLUSION

EMS transported patients have quicker sepsis declaration times and are seen sooner by ED providers. However, we found no statistical difference in bundle compliance or patient outcomes between walk in patients and EMS transported patients.

Identification of Generalized Convulsive Status Epilepticus from Emergency Medical Service Records: A Validation Study of Diagnostic Coding

BACKGROUND

Generalized convulsive status epilepticus (GCSE) is a neurologic emergency demanding prehospital identification and treatment. Evaluating real-world practice requires accurately identifying the target population; however, it is unclear whether emergency medical services (EMS) documentation accurately identifies patients with GCSE.

OBJECTIVE

To evaluate the validity of EMS diagnostic impressions for GCSE.

METHODS

This was an analysis of electronic medical records of a California county EMS system from 2013 to 2018. We identified all cases with a primary diagnostic impression of "seizure-active," "seizure-post," or "seizure-not otherwise specified (NOS)" and within each diagnostic category, we randomly selected 75 adult and 25 pediatric records. Two authors reviewed the provider narrative of these 300 charts to determine a clinical seizure diagnosis according to prespecified definitions. We calculated a kappa for interrater reliability of the clinical diagnosis. We then calculated the positive predictive value (PPV), sensitivity, and specificity of an EMS diagnosis of "seizure-active" diagnosis for identifying GCSE. Sensitivity and specificity calculations were weighted according to the distribution of seizure cases in the overall population. We performed a descriptive analysis of records with an incorrect EMS diagnosis of GCSE or seizure.

RESULTS

Of 38,995 total records for seizure, there were 3401 (8.7%) seizure-active cases, 12,478 (32.0%) seizure-NOS cases, and 23,116 (59.4%) seizure-post cases. An EMS diagnosis of "seizure-active" had a PPV of 65.0% (95% CI 54.8-74.3), sensitivity of 54.6% (95% confidence interval [CI] 39.3-69.0), and specificity of 96.6% (95% CI 95.1-97.6) for capturing GCSE. Limiting the case definition to patients who received an EMS diagnosis of "seizure-active" and were treated with a benzodiazepine increased the PPV (80.2%; 95% CI 69.9-88.2) and specificity (99.3%; 95% CI 98.7-99.6) while the sensitivity decreased (25.1%; 95% CI 17.0-35.3). Across the 300 records reviewed, there were 19 (6.3%) patients who had a non-seizure related diagnosis including non-epileptic spells (7 records), altered mental status (8 records), tremors (2 records), anxiety (1 record), and stroke (1 record).

CONCLUSIONS

EMS diagnostic impressions have reasonable PPV and specificity but low sensitivity for GCSE. Improved coding algorithms and training will allow for improved benchmarking, quality improvement, and research about this neurologic emergency.

Implementing a Statewide Prehospital Sepsis Protocol: Perspectives of Emergency Medical Services Medical Directors

Background

Sepsis is a medical emergency that requires prompt recognition and treatment. Multiple Emergency Medical Services (EMS) agencies across the United States have implemented sepsis protocols. In 2016, Maryland instituted its own state-wide EMS sepsis protocol which includes fluid resuscitation, vasopressor administration, and requires alerting the hospital of an incoming sepsis patient.

Objective

The purpose of this study was to quantify the perspectives of EMS medical directors in Maryland regarding prehospital sepsis care and to identify challenges encountered during the implementation of the statewide sepsis protocol.

Methods

A 17-question survey was sent to all 24 jurisdictional medical directors in the state of Maryland.

Results

A total of 14 (58%) medical directors responded, representing four of the five EMS regions in the state. More than half (57%) stated sepsis alerting was a priority in their jurisdiction; however, in a listing of eight initiatives, sepsis was the least prioritized. Most (64%) respondents believed their clinicians had adequate training on sepsis. A majority (79%) of medical directors surveyed felt that core measures of sepsis management would be beneficial. The potentially most helpful core measures were the volume of IV fluid administration (92%), true positive sepsis alerts (83%), and cases of failure to activate a sepsis alert (75%). Engagement of field personnel was rated as the biggest challenge for the implementation of a sepsis protocol in general, and lack of a thermometer on EMS units (50%) was the largest hurdle specifically in the 2016 statewide sepsis protocol. Surveyed medical directors (86%) believe the most difficult obstacle to overcome for EMS clinicians in the treatment of sepsis are nonspecific signs and symptoms.

Conclusions

Prehospital sepsis care was viewed to be important amongst the medical directors surveyed. However, significant challenges to implementation of a sepsis protocol and delivery of prehospital sepsis care are perceived by jurisdictional medical directors. Additional investment and dedication to sepsis care will advance prehospital sepsis treatment in Maryland.

Screening strategies to identify sepsis in the prehospital setting: a validation study

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.

Telephonic description of sepsis among callers to an emergency dispatch centre in South Africa

Introduction

Sepsis is an acute, life-threatening condition caused by a dysregulated systemic response to infection. Early medical intervention such as antibiotics and fluid resuscitation can be life-saving. Diagnosis or suspicion of sepsis by an emergency call-taker could potentially improve patient outcome. Therefore, the aim was to determine the keywords used by callers to describe septic patients in South Africa when calling a national private emergency dispatch centre.

Methods

A retrospective review of prehospital patient records was completed to identify patients with sepsis in the prehospital environment. A mixed-methods design was employed in two-sequential phases. The first phase was qualitative. Thirty cases of sepsis were randomly selected, and the original call recording was extracted. These recordings were transcribed verbatim and subjected to content analysis to determine keywords of signs and symptoms telephonically. Once keywords were identified, an additional sample of sepsis cases that met inclusion and exclusion criteria were extracted and listened to. The frequency of each of the keywords was quantified.

Results

Eleven distinct categories were identified. The most prevalent categories that were used to describe sepsis telephonically were: gastrointestinal symptoms (40%), acute altered mental status (35%), weakness of the legs (33%) and malaise (31%). At least one of these four categories of keywords appeared in 86% of all call recordings.

Conclusion

It was found that certain categories appeared in higher frequencies than others so that a pattern could be recognised. Utilising these categories, telephonic recognition algorithms for sepsis could be developed to aid in predicting sepsis over the phone. This would allow for dispatching of the correct level of care immediately and could subsequently have positive effects on patient outcome.

Epidemiology of septic shock in prehospital medical services in five Colombian cities

Objective

To explore the association between demographic and clinical factors and the presentation of septic shock in patients treated by prehospital emergency services in five Colombian cities between 2015 and 2016.

Methods

This was a cross-sectional study with retrospective data collection. Clinical and demographic data were collected from the medical records of patients diagnosed with sepsis who received prehospital care in five Colombian cities in 2015 and 2016. The diagnosis of septic shock was checked in 20% of the cases, generating two analyzed scenarios: observed and verified. Data were analyzed using the chi-square test, Student’s t test and an adjusted logistic regression model. Covariates with p < 0.05 were considered significant.

Results

There was a higher frequency of septic shock in women (62.6%) and in individuals older than 80 years (64.5%), but these were not differentiating factors for septic shock. The most common source of infection was the urinary tract. In the observed scenario, age over 60 (prevalence ratio (PR): 3.22; 95% confidence interval (CI): 1.45 - 35.01) and history of cancer (PR: 1.20; 95%CI: 1.2 - 12.87) were the characteristics associated with septic shock, whereas in the verified scenario, chronic obstructive pulmonary disease (PR: 1.99; 95%CI: 1.26 - 7.14), history of cancer (PR: 1.15; 95%CI: 1.11 - 6.62) and presence of hypovolemia (PR: 1.41; 95%CI: 1.02 - 5.50) were observed.

Conclusion

The most important risk factors for septic shock in prehospital care patients in five Colombian cities were oncological and pulmonary diseases and hypovolemia.

Care of the patient with invasive meningococcal disease by prehospital emergency medical service clinicians: a scoping review

OBJECTIVE

The objective of this scoping review is to systematically map the literature to identify the scope, depth, key concepts and gaps in the evidence regarding care of the patient with invasive meningococcal disease by emergency medical service (EMS) clinicians.

DESIGN

Scoping review. This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews reporting guideline.

ELIGIBILITY CRITERIA

Sources which focused on patients with invasive meningococcal disease (population), where the care of EMS clinicians was the focus (concept), in EMS systems worldwide (context) were eligible for inclusion.

SEARCH STRATEGY

This review utilised a comprehensive search strategy including MEDLINE, Embase, Emcare, CINAHL, Scopus, Web of Science, Google Scholar and 'grey' literature databases from 1992 to January 2019. The search also included a Google search, a hand-search of relevant journals, screening of reference lists, contact with authors of included sources and use of social media in an attempt to locate all sources of evidence which fit the inclusion criteria of the review. Two reviewers independently screened sources for inclusion.

RESULTS

The search yielded 1803 unique records, of which 10 were included in the synthesis. No original research papers were identified, with all sources classed as either clinical audit or text and opinion literature. The dominant concept throughout the literature is that early antibiotic therapy is critical in the treatment of invasive meningococcal disease.

CONCLUSIONS

Overall, there is a very narrow scope and shallow depth of literature on the topic of interest. There are gaps in the evidence regarding the care of the patient with invasive meningococcal disease by EMS clinicians. Despite these shortfalls, current consensus-based guidelines should direct clinical practice. Further research is planned to bridge the gaps in knowledge to support best practice.

Development of a clinical prediction rule for sepsis in primary care: protocol for the TeSD-IT study

BACKGROUND

Early recognition and treatment of sepsis is crucial to prevent detrimental outcomes. General practitioners (GPs) are often the first healthcare providers to encounter seriously ill patients. The aim of this study is to assess the value of clinical information and additional tests to develop a clinical prediction rule to support early diagnosis and management of sepsis by GPs.

METHODS

We will perform a diagnostic study in the setting of out-of-hours home visits in four GP cooperatives in the Netherlands. Acutely ill adult patients suspected of a serious infection will be screened for eligibility by the GP. The following candidate predictors will be prospectively recorded: (1) age, (2) body temperature, (3) systolic blood pressure, (4) heart rate, (5) respiratory rate, (6) peripheral oxygen saturation, (7) mental status, (8) history of rigors, and (9) rate of progression. After clinical assessment by the GP, blood samples will be collected in all patients to measure C-reactive protein, lactate, and procalcitonin. All patients will receive care as usual. The primary outcome is the presence or absence of sepsis within 72 h after inclusion, according to an expert panel. The need for hospital treatment for any indication will be assessed by the expert panel as a secondary outcome. Multivariable logistic regression will be used to design an optimal prediction model first and subsequently derive a simplified clinical prediction rule that enhances feasibility of using the model in daily clinical practice. Bootstrapping will be performed for internal validation of both the optimal model and simplified prediction rule. Performance of both models will be compared to existing clinical prediction rules for sepsis.

DISCUSSION

This study will enable us to develop a clinical prediction rule for the recognition of sepsis in a high-risk primary care setting to aid in the decision which patients have to be immediately referred to a hospital and who can be safely treated at home. As clinical signs and blood samples will be obtained prospectively, near-complete data will be available for analyses. External validation will be needed before implementation in routine care and to determine in which pre-hospital settings care can be improved using the prediction rule.

TRIAL REGISTRATION

The study is registered in the Netherlands Trial Registry (registration number NTR7026).

Applying interprofessional education to the practice setting

Interprofessional education is a key requirement identified in various professional and regulatory body education standards in the UK. However, recent high-profile investigatory reports into adverse incidents in NHS organisations have demonstrated failures of translating interprofessional education into practice. This paper explores how a university in the south of England uses service improvement projects to address this. Working with key senior clinicians, small groups of students from a variety of professional backgrounds collaborate to address an identified problem in practice to bring about better, safer practice to benefit patients. This style of learning enables students to acquire essential attributes in preparation for employment, such as critical thinking, teamworking, ethical practice and leadership.

Impact of Prehospital Mobile Intensive Care Unit Intervention on Mortality of Patients with Sepsis

OBJECTIVE

The outcome of sepsis relies on the early diagnosis and implementation of appropriate treatments. For management of out-of-hospital patients with sepsis, prehospital emergency services, named Service d'Aide Médicale d'Urgence (SAMU) in France, dispatch to the scene an emergency mobile team (EMT) or a mobile intensive care unit (MICU) based on the patient's severity. Therefore, patients are admitted to the emergency department (ED) or to the intensive care unit (ICU). The impact of MICU intervention on patient's prognosis remains unclear. The aim of the present study was to describe the impact of MICU intervention on mortality on day 28 (D28) of patients with sepsis.

METHODS

We performed a retrospective study on patients with sepsis managed by prehospital teams, MICU or EMT, before admission to the ED or ICU. The primary outcome was mortality on D28.

RESULTS

The SAMU received 30,642 calls during the study period with 140 patients with suspected sepsis. The suspected origin of sepsis was mainly pulmonary for 78 (55%) patients. Thirteen (9%) patients died on D28, 12 in the ED and 1 in the ICU. Two patients were admitted to the hospital by a MICU. After adjusting for confounding factors, the relative risk of mortality on D28 for patients admitted to the hospital by a MICU was 0.40.

CONCLUSION

We describe an association between MICU intervention and mortality on D28. MICU intervention for out-of-hospital patients with sepsis is associated with 60% reduced mortality on D28. Larger studies are needed to confirm the impact of the intervention of MICU on mortality of patients with sepsis.

Derivation and internal validation of the screening to enhance prehospital identification of sepsis (SEPSIS) score in adults on arrival at the emergency department

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.

Shock index and modified shock index as triage screening tools for sepsis

BACKGROUND

Fever is one of the common conditions encountered in the emergency department, which related to a spectrum of diseases severity. Identifying sepsis patients from uncomplicated febrile patients is challenging in the emergency triage areas and pre-hospital settings.

OBJECTIVES

Assess the triage shock index (SI) and modified shock index (MSI) in febrile patients as predictors for sepsis and sepsis-related outcomes.

DESIGN

A retrospective cohort study.

SETTING

Patients presented to the Emergency Department of King Khalid University Hospital.

PATIENTS AND METHODS

The analysis included all febrile adult patients triaged with a temperature of 38 °C or more from January 2016 to December 2017. Based on triage vital sign we calculate the SI with cut-off levels of ≥0.7 and ≥1 and MSI with cut-off levels of ≥1 and ≥1.3. We report the Relative Risk, Sensitivity, Specificity, Positive and Negative Predictive Values of the predictors.

MAIN OUTCOME MEASURES

Sepsis and sepsis-related outcomes such as hyperlactatemia, ICU admission, and 28 days mortality.

SAMPLE SIZE

274 patients.

RESULTS

274 patients met our inclusion/exclusion criteria. Of the 274 patients, 252 patient (92%) were septic, 62 patients (22%) had hyperlactatemia, 20 patients admitted to the ICU, and 5 patient died within 28 days. An MSI of ≥1 had a sensitivity of 90% for sepsis predication, 85% for ICU admission and 100% for 28 days mortality. MSI of ≥1.3 showed a specificity (59%-100%) for all the outcomes of interest. Non-significant statistical trends of greater accuracy of MSI over SI.

CONCLUSION

MSI and SI were found to be promising predictors in triaging febrile patients. However no single cut-off values of MSI or SI were found to have an optimal accuracy for prediction of sepsis and sepsis-related outcomes. Further studies are required to assess the incorporation of MSI in a multi-item scaling system for the prediction of sepsis and its related outcomes.

LIMITATIONS

Small single center study and the results may not be generalizable.

Use of prehospital qSOFA in predicting in-hospital mortality in patients with suspected infection: A retrospective cohort study

Background

The quick sequential organ failure assessment (qSOFA) score has recently been introduced to the emergency department (ED) and wards, and it predicted a higher number of deaths among patients with sepsis compared with baseline risk. However, studies about the application of the qSOFA score are limited in prehospital settings. Thus, this study aimed to assess the performance of prehospital qSOFA score in predicting the risk of mortality among patients with infection.

Methods

This single center, retrospective cohort study was conducted in a Japanese tertiary care teaching hospital between April 2016 and March 2017. We enrolled all consecutive adult patients transported to the hospital by ambulance and admitted to the ED due to a suspected infection. We calculated the prehospital qSOFA score using the first vital sign obtained at the scene by emergency medical service (EMS) providers. The primary outcome was in-hospital mortality. The Cox proportional hazards model was used to assess the association between prehospital qSOFA positivity and in-hospital mortality.

Results

Among the 925 patients admitted to the ED due to a suspected infection, 51.1% (473/925) were prehospital qSOFA-positive and 48.9% (452/925) were prehospital qSOFA-negative. The in-hospital mortality rates were 14.0% (66/473) in prehospital qSOFA-positive patients and 6.0% (27/452) in prehospital qSOFA-negative patients. The Cox proportional hazard regression model revealed a strong association between prehospital qSOFA score and in-hospital mortality (adjusted hazard ratio: 2.41, 95% confidence interval: 1.51–3.98; p <0.01).

Conclusions

Among the patients with suspected infection who were admitted at the ED, a strong association was observed between the prehospital qSOFA score and in-hospital mortality. In order to use this score in clinical practice, future study is necessary to evaluate how infection is suspected in the prehospital arena.

Prehospital Care and Emergency Department Door-to-Antibiotic Time in Sepsis

RATIONALE

Early antibiotics improve outcomes for patients with sepsis. Factors influencing antibiotic timing in emergency department (ED) sepsis remain unclear.

OBJECTIVES

Determine the relationship between prehospital level of care of patients with sepsis and ED door-to-antibiotic time.

METHODS

This retrospective cohort study comprised patients admitted from the community to an academic ED June 2009 to February 2015 with fluid-refractory sepsis or septic shock. Transfer patients and those whose antibiotics began before ED arrival or after ED discharge were excluded. We used multivariable regression to evaluate the association between the time from ED arrival to antibiotic initiation and prehospital level of care, defined as the highest level of emergency medical services received: none, basic life support (BLS) ambulance, or advanced life support (ALS) ambulance. We measured variation in this association when hypotension was or was not present by ED arrival.

RESULTS

Among 361 community-dwelling patients with sepsis, the level of prehospital care correlated with illness severity. ALS-treated patients received antibiotics faster than patients who did not receive prehospital care (median, 103 [interquartile range, 75 to 135] vs. 144 [98 to 251] minutes, respectively) or BLS-only patients (168 [100-250] minutes; P < 0.001 for each pairwise comparison with ALS). This pattern persisted after multivariable adjustment, where ALS care (-43 min; 95% confidence interval [CI], -84 to -2; P = 0.033) but not BLS-only care (-4 min; 95% CI, -41 to +34; P = 0.97) was associated with less antibiotic delay compared with no prehospital care. ALS-treated patients more frequently received antibiotics within 3 hours of ED arrival (91%) compared with walk-in patients (62%; adjusted odds ratio, 3.11; 95% CI, 1.20 to 8.03; P = 0.015) or BLS-treated patients (56%; adjusted odds ratio, 4.51; 95% CI, 1.89 to 11.35; P < 0.001). ALS-treated patients started antibiotics faster than walk-in patients in the absence of hypotension by ED arrival (-41 min; 95% CI, -110 to -13; P = 0.009) but not when hypotension was present (+25 min; 95% CI, -43 to +92; P = 0.66).

CONCLUSIONS

Prehospital ALS but not BLS-only care was associated with faster antibiotic initiation for patients with sepsis without hypotension. Process redesign for non-ALS patients may improve antibiotic timeliness for ED sepsis.

Early recognition of sepsis through emergency medical services pre-hospital screening

BACKGROUND

The Surviving Sepsis Campaign implemented a 3-hour bundle including blood cultures, lactate, intravenous fluids, and antibiotics to improve mortality in sepsis. Though difficult to achieve, bundle compliance is associated with decreased hospital mortality. We predict that the implementation of an Emergency Medical Services (EMS) sepsis screening tool will improve 3-hour bundle compliance.

OBJECTIVES

To determine if pre-hospital sepsis screening improves 3-hour bundle compliance.

METHODS

Prospective implementation of an EMS sepsis screening tool (June 2016-November 2016) was compared to a historical control (August 2015-March 2016). The protocol was facilitated via communication between nurses and EMS personnel. The primary outcome was 3-hour bundle compliance. Secondary outcomes included time to individual bundle components.

RESULTS

Of 135 patients screened, 20 were positive and included in the study, and subsequently compared to 43 control patients. Baseline demographics were similar, except median Sequential Organ Failure Assessment (SOFA) score was higher for the pre-EMS tool group (5 [interquartile range (IQR) 2-8] vs. 2 [IQR 1-4], p < 0.01). Three-hour bundle compliance was significantly higher in the EMS tool group (80% vs. 44.2%, p < 0.01). The pre-EMS tool group had lower median time to lactate (15 [IQR 0-35] vs. 46 min [IQR 34-57], p < 0.001), 30 mL/kg IV fluids (6.5 [IQR 0-38] vs. 46 min [IQR 27.5-72], p < 0.001), and, although not significant, antibiotics (63.5 [IQR 44-92] vs. 72 min [IQR 59.5-112], p = 0.26).

CONCLUSION

Implementation of an EMS sepsis screening tool resulted in improved 3-hour bundle compliance compared to retrospective control.

[Sepsis detection in emergency medicine : Results of an interprofessional survey on sepsis detection in prehospital emergency medicine and emergency departments]

BACKGROUND

Sepsis is associated with a high mortality, which can be reduced by starting screening, diagnostics and treatment as early as possible. Due to multiple educational programs and increased awareness, a decreased sepsis mortality on intensive care units has been achieved. Many patients with sepsis are admitted by the prehospital emergency service to hospital emergency departments. Thus, prehospital emergency services and emergency departments provide an opportunity to start screening, diagnosis and treatment earlier.

OBJECTIVES

To detect sepsis it is paramount that emergency personnel are aware of the disease and have a profound knowledge regarding symptoms, screening and diagnostics. The objective of this survey was to examine the state of knowledge regarding sepsis among staff working in emergency medicine.

MATERIAL AND METHODS

To assess the awareness and knowledge, a paper-based, anonymous survey was conducted among prehospital and emergency department personnel from May to August 2017 in northeastern Germany. Testing of significance was carried out using the χ²-testand Fisher's exact test.

RESULTS

Out of 411 persons polled 212 answered (response rate 51.6%) and 24 questionnaires were incomplete and thus excluded. A total of 188 questionnaires were included covering 55 emergency physicians, 23 nurses, 82 paramedics and 19 emergency dispatchers. On a 4-point Likert scale 100% of emergency doctors, 96% of nurses, 84% of paramedics and 84% of emergency dispatchers considered early initiation of sepsis treatment to be important. Additionally, 92% of emergency physicians and 65% of nurses had attended educational programs on sepsis within the last year, which is significantly higher than among paramedics (19%, p < 0.01) and emergency dispatchers (21%, p = 0.025). In addition, 38% of paramedics and 47% of emergency dispatchers had never attended lectures on sepsis. The quick sequential (sepsis-related) organ failure assessment (qSOFA) was known by 80% of emergency doctors, thus, significantly more often than by nurses (26%), paramedics (29%) and emergency dispatchers (29%, p < 0.01). The emergency personnel were asked to tick all symptoms they associated with sepsis from a display of 14 symptoms. Among all occupation groups the majority selected "increased body temperature", "drop in blood pressure" and "altered breathing". In relation to "increased body temperature" the symptom "altered mental status" was selected significantly more frequently by emergency doctors than by nurses and paramedics (p = 0.02 and p < 0.01, respectively). The combination of at least all 3 qSOFA parameters was selected significantly more often by emergency doctors (62%) than by nurses (13%) and paramedics (10%, p = 0.017 and p < 0.01, respectively).

CONCLUSION

Although emergency personnel rated an early initiation of sepsis treatment as important, sepsis knowledge was limited. While the majority of emergency doctors and many nurses had attended educational programs on sepsis within the last year, an alarmingly high percentage of paramedics and emergency dispatchers had never received sepsis education. Emergency personnel are mostly unfamiliar with the qSOFA score and did not associate an altered mental status with sepsis. In light of the high sepsis morbidity and mortality, further achievements might be made by initiating sepsis screening and diagnostics in the prehospital setting. Analogous to advancements in intensive care units, increased educational programs for emergency personnel might lead to an earlier detection and improved prognosis of sepsis.

Developing a decision support system for patients with severe infection conditions in pre-hospital care

OBJECTIVE

To develop and validate a pre-hospital decision support system (DSS) for the emergency medical services (EMS), enabling the identification and steering of patients with critical infectious conditions (i.e., severe respiratory tract infections, severe central nervous system (CNS) infections, and sepsis) to a specialized emergency department (ED) for infectious diseases.

METHODS

The development process involved four consecutive steps. The first step was gathering data from the electronic patient care record system (ePCR) on patients transported by the EMS, in order to identify retrospectively appropriate patient categories for steering. The second step was to let a group of medical experts give advice and suggestions for further development of the DSS. The third and fourth steps were the evaluation and validation, respectively, of the whole pre-hospital DSS in a pilot study.

RESULTS

A pre-hospital decision support tool (DST) was developed for three medical conditions: severe respiratory infection, severe CNS infection, and sepsis. The pilot study included 72 patients, of whom 60% were triaged to a highly specialized emergency department (ED-Spec) with an attending infectious disease physician (ID physician). The results demonstrated that the pre-hospital emergency nurses (PENs) adhered to the DST in 66 of 72 patient cases (91.6%). For those patients steered to the ED-Spec, the assessment made by PENs and the ID physician at the ED was concordant in 94% of cases.

CONCLUSIONS

The development of a specific DSS aiming to identify patients with three different severe infectious diseases appears to give accurate decision support to PENs when steering patients to the optimal level of care.