Prehospital management and identification of sepsis by emergency medical services: a systematic review

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.

Effectiveness of a Novel Rapid Infusion Device and Clinician Education for Early Fluid Therapy by Emergency Medical Services in Sepsis Patients: A Pre-Post Observational Study

OBJECTIVE

Emergency medical services (EMS) clinicians are tasked with early fluid resuscitation for patients with sepsis. Traditional methods for prehospital fluid delivery are limited in speed and ease-of-use. We conducted a comparative effectiveness study of a novel rapid infusion device for prehospital fluid delivery in suspected sepsis patients.

METHODS

This pre-post observational study evaluated a hand-operated, rapid infusion device in a single large EMS system from July 2021-July 2022. Prior to device deployment, EMS clinicians completed didactic and simulation-based device training. Data were extracted from the EMS electronic health record. Eligible patients included adults with suspected sepsis treated by EMS with intravenous fluids. The primary outcome was the proportion of patients receiving goal fluid volume (at least 500 mL) prior to hospital arrival. Secondary outcomes included in-hospital mortality, disposition, and length of stay. Multivariable logistic regression was used to compare outcomes between 6-month pre- and post-implementation periods (July-December 2021 and February-July 2022, respectively), adjusting for patient demographics, abnormal prehospital vital signs, and EMS transport interval.

RESULTS

Of 1,180 eligible patients (552 in the pre-implementation period; 628 in the post-implementation period), the mean age was 72 years old, 45% were female, and 25% were minority race-ethnicity. Median (interquartile range) fluid volume (in mL) increased between the pre- and post-implementation periods (600 [400,1,000] and 850 [500-1,000], respectively). Goal fluid volume was achieved in 70% of pre-implementation patients and 82% of post-implementation patients. In adjusted analysis, post-implementation patients were significantly more likely to receive goal fluid volume than pre-implementation patients (adjusted odds ratio (aOR) 2.00, 95% confidence interval (CI) 1.51-2.66). Pre-post in-hospital mortality was not significantly different (aOR 0.91, 95% CI 0.59-1.39)Conclusion: In a single EMS system, sepsis education and introduction of a rapid infusion device was associated with achieving goal fluid volume for suspected sepsis. Further research is needed to assess the clinical effectiveness of infusion device implementation to improve sepsis patient outcomes.

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/.

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.

Prehospital Fluid Administration for Suspected Sepsis in a Large EMS System: Opportunities to Improve Goal Fluid Delivery

OBJECTIVES

Despite EMS-implemented screening and treatment protocols for suspected sepsis patients, prehospital fluid therapy is variable. We sought to describe prehospital fluid administration in suspected sepsis patients, including demographic and clinical factors associated with fluid outcomes.

METHODS

A retrospective cohort of adult patients from a large, county-wide EMS system from January 2018-February 2020 was identified. Patient care reports for suspected sepsis were included, as identified by EMS clinician impression of sepsis, or keywords "sepsis" or "septic" in the narrative. Outcomes were the proportions of suspected sepsis patients for whom intravenous (IV) therapy was attempted and those who received ≥500 mL IV fluid if IV access was successful. Associations between patient demographics and clinical factors with fluid outcomes were estimated with multivariable logistic regression adjusting for transport interval.

RESULTS

Of 4,082 suspected sepsis patients identified, the mean patient age was 72.5 (SD 16.2) years, 50.6% were female, and 23.8% were Black. Median (interquartile range [IQR]) transport interval was 16.5 (10.9-23.2) minutes. Of identified patients, 1,920 (47.0%) had IV fluid therapy attempted, and IV access was successful in 1,872 (45.9%). Of those with IV access, 1,061 (56.7%) received ≥500mL of fluid from EMS. In adjusted analyses, female (versus male) sex (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.69-0.90), Black (versus White) race (OR 0.57, 95% CI 0.49-0.68), and end stage renal disease (OR 0.51, 95% CI 0.32-0.82) were negatively associated with attempted IV therapy. Systolic blood pressure (SBP) <90 mmHg (OR 3.89, 95% CI 3.25-4.65) and respiratory rate >20 (OR 1.90, 95% CI 1.61-2.23) were positively associated with attempted IV therapy. Female sex (OR 0.72, 95% CI 0.59-0.88) and congestive heart failure (CHF) (OR 0.55, 95% CI 0.40-0.75) were negatively associated with receiving goal fluid volume while SBP <90 mmHg (OR 2.30, 95% CI 1.83-2.88) and abnormal temperature (>100.4 F or <96 F) (OR 1.41, 95% CI 1.16-1.73) were positively associated.

CONCLUSIONS

Fewer than half of EMS sepsis patients had IV therapy attempted, and of those, approximately half met fluid volume goal, especially when hypotensive and no CHF. Further studies are needed on improving EMS sepsis training and prehospital fluid delivery.

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.

Using machine learning to predict subsequent events after EMS non-conveyance decisions

Background

Predictors of subsequent events after Emergency Medical Services (EMS) non-conveyance decisions are still unclear, though patient safety is the priority in prehospital emergency care. The aim of this study was to find out whether machine learning can be used in this context and to identify the predictors of subsequent events based on narrative texts of electronic patient care records (ePCR).

Methods

This was a prospective cohort study of EMS patients in Finland. The data was collected from three different regions between June 1 and November 30, 2018. Machine learning, in form of text classification, and manual evaluation were used to predict subsequent events from the clinical notes after a non-conveyance mission.

Results

FastText-model (AUC 0.654) performed best in prediction of subsequent events after EMS non-conveyance missions (n = 11,846). The model and manual analyses showed that many of the subsequent events were planned before, EMS guided the patients to visit primary health care facilities or ED next or following days after non-conveyance. The most frequent signs and symptoms as subsequent event predictors were musculoskeletal-, infection-related and non-specific complaints. 1 in 5 the EMS documentation was inadequate and many of these led to a subsequent event.

Conclusion

Machine learning can be used to predict subsequent events after EMS non-conveyance missions. From the patient safety perspective, it is notable that subsequent event does not necessarily mean that patient safety is compromised. There were a number of subsequent visits to primary health care or EDs, which were planned before by EMS. This demonstrates the appropriate use of limited resources to avoid unnecessary conveyance to the ED. However, further studies are needed without planned subsequent events to find out the harmful subsequent events, where EMS non-conveyance puts patient safety at risk.

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.

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.

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.

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.

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.

Emergency Medical Services Care and Sepsis Trajectories

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

Does Being Transported by Emergency Medical Services Improve Compliance with the Surviving Sepsis Bundle and Mortality Rate? A Retrospective Cohort Study

Background: This study aimed to investigate the relationship between patients with severe sepsis or septic shock being transported to the Emergency Department (ED) by Emergency Medical Services (EMS) and the compliance with the 3-h sepsis resuscitation bundle [Surviving Sepsis Campaign (SSC)], and to compare the management and laboratory results of patients transported by EMS or non-EMS transport.

Methods: A retrospective cohort study was conducted using data from a quality-improvement project at King Abdulaziz Medical City in Riyadh. The data for patients who presented to ED with sepsis (severe sepsis or septic shock) was categorized as being transported with EMS or non-EMS. The two groups were compared in terms of compliance with the SSC bundle and 30-day mortality.

Results: In a sample of 436 patients with severe sepsis or septic shock presented at the ED during the study period, EMS transported almost one-third of the patients (134, 31%) and 302 patients (69%) used non-EMS transport. For the EMS group, adherence to intravenous fluid was 91.4% compared with 87% for the non-EMS group (p = 0.19), antibiotics (EMS 50.7% vs non-EMS 52%, p = 0.81), blood cultures before antibiotics (EMS 53% vs non-EMS 47.4%, p = 0.21), and measuring lactate levels (EMS 73.1% vs non-EMS 57%, p = <0.01). The mortality rate was 48.5% for the EMS group and 54% for the non-EMS group, which was not statistically significant.

Conclusion: Whether transported with or without EMS did not result in a statistically significant difference in patients presenting with sepsis, in terms of the adherence to the SSC bundle elements or the 30-day hospital mortality rate. The only statistically significant difference was the time to lactate measurement.

The prehospital assessment of patients with a final hospital diagnosis of sepsis: Results of an observational study

BACKGROUND

Sepsis is a severe condition which affects 300-800/100,000 persons each year. There are indications that the prehospital identification of patients with sepsis is difficult. The aim of the study was, among patients with a final hospital diagnosis of sepsis, to compare emergency medical service (EMS) field assessments of patients in whom there was a prehospital suspicion of sepsis with those without this suspicion.

METHODS

The study had a retrospective, observational design. The data used in the study were retrieved from the prehospital and hospital medical records of patients with a final hospital diagnosis of sepsis, transported to hospital by the EMS within a region in the south west of Sweden during a period of one year.

RESULTS

Among patients with a final diagnosis of sepsis (n=353), the EMS identified the condition in 36% of the cases. These patients were characterised by more abnormal vital signs (a higher respiratory rate and heart rate and more frequent temperature abnormalities) and were more ambitiously assessed (more lung auscultations and more assessments of the degree of consciousness).

CONCLUSION

The EMS was already able to identify 36% of patients with a final diagnosis of sepsis in the prehospital phase. There were minor differences in the prehospital assessment between patients who were identified by the EMS nurse and those who were not.

A survey of sepsis knowledge among Canadian emergency department registered nurses

BACKGROUND

With the rise of patients with sepsis presenting to emergency departments, emergency nurses, as frontline healthcare workers, require current clinical knowledge of sepsis. The aim of this study was to assess emergency department registered nurses' knowledge of sepsis and their perspectives of caring for patients with sepsis.

METHODS

A descriptive cross-sectional survey was used to survey Registered Nurses from four emergency departments in a western Canadian city (N=312).

RESULTS

The majority of nurses scored poorly on questions examining knowledge of systemic inflammatory response syndrome variables associated with sepsis, and sepsis definitions, general knowledge, and treatment (mean score 51.8%). Nurses acknowledged their lack of knowledge and indicated a desire for further sepsis education. Challenges in providing sepsis-related care concerned perceived heavy workloads and clinical implications related to the patient's status.

CONCLUSIONS

Educational programs and coaching approaches that maximize nurses' abilities to enhance their decision-making with regards to early assessment and appropriate intervention for persons with sepsis are needed. Such multifaceted approaches would acknowledge nurses' existing knowledge and provide practical supports to help nurses extend and mobilize their knowledge for everyday decision-making within the complex clinical environment of the emergency department.

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.

Prehospital Sepsis Care

Prehospital care providers are tasked with the delivery of time-sensitive care, and emergency medical services (EMS) systems must match patients to appropriate clinical resources. Modern systems are uniquely positioned to recognize and treat patients with sepsis. Interventions such as administration of intravenous fluid and transporting patients to the appropriate level of definitive care are linked to improved patient outcomes. As EMS systems refine their protocols for the recognition and stabilization of patients with suspected or presumed sepsis, EMS providers need to be educated about the spectrum of sepsis-related presentations and treatment strategies need to be standardized.

A collaborative improvement project by an NHS Emergency Department and Scottish Ambulance Paramedics to improve the identification and delivery of sepsis 6

Early identification of patients with sepsis is key to the delivery of the sepsis 6 bundle including antibiotic therapy within an hour.[1-3] Demand versus capacity challenges in the Emergency Department (ED) led to delays in antibiotic and sepsis 6 delivery. An alerting tool was developed that provided criteria for Scottish Ambulance Service (SAS) Paramedics to alert the ED of potential sepsis patients.

Data from patients presenting to the ED prior to the alerting process commencing (n=50) and during alerting (n=50) were analysed, a questionnaire was used to ascertain feedback from all staff groups; nurses doctors, and paramedics (n=38). Mean Time to triage improved by 82% from 17 minutes to 3 minutes (p=0.01), time to first antibiotic improved by 39% from 49 minutes to 30 minutes. Overall 78% of patients received antibiotics within an hour of leaving their home; no significant increase in workload was reported by staff.

In conclusion alerting by paramedics of potential sepsis patients reduced the time taken to deliver the Sepsis 6 Bundle. Process reliability has been sustained over several months. This process has been spread to seven regional ambulance stations in Lanarkshire Scotland.

Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review

OBJECTIVES

This review aimed to analyze published literature to introduce the use and implementation of standard operating procedures (SOPs) and checklists in prehospital emergency medicine and their impact on guideline adherence and patient outcome.

METHODS

An English literature search was carried out using the Cochrane Library, MEDLINE, EMBASE, Springer, Elsevier, and ProQuest databases. Original articles describing the use and implementation of SOPs or checklists in prehospital emergency medicine were included. Editorials, comments, letters, bulletins, news articles, conference abstracts, and notes were excluded from the analysis. Relevant information was extracted relating to application areas, development of SOPs/checklists, educational preparation and training regarding SOPs/checklists implementation, staff attitudes and the effects of SOPs/checklists use on guideline adherence and patient outcomes.

RESULTS

The literature search found 2187 potentially relevant articles, which were narrowed down following an abstract review and a full text review. A final total of 13 studies were identified that described the use and implementation of SOPs (9 studies) and checklists (4 studies) in different areas of prehospital emergency medicine including prehospital management of patients with acute exacerbated chronic obstructive pulmonary disease and acute coronary syndrome, prehospital airway management, medical documentation, Emergency Medical Services triage, and transportation of patients.

CONCLUSIONS

The use and implementation of SOPs and checklists in prehospital emergency medicine have shown some benefits of improving guidelines adherence and patient outcomes in airway management, patient records, identification and triage, and other prehospital interventions. More research in this area is necessary to optimize the future use and implementation of SOPs and checklists to improve emergency personnel performance and patient outcomes.