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Goodacre S, Sutton L, Ennis K, Thomas B, Hawksworth O, Iftikhar K, Croft SJ, Fuller G, Waterhouse S, Hind D, Stevenson M, Bradburn MJ, Smyth M, Perkins GD, Millins M, Rosser A, Dickson J, Wilson M. Prehospital early warning scores for adults with suspected sepsis: the PHEWS observational cohort and decision-analytic modelling study. Health Technol Assess 2024; 28:1-93. [PMID: 38551135 PMCID: PMC11017155 DOI: 10.3310/ndty2403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024] Open
Abstract
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.
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Affiliation(s)
- Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
- Emergency Department, Northern General Hospital, Sheffield, UK
| | - Laura Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Kate Ennis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ben Thomas
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Olivia Hawksworth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Susan J Croft
- Emergency Department, Northern General Hospital, Sheffield, UK
| | - Gordon Fuller
- Emergency Department, Northern General Hospital, Sheffield, UK
| | - Simon Waterhouse
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mike J Bradburn
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Michael Smyth
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Mark Millins
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Andy Rosser
- West Midlands Ambulance Service University NHS Foundation Trust, Midlands, UK
| | - Jon Dickson
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Matthew Wilson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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2
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Patel MD, Williams JG, Bachman MW, Cyr JM, Cabañas JG, Miller NS, Gorstein LN, Hajjar MA, Turcios H, Malcolm JT, Brice JH. 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. PREHOSP EMERG CARE 2023:1-11. [PMID: 38015064 DOI: 10.1080/10903127.2023.2286292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023]
Abstract
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.
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Affiliation(s)
- Mehul D Patel
- Department of Emergency Medicine, University of North Carolina at Chapel Hill
| | - Jefferson G Williams
- Department of Emergency Medicine, University of North Carolina at Chapel Hill
- Wake County EMS, Raleigh, North Carolina
| | | | - Julianne M Cyr
- Department of Emergency Medicine, University of North Carolina at Chapel Hill
| | - José G Cabañas
- Department of Emergency Medicine, University of North Carolina at Chapel Hill
- Wake County EMS, Raleigh, North Carolina
| | - Nathaniel S Miller
- Department of Emergency Medicine, University of North Carolina at Chapel Hill
| | - Lauren N Gorstein
- Department of Emergency Medicine, University of North Carolina at Chapel Hill
| | - M Abdul Hajjar
- School of Medicine, University of North Carolina at Chapel Hill
| | - Henry Turcios
- School of Medicine, University of North Carolina at Chapel Hill
| | | | - Jane H Brice
- Department of Emergency Medicine, University of North Carolina at Chapel Hill
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3
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Goodacre S, Sutton L, Thomas B, Hawksworth O, Iftikhar K, Croft S, Fuller G, Waterhouse S, Hind D, Bradburn M, Smyth MA, Perkins GD, Millins M, Rosser A, Dickson JM, Wilson MJ. Prehospital early warning scores for adults with suspected sepsis: retrospective diagnostic cohort study. Emerg Med J 2023; 40:768-776. [PMID: 37673643 PMCID: PMC10646863 DOI: 10.1136/emermed-2023-213315] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023]
Abstract
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/.
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Affiliation(s)
- Steve Goodacre
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Laura Sutton
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Ben Thomas
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Olivia Hawksworth
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | | | - Susan Croft
- Emergency Department, Northern General Hospital, Sheffield, UK
| | - Gordon Fuller
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Simon Waterhouse
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Daniel Hind
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | | | | | - Mark Millins
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Andy Rosser
- West Midlands Ambulance Service, West Midlands, UK
| | - Jon M Dickson
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Matthew Joseph Wilson
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
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4
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Kotnarin R, Sirinawee P, Supasaovapak J. Impact of Prehospital Antibiotics on in-Hospital Mortality in Emergency Medical Service Patients with Sepsis. Open Access Emerg Med 2023; 15:199-206. [PMID: 37260737 PMCID: PMC10228518 DOI: 10.2147/oaem.s413791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023] Open
Abstract
Background Sepsis is a life-threatening medical condition that requires early recognition and timely management to improve patient outcomes and reduce mortality rates. Administering antibiotics in the prehospital setting can be effective to reduce the time to antibiotic therapy, which may be crucial for sepsis patients. However, the impact of prehospital antibiotics on mortality in sepsis patients remains uncertain, and the current evidence to support this practice in middle-income countries is particularly limited. Methods This was a single-center, retrospective-prospective cohort study aimed at determining the impact of prehospital antibiotics on in-hospital mortality rates among adult patients with sepsis. The study included patients who received care from the advanced level of Emergency Medical Service between June 2020 and October 2022 and compared the mortality rates of patients who received prehospital antibiotics with those of their counterparts who did not. Results In this study, 180 patients with a mean age of 71.6 ± 15.7 years were included, of whom 68.9% experienced respiratory infections. The results demonstrated that the prehospital antibiotic group had a significantly lower in-hospital mortality rate (32.2%) than the non-prehospital antibiotic group (47.8%; p=0.034). After adjusting for confounding factors, the odds ratio was 0.304 (95% CI: 0.11, 0.82; p=0.018), indicating a 69.6% lower incidence of in-hospital mortality in the prehospital antibiotic group. Furthermore, the prehospital antibiotic group received antibiotics significantly earlier (16.0 ± 7.4 minutes) than the non-prehospital group (50.9 ± 29.4 minutes; p<0.001). Conclusion This study provides evidence to support the administration of antibiotics to sepsis patients in the prehospital setting, as this practice can reduce mortality rates. However, larger, multicenter studies are required to confirm these findings and to further investigate the potential benefits of prehospital antibiotics in improving patient outcomes.
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Affiliation(s)
- Rujabhorn Kotnarin
- Department of Emergency Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Penpischa Sirinawee
- Department of Emergency Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Jirapong Supasaovapak
- Department of Emergency Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
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5
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Masot O, Cox A, Mold F, Sund-Levander M, Tingström P, Boersema GC, Botigué T, Daltrey J, Hughes K, Mayhorn CB, Montgomery A, Mullan J, Carey N. Decision support-tools for early detection of infection in older people (aged> 65 years): a scoping review. BMC Geriatr 2022; 22:552. [PMID: 35778707 PMCID: PMC9247966 DOI: 10.1186/s12877-022-03218-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 05/23/2022] [Indexed: 11/21/2022] Open
Abstract
Background Infection is more frequent, and serious in people aged > 65 as they experience non-specific signs and symptoms delaying diagnosis and prompt treatment. Monitoring signs and symptoms using decision support tools (DST) is one approach that could help improve early detection ensuring timely treatment and effective care. Objective To identify and analyse decision support tools available to support detection of infection in older people (> 65 years). Methods A scoping review of the literature 2010–2021 following Arksey and O’Malley (2005) framework and PRISMA-ScR guidelines. A search of MEDLINE, Cochrane, EMBASE, PubMed, CINAHL, Scopus and PsycINFO using terms to identify decision support tools for detection of infection in people > 65 years was conducted, supplemented with manual searches. Results Seventeen papers, reporting varying stages of development of different DSTs were analysed. DSTs largely focussed on specific types of infection i.e. urine, respiratory, sepsis and were frequently hospital based (n = 9) for use by physicians. Four DSTs had been developed in nursing homes and one a care home, two of which explored detection of non- specific infection. Conclusions DSTs provide an opportunity to ensure a consistent approach to early detection of infection supporting prompt action and treatment, thus avoiding emergency hospital admissions. A lack of consideration regarding their implementation in practice means that any attempt to create an optimal validated and tested DST for infection detection will be impeded. This absence may ultimately affect the ability of the workforce to provide more effective and timely care, particularly during the current covid-19 pandemic. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03218-w.
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Affiliation(s)
- Olga Masot
- Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain. .,Health Care Research Group (GRECS), [Lleida Institute for Biomedical Research Dr. Pifarré Foundation], IRBLleida, 25198, Lleida, Spain.
| | - Anna Cox
- School of Health Sciences, University of Surrey, Guildford, GU2 7YH, UK
| | - Freda Mold
- School of Health Sciences, University of Surrey, Guildford, GU2 7YH, UK
| | - Märtha Sund-Levander
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Pia Tingström
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | - Teresa Botigué
- Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain.,Health Care Research Group (GRECS), [Lleida Institute for Biomedical Research Dr. Pifarré Foundation], IRBLleida, 25198, Lleida, Spain
| | - Julie Daltrey
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Karen Hughes
- School of Health Sciences, University of Surrey, Guildford, GU2 7YH, UK
| | - Christopher B Mayhorn
- Department of Psychology, North Carolina State University, Raleigh, NC, 27695-7801, USA
| | - Amy Montgomery
- School of Nursing, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Judy Mullan
- School of Medicine, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Nicola Carey
- Department of Nursing and Midwifery, University of the Highlands and Islands, Inverness, IV2 3JH, UK
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6
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Cunningham CT, Sanseverino A, Reznek M, Borges E, Beth Urhoy M, Gross K, Broach JP, O’Connor L. A pilot study of prehospital antibiotics for severe sepsis. Acad Emerg Med 2022; 29:231-233. [PMID: 34480817 DOI: 10.1111/acem.14388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/20/2021] [Accepted: 09/02/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - Alexandra Sanseverino
- Department of Emergency Medicine University of Massachusetts Medical School Worcester Massachusetts USA
| | - Martin Reznek
- Department of Emergency Medicine University of Massachusetts Medical School Worcester Massachusetts USA
| | - Eric Borges
- Department of Emergency Medicine University of Massachusetts Medical School Worcester Massachusetts USA
| | - Matthew Beth Urhoy
- Department of Emergency Medicine University of Massachusetts Medical School Worcester Massachusetts USA
| | - Karen Gross
- Department of Emergency Medicine University of Massachusetts Medical School Worcester Massachusetts USA
| | - John P. Broach
- Department of Emergency Medicine University of Massachusetts Medical School Worcester Massachusetts USA
| | - Laurel O’Connor
- Department of Emergency Medicine University of Massachusetts Medical School Worcester Massachusetts USA
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7
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Obermaier M, Weigand MA, Popp E, Uhle F. [Sepsis in out-of-hospital emergency medicine]. Notf Rett Med 2021; 25:541-551. [PMID: 34812248 PMCID: PMC8597546 DOI: 10.1007/s10049-021-00949-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 10/28/2022]
Abstract
Background Sepsis is a challenge in emergency medicine, as this life-threatening organ dysfunction, caused by a dysregulated host response to an infection, presents manifold and therefore is often recognized too late. Objectives Recently published surviving sepsis campaign and German S3 guidelines provide recommendations for diagnosis and therapy of sepsis in an in-hospital or intensive care setting, but do not particularly address out-of-hospital emergency medical care. We aim to work out the evidence base with regard to the out-of-hospital care of patients with suspected sepsis and to derive treatment recommendations for emergency medical services. Conclusions Therapy of sepsis and septic shock is summarized in bundles, whereby the first bundle should ideally be completed within the first hour-in analogy to "golden hour" concepts in other emergency medical entities, such as trauma care. In the out-of-hospital setting, therapy focuses on securing vital parameters, according to the ABCDE scheme, with a particular focus on volume therapy. Further procedures within the 1 h bundle, such as lactate measurement, obtaining microbiological samples, and starting an anti-infective therapy, are broadly available in hospital only. The aim is to control the site of infection as soon as possible. Therefore, an appropriate designated hospital should be chosen carefully and informed in advance, in order to initiate and pave the way for further clinical diagnostic and treatment paths. Moreover, structured and target-oriented handovers, as well as regular training, are required.
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Affiliation(s)
- Manuel Obermaier
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Erik Popp
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Florian Uhle
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
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8
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Martín-Rodríguez F, López-Izquierdo R, Medina-Lozano E, Ortega Rabbione G, Del Pozo Vegas C, Carbajosa Rodríguez V, Castro Villamor MÁ, Sánchez-Soberon I, Sanz-García A. Accuracy of prehospital point-of-care lactate in early in-hospital mortality. Eur J Clin Invest 2020; 50:e13341. [PMID: 32648960 DOI: 10.1111/eci.13341] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/21/2020] [Accepted: 07/05/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Emergency medical services (EMS) routinely face complex scenarios where decisions should be taken with limited clinical information. The development of fast, reliable and easy to perform warning biomarkers could help in such decision-making processes. The present study aims at characterizing the validity of point-of-care lactate (pLA) during prehospital tasks for predicting in-hospital mortality within two days after the EMS assistance. MATERIALS AND METHODS Prospective, multicentric, ambulance-based and controlled observational study without intervention, including six advanced life support and five hospitals. The pLA levels were recorded during EMS assistance of adult patients. The validity of pLA to determine the in-hospital mortality was assessed by the area under the curve (AUC) of the receiver operating curve (ROC). RESULTS A total of 2997 patients were considered in the study, with a median of 69 years (IQR 54-81) and 41.4% of women. The median pLA value was 2.7 mmol/L (1.9-3.8) in survivors and 5.7 mmol/L (4.4-7.6) in nonsurvivors. The global discrimination level of pLA reached an AUC of 0.867, being 1.9 mmol/L and 4 mmol/L the cut-off point for low and high mortality. The discrimination value of pLA was not affected by sex, age or pathology. CONCLUSIONS Our results highlight the clinical importance of prehospital pLA to determine the in-hospital risk of mortality. The incorporation of pLA into the EMS protocols could improve the early identification of risky patients, leading to a better care of such patients.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Advanced Clinical Simulation Center, School of Medicine, Valladolid University, Valladolid, Spain.,Emergency Medical Services-SACYL, Paseo Hospital Militar, Valladolid, Spain
| | - Raúl López-Izquierdo
- Advanced Clinical Simulation Center, School of Medicine, Valladolid University, Valladolid, Spain.,Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Elena Medina-Lozano
- Advanced Clinical Simulation Center, School of Medicine, Valladolid University, Valladolid, Spain
| | - Guillermo Ortega Rabbione
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa (IIS-IP), Madrid, Spain.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), CABA, Argentina
| | | | | | | | | | - Ancor Sanz-García
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa (IIS-IP), Madrid, Spain
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9
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Garfinkel E, Tanigawa M, Margolis A, Levy M. Implementing a Statewide Prehospital Sepsis Protocol: Perspectives of Emergency Medical Services Medical Directors. Cureus 2020; 12:e10781. [PMID: 33154849 PMCID: PMC7606223 DOI: 10.7759/cureus.10781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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10
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Lane DJ, Wunsch H, Saskin R, Cheskes S, Lin S, Morrison LJ, Scales DC. Screening strategies to identify sepsis in the prehospital setting: a validation study. CMAJ 2020; 192:E230-E239. [PMID: 32152051 DOI: 10.1503/cmaj.190966] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In the prehospital setting, differentiating patients who have sepsis from those who have infection but no organ dysfunction is important to initiate sepsis treatments appropriately. We aimed to identify which published screening strategies for paramedics to use in identifying patients with sepsis provide the most certainty for prehospital diagnosis. METHODS We identified published strategies for screening by paramedics through a literature search. We then conducted a validation study in Alberta, Canada, from April 2015 to March 2016. For adult patients (≥ 18 yr) who were transferred by ambulance, we linked records to an administrative database and then restricted the search to patients with infection diagnosed in the emergency department. For each patient, the classification from each strategy was determined and compared with the diagnosis recorded in the emergency department. For all strategies that generated numeric scores, we constructed diagnostic prediction models to estimate the probability of sepsis being diagnosed in the emergency department. RESULTS We identified 21 unique prehospital screening strategies, 14 of which had numeric scores. We linked a total of 131 745 eligible patients to hospital databases. No single strategy had both high sensitivity (overall range 0.02-0.85) and high specificity (overall range 0.38-0.99) for classifying sepsis. However, the Critical Illness Prediction (CIP) score, the National Early Warning Score (NEWS) and the Quick Sepsis-Related Organ Failure Assessment (qSOFA) score predicted a low to high probability of a sepsis diagnosis at different scores. The qSOFA identified patients with a 7% (lowest score) to 87% (highest score) probability of sepsis diagnosis. INTERPRETATION The CIP, NEWS and qSOFA scores are tools with good predictive ability for sepsis diagnosis in the prehospital setting. The qSOFA score is simple to calculate and may be useful to paramedics in screening patients with possible sepsis.
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Affiliation(s)
- Daniel J Lane
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont.
| | - Hannah Wunsch
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Refik Saskin
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Sheldon Cheskes
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Steve Lin
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Laurie J Morrison
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Damon C Scales
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
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López-Medina DC, Henao-Perez M, Arenas-Andrade J, Hinestroza-Marín ED, Jaimes-Barragán FA, Quirós-Gómez OI. Epidemiology of septic shock in prehospital medical services in five Colombian cities. Rev Bras Ter Intensiva 2020; 32:28-36. [PMID: 32401984 PMCID: PMC7206937 DOI: 10.5935/0103-507x.20200006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 09/01/2019] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
| | - Marcela Henao-Perez
- Facultad de Medicina, Universidad Cooperativa de Colombia, Antioquia, Colombia
| | | | | | | | - Oscar Iván Quirós-Gómez
- División de Salud Pública, Facultad de Medicina, Universidad CES - Medellín, Antioquia, Colombia
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Liu R, Chaudhary NS, Yealy DM, Huang DT, Wang HE. Emergency Medical Services Care and Sepsis Trajectories. PREHOSP EMERG CARE 2020; 24:733-740. [PMID: 31971839 DOI: 10.1080/10903127.2019.1704321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
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.
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Alhusain F, Alsuwailem H, Aldrees A, Bugis A, Alzuhairi S, Alsulami S, Arabi Y, Aljerian N. Does Being Transported by Emergency Medical Services Improve Compliance with the Surviving Sepsis Bundle and Mortality Rate? A Retrospective Cohort Study. J Epidemiol Glob Health 2019; 10:276-279. [PMID: 32959607 PMCID: PMC7758847 DOI: 10.2991/jegh.k.191215.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/11/2019] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Faisal Alhusain
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hanin Alsuwailem
- College of Medicine, Riyadh Elm University, Riyadh, Saudi Arabia
| | - Alanoud Aldrees
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ahad Bugis
- College of Medicine, Riyadh Elm University, Riyadh, Saudi Arabia
| | - Sarah Alzuhairi
- College of Medicine, Riyadh Elm University, Riyadh, Saudi Arabia
| | - Sami Alsulami
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Emergency Medicine Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yaseen Arabi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Intensive Care Unit Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Nawfal Aljerian
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Emergency Medicine Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Abstract
Introduction: Lactate devices offer the potential for paramedics to improve patient triage and escalation of care for specific presentations. There is also scope to improve existing prehospital tools by including lactate measurement. Method: A literature search was conducted using the Medline, CINAHL, Academic Search Premier, Sciencedirect and Scopus databases. Findings: Acquiring prehospital lactate measurement in trauma settings improved triage and recognition of the need for critical care. Within a medical setting, studies offered mixed results in relating prehospital lactate measurement to diagnosis, escalating treatments and mortality. The accuracy of prehospital lactate measurements acquired varies, which could impact decision making. Conclusion: Prehospital lactate thresholds could aid decision making, although the literature is limited and evidence varies. Lactate values of ≥4 mmol/litre in medical and ≥2.5 mmol/litre in trauma patients could signify that care should be escalated to an appropriate facility, and that resuscitative measures should be initiated, particularly with sepsis, as reflected by standardised lactate values that guide treatment in hospitals. Similarly, a lactate value of <2 mmol/litre could mean de-escalating care into the community, although further research is warranted on this.
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15
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Hunter CL, Silvestri S, Stone A, Shaughnessy A, Miller S, Rodriguez A, Papa L. Prehospital sepsis alert notification decreases time to initiation of CMS sepsis core measures. Am J Emerg Med 2019; 37:114-117. [DOI: 10.1016/j.ajem.2018.09.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/20/2018] [Accepted: 09/22/2018] [Indexed: 12/22/2022] Open
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Martín-Rodríguez F, López-Izquierdo R, Castro Villamor MA, Mangas IM, Del Brío Ibáñez P, Delgado Benito JF, Martín Conty JL, Manzanares JÁ, Mayo-Iscar A, Del Pozo Vegas C. Prognostic value of lactate in prehospital care as a predictor of early mortality. Am J Emerg Med 2018; 37:1627-1632. [PMID: 30471934 DOI: 10.1016/j.ajem.2018.11.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/25/2018] [Accepted: 11/18/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Prehospital Emergency Medical Services must attend to patients with complex physiopathological situations with little data and in the shortest possible time. The objective of this work was to study lactic acid values and their usefulness in the prehospital setting to help in clinical decision-making. STUDY DESIGN We conducted a longitudinal prospective, observational study on patients over 18 years of age who, after being evaluated by the Advanced Life Support Unit, were taken to the hospital between April and June 2018. We analyzed demographic variables, prehospital lactic acid values and early mortality (<30 days). The area under the curve of the receiver operating characteristic was calculated for the prehospital value of lactic acid. RESULTS A total of 279 patients were included in our study. The median age was 68 years (interquartile range: 54-80 years). Overall 30-day mortality was 9% (25 patients). The area under the curve for lactic acid to predict overall mortality at 30 days of care was 0.82 (95% CI: 0.76-0.89). The lactate value with the best sensitivity and specificity overall was 4.25 mmol/L with a sensitivity of 84% (95% CI: 65.3-93.6) and specificity of 70% (95% CI: 65.0-76.1). CONCLUSIONS The level of lactic acid can be a complementary tool in the field of prehospital emergencies that will guide us early in the detection of critical patients.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Advanced Clinical Simulation Center, Department of Medicine, Dermatology and Toxicology, Faculty of Medicine, University of Valladolid, Avda. Ramón y Cajal, 7, 47005 Valladolid, Spain; Prehospital Emergency Medical Services, Advanced Medical Life Support, SACYL, Castilla y León, Spain.
| | - Raúl López-Izquierdo
- Emergency Department, Rio Hortega University Hospital of Valladolid, SACYL, Spain.
| | - Miguel A Castro Villamor
- Advanced Clinical Simulation Center, Department of Medicine, Dermatology and Toxicology, Faculty of Medicine, University of Valladolid, Avda. Ramón y Cajal, 7, 47005 Valladolid, Spain
| | | | | | - Juan F Delgado Benito
- Prehospital Emergency Medical Services, Advanced Medical Life Support, SACYL, Castilla y León, Spain
| | - José L Martín Conty
- Faculty of Occupational Therapy, Speech Therapy and Nursing, University of Castilla la Mancha, Talavera de la Reina, Toledo, Spain
| | | | - Agustín Mayo-Iscar
- Department of Statistics and Operative Research, Faculty of Medicine, University of Valladolid, Spain
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Marino MC, Ostermayer DG, Mondragon JA, Camp EA, Keating EM, Fornage LB, Brown CA, Shah MI. Improving Prehospital Protocol Adherence Using Bundled Educational Interventions. PREHOSP EMERG CARE 2018; 22:361-369. [PMID: 29364730 DOI: 10.1080/10903127.2017.1399182] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Seizures and anaphylaxis are life-threatening conditions that require immediate treatment in the prehospital setting. There is variation in treatment of pediatric prehospital patients for both anaphylaxis and seizures. This educational study was done to improve compliance with pediatric prehospital protocols, educate prehospital providers and decrease variation in care. OBJECTIVE To improve the quality of care for children with seizures and anaphylaxis in the prehospital setting using a bundled, multifaceted educational intervention. METHODS Evidence-based pediatric prehospital guidelines for seizures and anaphylaxis were used to create a curriculum for the paramedics in the EMS system. The curriculum included in-person training, videos, distribution of decision support tools, and a targeted social media campaign to reinforce the evidence-based guidelines. Prehospital charts were reviewed for pediatric patients with a chief complaint of anaphylaxis or seizures who were transported by paramedics to one of ten hospitals, including three children's hospitals, for 8 months prior to the intervention and eight months following the intervention. The primary outcome for seizures was whether midazolam was given via the preferred intranasal (IN) or intramuscular (IM) routes. The primary outcome for anaphylaxis was whether IM epinephrine was given. RESULTS A total of 1,402 pediatric patients were transported for seizures by paramedics to during the study period. A total of 88 patients were actively seizing pre-intervention and 93 post-intervention. Of the actively seizing patients, 52 were given midazolam pre-intervention and 62 were given midazolam post-intervention. Pre-intervention, 29% (15/52) of the seizing patients received midazolam via the preferred IM or IN routes, compared to 74% (46/62) of the seizing patients post-intervention. A total of 45 patients with anaphylaxis were transported by paramedics, 30 pre-intervention and 15 post-intervention. Paramedics administered epinephrine to 17% (5/30) patients pre-intervention and 67% (10/15) patients post-intervention. CONCLUSION The use of a bundled, multifaceted educational intervention including in-person training, decision support tools, and social media improved adherence to updated evidence-based pediatric prehospital protocols.
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Fishe JN, Crowe RP, Cash RE, Nudell NG, Martin-Gill C, Richards CT. Implementing Prehospital Evidence-Based Guidelines: A Systematic Literature Review. PREHOSP EMERG CARE 2018; 22:511-519. [PMID: 29351495 DOI: 10.1080/10903127.2017.1413466] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE As prehospital research advances, more evidence-based guidelines (EBGs) are implemented into emergency medical services (EMS) practice. However, incomplete or suboptimal prehospital EBG implementation may hinder improvement in patient outcomes. To inform future efforts, this study's objective was to review existing evidence pertaining to prehospital EBG implementation methods. METHODS This study was a systematic literature review and evaluation following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. PubMed, EMBASE, Scopus, and Google Advanced Search were searched without language or publication date filters for articles addressing prehospital EBG implementation. Conference proceedings, textbooks, and non-English articles were excluded. GRADE was applied to the remaining articles independently by three of five study investigators. Study characteristics and salient findings from the included articles are reported. RESULTS The systematic literature review identified 1,367 articles, with 41 meeting inclusion criteria. Most articles described prehospital EBG implementation (n = 24, 59%), or implementation barriers (n = 13, 32%). Common study designs were statement documents (n = 12, 29%), retrospective cohort studies (n = 12, 29%), and cross-sectional studies (n = 9, 22%). Using GRADE, evidence quality was rated low (n = 18, 44%), or very low (n = 23, 56%). Salient findings from the articles included: (i) EBG adherence and patient outcomes depend upon successful implementation, (ii) published studies generally lack detailed implementation methods, (iii) EBG implementation takes longer than planned (mostly for EMS education), (iv) EMS systems' heterogeneity affects EBG implementation, and (v) multiple barriers limit successful implementation (e.g., financial constraints, equipment purchasing, coordination with hospitals, and regulatory agencies). This review found no direct evidence for best prehospital EBG implementation practices. There were no studies comparing implementation methods or implementation in different prehospital settings (e.g., urban vs. rural, advanced vs. basic life support). CONCLUSIONS While prehospital EBG implementation barriers are well described, there is a paucity of evidence for optimal implementation methods. For scientific advances to reach prehospital patients, EBG development efforts must translate into EMS practice. Future research should consider comparing implementation methodologies in different prehospital settings, with a goal of defining detailed, reproducible best practices.
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Redlener M, Olivieri P, Loo GT, Munjal K, Hilton MT, Potkin KT, Levy M, Rabrich J, Gunderson MR, Braithwaite SA. National Assessment of Quality Programs in Emergency Medical Services. PREHOSP EMERG CARE 2018; 22:370-378. [PMID: 29297735 DOI: 10.1080/10903127.2017.1380094] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This study aims to understand the adoption of clinical quality measurement throughout the United States on an EMS agency level, the features of agencies that do participate in quality measurement, and the level of physician involvement. It also aims to barriers to implementing quality improvement initiatives in EMS. METHODS A 46-question survey was developed to gather agency level data on current quality improvement practices and measurement. The survey was distributed nationally via State EMS Offices to EMS agencies nation-wide using Surveymonkey©. A convenience sample of respondents was enrolled between August and November, 2015. Univariate, bivariate and multiple logistic regression analyses were conducted to describe demographics and relationships between outcomes of interest and their covariates using SAS 9.3©. RESULTS A total of 1,733 surveys were initiated and 1,060 surveys had complete or near-complete responses. This includes agencies from 45 states representing over 6.23 million 9-1-1 responses annually. Totals of 70.5% (747) agencies reported dedicated QI personnel, 62.5% (663) follow clinical metrics and 33.3% (353) participate in outside quality or research program. Medical director hours varied, notably, 61.5% (649) of EMS agencies had <5 hours of medical director time per month. Presence of medical director time was correlated with tracking of QI measures. Air medical [OR 9.64 (1.13, 82.16)] and hospital-based EMS agencies [OR 2.49 (1.36, 4.59)] were more likely to track quality measures compared to fire-based agencies. Agencies in rural only environments were less likely to follow clinical quality metrics. (OR 0.47 CI 0.31 -0.72 p < 0.0004). For those that track QI measures, the most common are; Response Time (Emergency) (68.3%), On-Scene Time (66.4%), prehospital stroke screen (64.6%), aspirin administration (64.5%), and 12 lead ECG in chest pain patients (63.0%). CONCLUSIONS EMS agencies in the United States have significant practice variability with regard to quality improvement resources, medical direction and specific clinical quality measures. More research is needed to understand the impact of this variation on patient care outcomes.
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Cash RE, Crowe RP, Rodriguez SA, Panchal AR. Disparities in Feedback Provision to Emergency Medical Services Professionals. PREHOSP EMERG CARE 2017. [PMID: 28622074 DOI: 10.1080/10903127.2017.1328547] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Feedback to EMS professionals is a critical component for optimizing patient care and outcomes in the prehospital setting. There is a paucity of data concerning the feedback received by prehospital providers. OBJECTIVES The objective of this study was to describe the prevalence of feedback received by EMS professionals in the past 30 days including the types, sources, modes, and utility of feedback. The secondary objective was to identify factors associated with receiving any feedback and, specifically, feedback regarding medical care provided. METHODS This was a cross-sectional survey examining currently practicing nationally certified EMS patient care providers (EMT or higher) in non-military and non-tribal settings. Data were collected on provider characteristics along with feedback received. Descriptive statistics were calculated, and multivariable logistic regression models were constructed to assess the relationship between EMS provider characteristics and receiving feedback. A non-respondent survey was administered to assess for non-response bias. RESULTS Responses from 32,314 EMS providers were received (response rate = 10.4%) with 15,766 meeting inclusion criteria. In the 30 days preceding the survey, 69.4% (n = 10,924) of respondents received at least one type of feedback with 54.7% (n = 8,592) reporting receiving medical care feedback. Multivariable logistic regression modeling indicated that higher certification level, fewer years of experience in EMS, working for a hospital-based agency, air medical service, and higher weekly call volumes were significantly associated with increased odds of having received at least one type of feedback, and specifically medical care feedback. Additionally, providing primarily medical/convalescent transport and more years of EMS experience were significantly associated with decreased odds of receiving feedback. CONCLUSION Feedback to EMS providers is critical to improving prehospital care. In this study, nearly a third of providers did not receive any feedback in a 30-day period, and nearly half reported not receiving medical care feedback. Disparities in the frequency of feedback exist between different provider levels and service settings, while reported feedback decreased with years of experience in the profession. Future work is needed to assess the content of feedback and role in improving patient care and safety.
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Dorsett M, Kroll M, Smith CS, Asaro P, Liang SY, Moy HP. qSOFA Has Poor Sensitivity for Prehospital Identification of Severe Sepsis and Septic Shock. PREHOSP EMERG CARE 2017; 21:489-497. [DOI: 10.1080/10903127.2016.1274348] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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