Implementation of an EMS protocol to improve prehospital sepsis recognition.

PURPOSE: Optimal sepsis outcomes are achieved when sepsis is recognized early. Recognizing sepsis in the prehospital, EMS setting can be challenging and unreliable. The purpose of this study is to evaluate whether implementation of an EMS sepsis screening and prehospital alert protocol called PRESS (PREhospital SepsiS) is associated with improved sepsis recognition by EMS providers. DESIGN: We conducted a 12-month, before-after implementation study of the PRESS protocol in a large, public EMS system. The study intervention was a PRESS training program delivered to EMS providers. EMS patient inclusion criteria included: age ≥ 18 years, EMS systolic blood pressure < 110 mmHg, EMS heart rate > 90 bpm, and EMS respiratory rate > 20 bpm. Study exclusion criteria included the presence of any of following EMS conditions: trauma, cardiac arrest, pregnancy, toxic ingestion, or psychiatric emergency. Retrospective chart review was performed on all eligible EMS encounters during the study period. The primary outcome variable was the proportion of patients with sepsis who were identified by EMS providers. RESULTS: Approximately 300 EMS providers were trained to use PRESS. A total of 498 patient encounters met criteria for study inclusion; 222 were excluded, primarily due to trauma. A total of 276 patient encounters were analyzed. Sepsis recognition by EMS providers increased from 12% pre-PRESS protocol to 59% post-PRESS protocol (p < 0.001). In a post-hoc analysis of the post-PRESS cohort, septic patients who were identified by EMS received antibiotics 24 min faster than septic patients who were not identified by EMS [28 min (IQR 18-48) vs 52 (IQR 27-98), respectively, p = 0.021]. CONCLUSION: Implementation of an EMS sepsis screening and prehospital alert protocol was associated with an increase in sepsis recognition rates by EMS providers and a decrease in time to first antibiotic administration in the emergency department. Further studies are needed to evaluate the impact of this protocol in other populations.

Prehospital recognition of severe sepsis: development and validation of a novel EMS screening tool.

OBJECTIVE: To derive and validate a predictive model and novel emergency medical services (EMS) screening tool for severe sepsis (SS). DESIGN: Retrospective cohort study. SETTING: A single EMS system and an urban, public hospital. PATIENTS: Sequential adult, nontrauma, nonarrest, at-risk, EMS-transported patients between January 1, 2011, and December 31, 2012 were included in the study. At-risk patients were defined as having all 3 of the following criteria present in the EMS setting: (1) heart rate greater than 90 beats/min, (2) respiratory rate greater than 20 beats/min, and (3) systolic blood pressure less than 110 mm Hg. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 66,439 EMS encounters, 555 met the criteria for analysis. Fourteen percent (n = 75) of patients had SS, of which 19% (n = 14) were identified by EMS clinical judgment. In-hospital mortality for patients with SS was 31% (n = 23). Six EMS characteristics were found to be predictors of SS: older age, transport from nursing home, Emergency Medical Dispatch (EMD) 9-1-1 chief concern category of "sick person," hot tactile temperature assessment, low systolic blood pressure, and low oxygen saturation. The final predictive model showed good discrimination in derivation and validation subgroups (areas under curves, 0.843 and 0.820, respectively). Sensitivity of the final model was 91% in the derivation group and 78% in the validation group. At a predefined threshold of 2 or more points, prehospital severe sepsis (PRESS) score sensitivity was 86%. CONCLUSIONS: The PRESS score is a novel EMS screening tool for SS that demonstrates a sensitivity of 86% and a specificity of 47%. Additional validation is needed before this tool can be recommended for widespread clinical use.