Severe Sepsis In Prehospital Emergency Care: Analysis Of Incidence, Care, And Outcome

Abstract

Rationale: Severe sepsis is common and highly morbid, yet the epidemiology of severe sepsis at the frontier of the health care systempre-hospital emergency care-is unknown. Objectives: We examined the epidemiology of pre-hospital severe sepsis among emergency medical services (EMS) encounters, relative to acute myocardial infarction and stroke. Methods: Retrospective study using a community-based cohort of all nonarrest, nontrauma King County EMS encounters from 2000 to 2009 who were transported to a hospital. Measurements and Main Results: Overall incidence rate of hospitalization with severe sepsis among EMS encounters, as well as pre-hospital characteristics, admission diagnosis, and outcomes. Among 407,176 EMS encounters, we identified 13,249 hospitalizations for severe sepsis, of whom 2,596 died in the hospital (19.6%). The crude incidence rate of severe sepsis was 3.3 per 100 EMS encounters, greater than for acute myocardial infarction or stroke (2.3 per 100 and 2.2 per 100 EMS encounters, respectively). More than 40% of all severe sepsis hospitalizations arrived at the emergency department after EMS transport, and 80% of cases were diagnosed on admission. Pre-hospital care intervals, on average, exceeded 45 minutes for those hospitalized with severe sepsis. One-half or fewer of patients with severe sepsis were transported by paramedics (n ¼ 7,114; 54%) or received pre-hospital intravenous access (n ¼ 4,842; 37%). Conclusions: EMS personnel care for a substantial and increasing number of patients with severe sepsis, and spend considerable time on scene and during transport. Given the emphasis on rapid diagnosis and intervention for sepsis, the pre-hospital interval may represent an important opportunity for recognition and care of sepsis.Keywords: sepsis; emergency medical services; epidemiology Severe sepsis represents a large and increasing burden on the U.S. health care system. The incidence of severe sepsis is greater than 3.0 per 1,000 population, and case fatalities approach 20%, accounting for more than $17 billion annually in medical costs (1-3). Even sepsis survivors often suffer with cognitive impairment and functional disability (4, 5). Advances in severe sepsis therapy, such as time-sensitive antibiotic administration and fluid resuscitation, require prompt diagnosis, and in some cases, transfer to referral centers for definitive therapy (6-11). Until now, such early recognition occurs after patients arrive at hospitals, when a critical window for treatment and referral may already have passed.An alternative approach may be to diagnose and treat severe sepsis in the pre-hospital period, using emergency medical services (EMS) personnel (12, 13). More than 800,000 EMS personnel provide care to tens of millions of persons as part of an emergency system (14) that transports more than 35 patients every minute of every day (15). EMS systems already play a key role in the management of acute cardiovascular disease, stroke, and trauma, conditions that benefit from care at optimal centers with advanced ...

Hospital Case Volume and Outcomes among Patients Hospitalized with Severe Sepsis

“…Our results may at first glance appear to argue for similar centralization of care for severe sepsis. For example, approximately 40% of severe sepsis cases are transported via prehospital emergency medical service providers that potentially could recognize and selectively triage patients with severe sepsis to high-volume centers (21). However, such policy shifts would require substantial infrastructure changes for acutely ill patients with severe sepsis, as compared with patient scheduling for semielective high-risk cancer surgery.…”

“…In our a priori primary analysis we included only cases with severe sepsis present on admission because (1) processes of care can differ markedly for patients admitted with severe sepsis as opposed to those who develop nosocomial sepsis, (2) ICD-9-CM codes cannot discern the temporality of the onset of infection and organ dysfunction in cases without both infection and acute organ dysfunction present on admission, and (3) the development of acute organ failure after hospital admission may partly be the result of processes of care and may confound the case volume-outcome association. We identified cases of severe sepsis that were present on admission by requiring that ICD-9-CM codes for the diagnosis of sepsis and acute organ failure were present on admission modifiers (21).…”

Tie2 protects the vasculature against thrombus formation in systemic inflammation

“…Death from severe infection is a global health threat (1)(2)(3). Of all acute illnesses, the public health burden of sepsis may be the most pressing -patients spend longer in intensive care units (ICUs) and hospitals and more commonly suffer long-term health impairments compared with all other admission diagnoses (1).…”

Nye sepsiskriterier kan føre til forsinket behandling

“…Den samme studien viste at det i gjennomsnitt ble brukt 35  18 minutt på hentestedet (8). Transporttiden kommer i tillegg.…”

“…Denne erfaringen støttes av Seymour og medarbeideres studie omtalt i forrige avsnitt (8). Her fant man at hos sepsispasienter utenfor sykehus var hypotensjon et uvanlig funn, mens over halvparten av pasientene hadde takypné og takykardi.…”