Screening & Treating: EMS and the Sepsis Care Continuum

by Elizabeth Odom, MD MPH

EMS MEd editor: Maia Dorsett MD PhD (@maiadorsett)

Case Scenario

It’s a hot summer day and EMS is dispatched to an old farmhouse on the edge of the town for a patient who has been ”generally weak” and now unable to get out of bed.  Upon arrival, paramedics find a previously healthy 65 year old female who has had a productive cough for a week.  She has had little oral intake for 3 days and her urine has been dark and low in volume. Her husband called EMS because she has become progressively more confused over the course of the day. Her vital signs are T 38.1 HR 96 BP 115/80 RR 23 O2 Sat 91%. 

The patient is quickly loaded into the ambulance.  An IV is placed and fluid bolus is initiated. Fingerstick blood sugar is within normal limits and an ECG demonstrates sinus rhythm.  Given the semi-rural location, transport to the hospital will exceed 30 minutes.

The paramedic suspects sepsis.  What is the role of EMS in sepsis screening and treatment? How should we best screen for sepsis in the prehospital environment? Beyond IV fluids, should EMS administer antibiotics?

Literature Review

Sepsis is a Time-Critical Diagnosis

Advancements in protocols for STEMI and trauma patients have drastically improved early identification and treatment [1,2].  Like STEMI and Trauma, sepsis is a time-critical diagnosis where early screening and intervention can impact outcome [3-6].  With a mortality rate of 18-50% depending on other risk factors, severe sepsis should be acted on as quickly as possible [7]. Septic patients who are transported by EMS are sicker and have a higher mortality than those who arrive via other means, so the effect of any delay in antibiotic administration in this population may be amplified [8].  Delays in care of even 1 hour after first medical contact have been shown to increase mortality in patients with severe sepsis [9-12] while antibiotic therapy within the first hour of severe sepsis recognition contributed to an 80% survival [13].  The rapid administration of broad spectrum IV antibiotics may save more lives than the administration of aspirin in acute MI and epinephrine in anaphylaxis [14].

Current literature suggests that sepsis is both underrecognized and undertreated in the prehospital setting [15-16].  The reasons are likely multi-factorial, but include knowledge gaps as well as  poor prehospital performance of sepsis screening tools.  A recently published survey study from Atlanta found that 24% of paramedics were unaware of evidence supporting early sepsis treatment [17]. Moreover, 73% of participating Emergency Physicians reported caring for patients with sepsis almost every shift, while 62% of EMS providers reported caring for patients with sepsis no more than occasionally.  While there are multiple sets of criteria for diagnosing sepsis, sepsis screening tools have variable performance in the prehospital setting. MEWS (Modified Early Warning Score) and BAS 90-30-90 scores were 74% and 62% sensitive, while the Robson score has been found to be 75-90% sensitive [18-21].  The PRESS (prehospital severe sepsis) score to identify severe sepsis also has a sensitivity near 90%, but is rather complicated for prehospital use [22].  qSOFA was developed as a  simple tool to prompt clinicians to consider sepsis and escalate therapy as appropriate [23,24].  However, recent studies have demonstrated that although very specific, it has extremely poor sensitivity for severe sepsis in the prehospital setting, predominantly due to absence of hypotension until after ED admission [25,26].  SIRS itself lacks specificity in the prehospital setting.  Moreover, in the hospital, 12.1% of patients with documented severe infection causing end-organ dysfunction are SIRS-negative [27].

Some services have successfully introduced lactate meters to detect occult hypoperfusion to enable hospital notification of a need for early, aggressive intervention [6].  As lactate meters are cost-prohibitive for many services, an important alternative to is end-tidal capnography, which is more widely available and has increasing applications in the prehospital setting.   More recently, end-tidal CO2 levels were found to correlate with lactate levels and mortality in the ED setting [28].  Incorporation of end-tidal capnography into a SIRS-based prehospital sepsis alert protocol had a sensitivity of 90% (95% CI 81-95%), a specificity of 58% (95% CI 52-65%), and a negative predictive value of 93% (95% CI 87-97%) for sepsis and severe sepsis [29] .

EMS Interventions and Antibiotic Administration

Although decreased time to from first medical contact to antibiotic administration has the potential to impact mortality for patients with severe sepsis and septic shock, few EMS systems have initiated the administration of antibiotics to septic patients in the prehospital setting.  This is due to a number of complexities.  First, as discussed above, sepsis may be difficult to diagnose, despite the numerous algorithms that have been presented.  Second, blood cultures allow for targeted antimicrobial therapy and these should typically be drawn prior to antibiotic administration, which may be subject to contamination or be difficult to obtain in the prehospital setting.  Third, logistics and costs behind carrying and administering antibiotic agents on ambulances limits feasibility without substantial evidence behind the routine administration of antibiotics in the field.  

Some EMS systems have standardized sepsis protocols based on one or a combination of scales references above. The mainstay of these protocols is fluid resuscitation and prehospital notification [6].  A small number of EMS systems have begun to introduce antibiotic administration into their protocols for patients with severe sepsis.  This has reduced time to antibiotic from an average of 131 minutes after first contact to 69 minutes [30].  Even with short transport times, antibiotics may be initiated prior to arrival, eliminating the wait time for a bed, to see a physician, to receive the drug from pharmacy, and for a nurse to administer it. In South Carolina, EMS has treated 650 septic patients according to this protocol and 59% have received antibiotics [31]. Patients with > 2 SIRS criteria and a Point of Care Lactate  >2.2mmol/L were treated with IV or interosseous ceftriaxone 1 g is in cases of suspected pneumonia or  piperacillin/tazobactam 4.5 g following obtainment of blood cultures.  Contamination rate for EMS-obtained blood cultures was <6%.  Preliminary data showing a reduction from 25.6% mortality vs 9.3% mortality for patients with sepsis within the hospital system.  In Australia and New Zealand, the PASS (Paramedic Antibiotics for Severe Sepsis) study, a randomized trial in which paramedics following a similar protocol is underway [32].

One of the most commonly cited fears regarding prehospital antibiotic administration is that it will cause an in antibiotic resistance.  Inappropriately prescribed antibiotics do indeed increase resistance [33].   “Inappropriate” antibiotic use in an undifferentiated patient is not straightforward to define.  Programs will have to fairly be compared to ED-administered antibiotics (rather than hospital final-diagnosis) and the impact on patient-centered outcomes measured prospectively. Empiric antibiotics provided are consistent with those recommended by local agencies for bacterial sensitivity resistance patterns for each area [34].  Ideally, a randomized-controlled trial will be conducted as the true risks-benefits of EMS-initiated antibiotics is unclear.

Take Home

Sepsis is a time-critical diagnosis and EMS can play a key role in reducing time to intervention and impacting patient-centered outcomes.  Currently, sepsis remains underrecognized and undertreated in the prehospital setting, largely due to knowledge gaps and poor performance of screening methods.  Recently, end-tidal capnography has emerged as a tool to enhance prehospital sepsis screening.  Some EMS agencies have introduced paramedic-initiated antibiotics with some success.  Further research is needed to fully understand the risks and benefits of this approach, which may vary regionally due to transport times and subsequent hospital-based patient management.  

References

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