Paramedic CAT (Critically Appraised Topic) 

007 | Sepsis recognition and the use of scoring tools for early recognition and intervention

Case study

You respond routine in the middle of the day to a patient at their home who is feeling lethargic and dizzy. The patient is tachycardic and hypotensive but seems alert and oriented. The history suggests a possible infection. You suspect sepsis. You are unsure how to assess how at risk of deterioration the patient might be. You also wonder if you should be giving a pre-notification to the receiving facility. 

Should the paramedic assist their clinical intuition with the use of a Sepsis scoring tool? Do communicating the results of these measurements affect clinical course?

PICO Question

“For patients suspected of Sepsis in the pre-hospital setting, does pre-notification of the receiving facility with use of a quantitative scoring system result in decreased time to treatment in the Emergency Department?”

Search Strategy #1: Do scoring tools work?

Pubmed: sepsis AND (prehospital OR paramedics OR EMS) AND (screening OR emergency department notification OR prenotification OR pre-alert) AND (time to treatment OR outcomes)

Search Outcome #1

91 Results (17 relevant) on 2020-05-04

Search Strategy #2: Which scoring tool is best?

Pubmed: sepsis AND (prehospital OR paramedics) AND (predicting OR comparison OR performance OR recognition OR identification OR accuracy OR mortality OR admission) AND (qSOFA OR SIRS OR NEWS OR NEWS-2)

Search Outcome #2:

24 results (13 relevant) on 2020-05-04

Clinical bottom line

Sepsis is underrepresented in awareness and recognition.

Sepsis is a life-threatening medical condition that carries a higher crude incidence rate (3.3/100) than MI (2.3/100) and CVA (2.2/100) [1]. Although Sepsis carries between a 17% and 26% (or 33% @ for severe sepsis 28-day mortality) [2] risk of mortality upon hospital admission [3] and carries with it a higher crude mortality rate than MI and Stroke, it remains an area that emergency clinicians report unfamiliarity with. Adequate initial therapy is only initiated for 58% of patients [4].

Early recognition is good, but often not achieved. 

Early intervention upon hospital admission has been shown to decrease mortality and shorten length of hospital stay, decreasing both the burden of injury and stress to the medical system. However, recognition of Sepsis by emergency clinicians (ED physician, ED nurse, EMS) remains low and current tools that are widely used often make large errors of omission in detecting Sepsis. 

Using a tool and prenotification is better. 

For patients presenting in the pre-hospital setting, use of a standardized scoring system is associated with better recognition of Sepsis when compared to clinical intuition. Pre-notification of the receiving Emergency Department has been demonstrated to be associated with shorter times to critical treatments and interventions which are associated with better outcomes. Several tools exist for prehospital screening of sepsis, each with varying degrees of sensitivity and specificity.

NEWS2 is the best tool. 

The widely used qSOFA score was originally developed for predicting outcomes in the ICU setting and has been shown to underperform in the prehospital and emergency setting. The NEWS2 tool was originally developed as a clinical predictive model for assessing risk of deterioration from acute illness and a NEWS2 score ≥ 5 has been demonstrated to be an accurate tool for recognition of Sepsis, as well as a good predictor for deterioration upon hospital admission. Furthermore, the NEWS2 tool is validated for use predicting deterioration of illness not caused by Sepsis, such as trauma and provides a standardized measure for risk stratification in the prehospital setting. Finally, system-wide implementation of the NEWS2 tool has been effective in reducing mortality from Sepsis compared to systems that did not implement the tool.  

Relevant Results

1. Seymour CW, Rea TD, Kahn JM, Walkey AJ, Yealy DM, Angus DC. Severe sepsis in pre-hospital emergency care: analysis of incidence, care, and outcome. 2012. [LINK]
2. Stevenson EK, Rubenstein AR, Radin GT, Wiener RS, Walkey AJ. Two decades of mortality trends among patients with severe sepsis: a comparative meta-analysis*. 2014. [LINK]
3. Fleischmann C, Scherag A, Adhikari NK, et al. Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations. 2016. [LINK]
4. BC Sepsis Network. BC Patient Safety and Quality Council. 2020 [cited: 2020-05-04]. [LINK]

Additional References:

1. Alam N, Doerga KB, Hussain T, et al. Epidemiology, recognition and documentation of sepsis in the pre-hospital setting and associated clinical outcomes: a prospective multicenter study. 2016. [LINK]
2. Askim Å, Moser F, Gustad LT, et al. Poor performance of quick-SOFA (qSOFA) score in predicting severe sepsis and mortality - a prospective study of patients admitted with infection to the emergency department. 2017. [LINK]
3. Band RA, Gaieski DF, Hylton JH, Shofer FS, Goyal M, Meisel ZF. Arriving by emergency medical services improves time to treatment endpoints for patients with severe sepsis or septic shock. 2011. [LINK]
4. Barbara P, Graziano C, Caputo W, Litvak I, Battinelli D, Hahn B. The quick sequential organ failure assessment (qSOFA) identifies septic patients in the out-of-hospital setting. 2018. [LINK]
5. Borrelli G, Koch E, Sterk E, Lovett S, Rech MA. Early recognition of sepsis through emergency medical services pre-hospital screening. 2019. [LINK]
6. Nannan Panday RS, Minderhoud TC, Alam N, Nanayakkara PWB. Prognostic value of early warning scores in the emergency department (ED) and acute medical unit (AMU): A narrative review. 2017. [LINK]
7. Femling J, Weiss S, Hauswald E, Tarby D. EMS patients and walk-in patients presenting with severe sepsis: differences in management and outcome. 2014. [LINK]
8. Groenewoudt M, Roest AA, Leijten FM, Stassen PM. Septic patients arriving with emergency medical services: a seriously ill population. 2014. [LINK]
9. Hunter CL, Silvestri S, Stone A, et al. Prehospital sepsis alert notification decreases time to initiation of CMS sepsis core measures. 2019.[LINK]
10. Jouffroy R, Saade A, Carpentier A, et al. Triage of Septic Patients Using qSOFA Criteria at the SAMU Regulation: A Retrospective Analysis. 2018. [LINK]
11. Jouffroy R, Saade A, Ellouze S, et al. Prehospital triage of septic patients at the SAMU regulation: Comparison of qSOFA, MRST, MEWS and PRESEP scores. 2018. [LINK]
12. Koyama S, Yamaguchi Y, Gibo K, Nakayama I, Ueda S. Use of prehospital qSOFA in predicting in-hospital mortality in patients with suspected infection: A retrospective cohort study. 2019. [LINK]
13. Lane DJ, Wunsch H, Saskin R, et al. Screening strategies to identify sepsis in the prehospital setting: a validation study. 2020.. [LINK]
14. Metelmann C, Metelmann B, Scheer C, et al. Sepsis detection in emergency medicine : Results of an interprofessional survey on sepsis detection in prehospital emergency medicine and emergency departments. 2018. [LINK]
15. Mixon M, Dietrich S, Floren M, et al. Time to antibiotic administration: Sepsis alerts called in emergency department versus in the field via emergency medical services. 2020. [LINK]
16. Nannan Panday RS, Minderhoud TC, Alam N, Nanayakkara PWB. Prognostic value of early warning scores in the emergency department (ED) and acute medical unit (AMU): A narrative review. 2017. [LINK]
17. Pullyblank A, Tavaré A, Little H, et al. Implementation of the National Early Warning Score in patients with suspicion of sepsis: evaluation of a system-wide quality improvement project. 2020. [LINK]
18. Seymour CW, Rea TD, Kahn JM, Walkey AJ, Yealy DM, Angus DC. Severe sepsis in pre-hospital emergency care: analysis of incidence, care, and outcome. 2012. [LINK]
19. Shu E, Ives Tallman C, Frye W, et al. Pre-hospital qSOFA as a predictor of sepsis and mortality. 2019. [LINK]
20. Silcock DJ, Corfield AR, Staines H, Rooney KD. Superior performance of National Early Warning Score compared with quick Sepsis-related Organ Failure Assessment Score in predicting adverse outcomes: a retrospective observational study of patients in the prehospital setting. 2019.[LINK]
21. Smyth MA, Brace-McDonnell SJ, Perkins GD. Identification of adults with sepsis in the prehospital environment: a systematic review. 2016. LINK
22. Smyth MA, Gallacher D, Kimani PK, Ragoo M, Ward M, Perkins GD. Derivation and internal validation of the screening to enhance prehospital identification of sepsis (SEPSIS) score in adults on arrival at the emergency department. 2019.[LINK]
23. Studnek JR, Artho MR, Garner CL Jr, Jones AE. The impact of emergency medical services on the ED care of severe sepsis. 2012.[LINK]
24. Tusgul S, Carron PN, Yersin B, Calandra T, Dami F. Low sensitivity of qSOFA, SIRS criteria and sepsis definition to identify infected patients at risk of complication in the prehospital setting and at the emergency department triage. 2017. [LINK]
25. Wallgren UM, Castrén M, Svensson AE, Kurland L. Identification of adult septic patients in the prehospital setting: a comparison of two screening tools and clinical judgment. 2014. [LINK]
26. Weiss SJ, Guerrero A, Root-Bowman C, et al. Sepsis alerts in EMS and the results of pre-hospital ETCO2. 2019. [LINK]
27. Williams TA, Tohira H, Finn J, Perkins GD, Ho KM. The ability of early warning scores (EWS) to detect critical illness in the prehospital setting: A systematic review. 2016. [LINK]