Presentations of adult septic patients in the prehospital setting as recorded by emergency medical services: a mixed methods analysis

Ulrika Margareta Wallgren, Katarina Eva Margareta Bohm, Lisa Kurland, Ulrika Margareta Wallgren, Katarina Eva Margareta Bohm, Lisa Kurland

Abstract

Background: Current sepsis screening tools rely on vital parameters which are, however, normal in one third of patients with serious infections. Therefore, there is a need to include other variables than vital parameters to identify septic patients. Our primary aim was to identify and quantify keywords related to the septic patients' symptom presentation in the prehospital setting. The secondary aims were to compare keywords in relation to in-hospital mortality and the distribution of keywords in relation to age categories, survivors/ deceased and severe/ non-severe sepsis.

Methods: A mixed methods analysis using a sequential exploratory design was performed, starting with a content analysis of presentations of septic patients as documented in Emergency Medical Services (EMS) records (n = 80) from 2012, to identify keywords related to sepsis presentation. Thereafter, the identified keywords were quantified among 359 septic patients from 2013. All patients were adults, admitted to Södersjukhuset and discharged with an ICD-10-code (International Classification of Diseases, Tenth Revision) compatible with sepsis.

Results: The most common keywords related to septic patients' symptom presentation were: abnormal/ suspected abnormal temperature (64.1.%), pain (38.4%), acute altered mental status (38.2%), weakness of the legs (35.1%), breathing difficulties (30.4%), loss of energy (26.2%) and gastrointestinal symptoms (24.0%). There was an association between keywords and in-hospital mortality. Symptoms varied between age categories, survivors/ deceased and severe/ non-severe sepsis.

Discussion: This is, to the best of our knowledge, the first study exploring the symptom presentation as documented by EMS, of septic patients in the prehospital setting. Keywords related to patients´ symptom presentation recurred in the EMS records of septic patients, so that a pattern was discernible. In addition, certain symptom presentations were associated with increased in-hospital mortality CONCLUSIONS: Information relating to symptom presentation is not included in current sepsis screening tools. We suggest that keywords related to patients´ symptom presentation could be integrated into screening tools and may thus increase the identification of sepsis, and potentially also identify high-risk patients. However, as a first step, the specificity of these keywords, with respect to sepsis, needs to be examined.

Keywords: Emergency Care; Emergency Medical Services; Prehospital; Sepsis.

Figures

Fig. 1
Fig. 1
Flow chart for inclusion and exclusion. Flow chart for inclusion and exclusion of patients in the content analysis of septic patients arriving by EMS and admitted to Södersjukhuset through the ED during 2012 and the quantification of the keywords among septic patients arriving by EMS and admitted to Södersjukhuset through the ED during 2013, respectively. EMS = Emergency Medical Services, ED = Emergency Department, HCAI = Health Care Associated Infection, ICD-10 = International Classification of Diseases, 10:th Revision
Fig. 2
Fig. 2
Example of the content analysis of septic patients arriving by EMS and admitted during 2012. EMS = Emergency Medical Services

References

    1. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) Jama. 2016;315(8):801–10. doi: 10.1001/jama.2016.0287.
    1. Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372(14):1301–11. doi: 10.1056/NEJMoa1500896.
    1. Peake SL, Delaney A, Bailey M, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496–506. doi: 10.1056/NEJMoa1404380.
    1. Peterson ED, Shah BR, Parsons L, et al. Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J. 2008;156(6):1045–55. doi: 10.1016/j.ahj.2008.07.028.
    1. Chung SC, Gedeborg R, Nicholas O, et al. Acute myocardial infarction: a comparison of short-term survival in national outcome registries in Sweden and the UK. Lancet (London, England) 2014;383(9925):1305–12. doi: 10.1016/S0140-6736(13)62070-X.
    1. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589–96. doi: 10.1097/01.CCM.0000217961.75225.E9.
    1. Ferrer R, Artigas A, Suarez D, et al. Effectiveness of treatments for severe sepsis: a prospective, multicenter, observational study. Am J Respir Crit Care Med. 2009;180(9):861–6. doi: 10.1164/rccm.200812-1912OC.
    1. Gaieski DF, Mikkelsen ME, Band RA, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010;38(4):1045–53. doi: 10.1097/CCM.0b013e3181cc4824.
    1. Ferrer R, Martin-Loeches I, Phillips G, et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med. 2014;42(8):1749–55. doi: 10.1097/CCM.0000000000000330.
    1. Sterling SA, Miller WR, Pryor J, Puskarich MA, Jones AE. The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis. Crit Care Med. 2015;43(9):1907–15. doi: 10.1097/CCM.0000000000001142.
    1. Youkee D, Hulme W, Roberts T, Daniels R, Nutbeam T, Keep J. Time Matters: Antibiotic Timing in Sepsis and Septic Shock. Crit Care Med. 2016;44(10):e1016–7. doi: 10.1097/CCM.0000000000001968.
    1. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock. Intensive Care Med. 2016;18:2017.
    1. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992;101(6):1644–55. doi: 10.1378/chest.101.6.1644.
    1. Levy MM, Fink MP, Marshall JC, et al. SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2001;31(4):1250–6. doi: 10.1097/01.CCM.0000050454.01978.3B.
    1. Suffoletto B, Frisch A, Prabhu A, Kristan J, Guyette FX, Callaway CW. Prediction of serious infection during prehospital emergency care. Prehosp Emerg Care. 2011;15(3):325–30. doi: 10.3109/10903127.2011.561411.
    1. Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R. Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med. 2015;372(17):1629–38. doi: 10.1056/NEJMoa1415236.
    1. Robson W, Nutbeam T, Daniels R. Sepsis: a need for prehospital intervention? Emerg Med J. 2009;26(7):535–8. doi: 10.1136/emj.2008.064469.
    1. Singer AJ, Taylor M, Domingo A, et al. Diagnostic characteristics of a clinical screening tool in combination with measuring bedside lactate level in emergency department patients with suspected sepsis. Acad Emerg Med. 2014;21(8):853–7. doi: 10.1111/acem.12444.
    1. Infektionsläkarföreningen S. Vårdprogram för svår sepsis och septisk chock. 2013.
    1. Creswell JW. Research Design : Qualitative, Quantitative, and Mixed Methods Approaches. Third edition ed. USA: SAGE, Publications, Inc; 2009.
    1. Zhang W, Creswell J. The Use of “Mixing” Procedure of Mixed Methods in Health Services Research. Med Care. 2013;51(8):e51–7. doi: 10.1097/MLR.0b013e31824642fd.
    1. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2003;24:105–12. doi: 10.1016/j.nedt.2003.10.001.
    1. Krippendorff K. Content Analysis. An Introduction to Its Methodology. 3. London: Sage Publications; 2013.
    1. About Södersjukhuset. 2016; . Accessed 19 Jan 2016.
    1. Wallgren UM, Castren M, Svensson AE, Kurland L. Identification of adult septic patients in the prehospital setting: a comparison of two screening tools and clinical judgment. Eur J Emerg Med. 2014;21(4):260–5. doi: 10.1097/MEJ.0000000000000084.
    1. Creswell J. Qualitative Inquiry and Research Design: Choosing Among Five Traditions. 2nd edition ed. London: Sage Publications; 2007.
    1. Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;348(16):1546–54. doi: 10.1056/NEJMoa022139.
    1. Satu Elo MK, Outi Kanste, Tarja Pölkki, Kati, Utriainen aHK. Qualitative Content Analysis: A Focus on Trustworthiness. Thousand Oaks: SAGE Publications Open: ; 2014.
    1. SBU: Swedish Agency for Health Technology Assessment and Assessment of Social Services. Evaluation and synthesis of studies conducted with qualitative analysis methodology. . SBU: Statens beredning för medicinsk och social utvärdering; Revised 2014:96.
    1. Vicente V, Ekebergh M, Castren M, Sjostrand F, Svensson L, Sundstrom BW. Differentiating frailty in older people using the Swedish ambulance service: a retrospective audit. Int Emerg Nurs. 2012;20(4):228–35. doi: 10.1016/j.ienj.2011.09.005.
    1. Karlsson AK, Lidell E, Johansson M. Health-care professionals’ documentation of wellbeing in patients following open heart surgery: a content analysis of medical records. J Nurs Manag. 2013;21(1):112–20. doi: 10.1111/j.1365-2834.2012.01458.x.
    1. The National Board of Health and Welfare; 2015. Healthcare-Associated Infection. . Accessed 23 Dec 2015.
    1. Holder AL, Gupta N, Lulaj E, et al. Predictors of early progression to severe sepsis or shock among emergency department patients with nonsevere sepsis. Int J Emerg Med. 2016;9(1):10. doi: 10.1186/s12245-016-0106-7.
    1. Lindvig KP, Henriksen DP, Nielsen SL, et al. How do bacteraemic patients present to the emergency department and what is the diagnostic validity of the clinical parameters; temperature, C-reactive protein and systemic inflammatory response syndrome? Scand J Trauma Resusc Emerg Med. 2014;22:39. doi: 10.1186/1757-7241-22-39.
    1. Hentie Cilliers TW, Bill T. Serious Complications of Sepsis. In: Ron Daniels TN, editor. ABC of Sepsis. Chichester: Blackwell Publishing Ltd; 2010. pp. 15–9.
    1. Consales G, De Gaudio AR. Sepsis associated encephalopathy. Minerva Anestesiol. 2005;71(1–2):39–52.
    1. Sharshar T, Hopkinson NS, Orlikowski D, Annane D. Science review: The brain in sepsis-culprit and victim. Crit Care (London, England) 2005;9(1):37–44. doi: 10.1186/cc2951.
    1. Callahan LA, Supinski GS. Sepsis-induced myopathy. Crit Care Med. 2009;37(10 Suppl):S354–67. doi: 10.1097/CCM.0b013e3181b6e439.
    1. Lee BH, Inui D, Suh GY, et al. Association of body temperature and antipyretic treatments with mortality of critically ill patients with and without sepsis: multi-centered prospective observational study. Crit Care (London, England) 2012;16(1):R33. doi: 10.1186/cc11211.
    1. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29(7):1303–10. doi: 10.1097/00003246-200107000-00002.
    1. Ljungstrom LR, Steinum O, Brink M, Gardlund B, Martner J, Sjolin J. Diagnosis and diagnostic coding of severe sepsis and septic shock. ICD-10 should be completed with additional codes. Lakartidningen. 2011;108(6):276–8.
    1. Henriksen DP, Laursen CB, Jensen TG, Hallas J, Pedersen C, Lassen AT. Incidence rate of community-acquired sepsis among hospitalized acute medical patients-a population-based survey. Crit Care Med. 2015;43(1):13–21. doi: 10.1097/CCM.0000000000000611.
    1. Elo SKH. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107–15. doi: 10.1111/j.1365-2648.2007.04569.x.
    1. Quinn Patton M. Strategic Themes in Qualitative Inquiry. Qualitative Research & Evaluation Methods. Fourth Edition ed. Thousand Oaks: SAGE Publications Ltd; 2015. p. 64.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir