Review Of: Band RA, Gaieski DF, Hylton JF, et al. Arriving by emergency medical services improves time to treatment endpoints for patients with severe sepsis or septic shock. Acad Emerg Med. 2011;18(9):1–7.
This is a prospective observational study of collected registry data on patients presenting to a tertiary hospital with severe sepsis or septic shock. The goal of this study was to evaluate the effect EMS has on the care provided to these patients in the hospital. Those interventions evaluated are time to initiation of antibiotics, time to initiation of intravenous fluids (IVF), and in-hospital mortality. A total of 963 patients were enrolled in the registry and showed the following results:
• Median time to antibiotics were faster for EMS (and statistically significant)
• Median time to IVF was faster for EMS (and statistically significant)
• Adjusted mortality showed a difference (not statistically significant).
The authors concluded that out-of-hospital care was associated with improved hospital processes for the care of critically ill patients, but a mortality benefit could not be shown.
Dr. Wesley: This is difficult study to interpret, and the devil is in the details. The title of the paper would imply that EMS is making a difference in the care of septic patients. But that is not the case. The authors did not examine any EMS treatment other than transporting the patient to the ED. These patients were older, sicker and more often white compared to those that checked in at the triage desk.
Several quality benchmarks exist for improved care of sepsis. None is more important than simply recognizing that a patient is septic. Perhaps ill patients arriving by EMS are more likely to be recognized as septic because of their EMS assessment or just because they came through the ambulance bay rather than the front door. Once sepsis is recognized, the two first therapies include IV fluid and antibiotics. Earlier recognition results in earlier administration of fluids and antibiotics. It’s interesting that these were the only two outcomes that were improved in the EMS group.
So why was there no mortality benefit to the EMS sepsis group? One factor may be that the cause of death from sepsis may be more complicated than simply starting IV fluids and antibiotics quickly. The only way we’ll know the value of EMS in sepsis is to study a system that institutes prehospital lactate measurement to identify sepsis and aggressive fluid administration despite normotensive vital signs.
Medic Marshall: I’m going to disagree with the Doc on the study part. I think the authors were able to answer their question of interest: Does presenting to an ED by ambulance affect the care rendered in the hospital? And the answer is yes; however, this study doesn’t demonstrate a statistically significant benefit in mortality. But that doesn’t necessarily mean there isn’t one … thus some of the problems you run into with statistics and research: How do you really interpret the results? Well in this case, although it’s not “statistically significant,” I still believe it to be significant.
I do, however, agree with him on sepsis. The most important part about it is recognition. And that’s a tough job. Sepsis is tricky, even for the best clinicians because it doesn’t always have the classic “shock presentation.” Furthermore, the study did show that patients presenting to the ED were generally older and sicker per se. To me, that suggests that patients who are older, despite early and aggressive treatments, tend to die, unfortunately. But does that mean EMS doesn’t make a difference? I’d say no … simply arriving by EMS to the ED improved the speed by which care was delivered.
Furthermore, I’d also like to reiterate what the Doc said. The only way to improve the care of sepsis is to increase point-of-care testing for EMS and make serum lactates as routine as blood glucose checks.
Band RA, Gaieski DF, Hylton JF, et al. Arriving by Emergency Medical Services Improves Time to Treatment Endpoints for patients with severe sepsis or septic shock. Acad Emerg Med. 2011;18(9):1–7.
Objectives: The objective was to evaluate the effect of arrival to the emergency department (ED) by emergency medical services (EMS) on time to initiation of antibiotics, time to initiation of intravenous fluids (IVF), and in-hospital mortality in patients with severe sepsis and septic shock.
Methods: The authors performed an evaluation of prospectively collected registry data of patients with a diagnosis of severe sepsis or septic shock who presented to an urban academic ED during a 2-year period from January 1, 2005, to December 31, 2006. Descriptive and multivariate analytic methods were used to analyze the data. Using unadjusted and adjusted models, out-of-hospital patients who presented to the ED by ambulance (EMS) were compared to control patients who arrived by alternative means (non-EMS). Primary outcomes measured were ED time to initiation of antibiotics, ED time to initiation of IVF, and in-hospital mortality.
Results: A total of 963 severe sepsis patients were enrolled in the registry. Median time to antibiotics was 116 minutes for EMS (interquartile range [IQR] = 66 to 199) vs. 152 minutes for non-EMS (IQR = 92 to 252, p £ 0.001). Median time to initiation of IVF was 34 minutes for EMS (IQR = 10 to 88) and 68 minutes for non-EMS (IQR = 25 to 121, p £ 0.001). After adjustment for the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, age, and initial serum lactate level, no significant differences in hospital mortality were seen (adjusted relative risk [aRR] for EMS vs. non EMS = 1.24, 95% confidenceinterval [CI] = 0.92 to 1.66, p = 0.16). The Cox proportional hazard ratio (HR) comparing EMS to non-EMS care after similar adjustment was HR = 1.27 for IVF (95% CI = 1.10 to 1.47, p = 0.004) and HR = 1.25 for antibiotics (95% CI = 1.08 to 1.44, p = 0.003).
Conclusions: Out-of-hospital care was associated with improved in-hospital processes for the care of critically ill patients. Despite shortened ED treatment times for septic patients who arrive by EMS, a mortality benefit could not be demonstrated.