Approaches in Prehospital Sepsis Screening

The photo shows the inside of an ambulance.
The inside of an ambulance at Cherry Point (NC) Fire and Emergency Services. (U.S. Marine Corps photo by Sgt. Micha Pierce)

Sepsis is a life-threatening emergency. According to the U.S. Centers for Disease Control and Prevention (CDC) (2019), at least 1.7 million American adults develop sepsis each year, of which 270,000 die from sepsis-related complications. Sepsis is an underlying infection that occurs in an individual’s body when he/she responds to a severe infection.1 An infection that may result in sepsis is not limited to one system of a person’s body,2 but often, sepsis is linked to infections in the lungs, kidneys, skin or bowels.1

Emergency medical service providers transfer approximately 50% of septic patients.3 Septic patients are very ill. These patients are at increased risk of death if sepsis progresses to septic shock.3 Without timely identification of sepsis, and prompt intervention methods to decrease the infection’s severity, an individual’s likelihood of mortality increases.

The CDC has several sepsis-related projects underway. Projects developed by the CDC to reduce sepsis mortality rates include community and consumer education, developing tools for tracking and surveilling sepsis, and further preventing infections contracted in healthcare settings.1 In 2016, the CDC created an early recognition and timely sepsis treatment effort entitled “Get Ahead of Sepsis.”2 The purpose of this effort is to emphasize the critical nature of early recognition of sepsis, prevention of infection through education to the layperson, emergency medical services (EMS), and healthcare professionals.

Related

In addition to the CDC’s (2016) effort, the Society of Critical Care Medicine (SCCM) has funded the “Surviving Sepsis Campaign,” which provides management strategies to reduce mortality and morbidity. While the efforts created by CDC and the SCCM seek to reduce sepsis mortality rates, neither initiative specifically targets prehospital screening techniques.

Practitioners need to address the critical importance of prehospital sepsis identification and early sepsis intervention techniques to reduce morbidity and mortality. Sepsis-specific EMS education can improve EMS identification of sepsis and improve mortality, and can improve outcomes.4 For this literature review, the project investigators (PIs) analyzed the current methods used in the prehospital settings for sepsis screenings and interventions. By identifying current trends in sepsis screening and applying these trends in prehospital settings, hospitals can be alerted about prompt intervention techniques, resulting in a decline in patient mortality rates.

Review of Literature

The PIs conducted a thorough literature review of articles published from 2014 to 2020 using the following keywords: sepsis, prehospital sepsis screening, early sepsis identification, prehospital qSOFA, qSOFA and SIRS. These keywords were utilized to evaluate sepsis screening standards in the prehospital setting. Articles included in this literature review discussed or studied screening tools for sepsis identification or sepsis risk in the prehospital setting.

Of the 22 articles identified, 12 met the criteria for this review (sepsis screening tools used in the prehospital setting). The PIs noted that very few studies addressed prehospital sepsis screening mechanisms that could be utilized by first responders. No randomized controlled trials were identified, and no studies validated any of the proposed prehospital sepsis screening tools. The PIs included all publication types and all study designs. There were no language restrictions. All publications were peer-reviewed.

Smyth et al. (2016) conducted a literature review to examine how sepsis was identified in prehospital settings. The researchers noted that early sepsis identification among first responders (i.e., EMS professionals) lacked.5 Of the 4,366 articles reviewed, the investigators only identified nine studies in the final published analysis (Smyth et al., 2016). No randomized controlled trials were included, and all studies were observational (Smyth et al., 2016). Smyth et al. (2016) noted that the selected studies provided low-quality/very low-quality evidence regarding prehospital sepsis recognition among ambulance clinicians. The researchers pointed out that sepsis recognition among EMS professionals varies greatly, thereby denoting the importance of a tailored intervention to improve recognition among providers.5

Guerra et al. (2013) conducted a pilot study to investigate a prehospital sepsis screening tool’s feasibility. The investigators designed a methodology, like a stroke or cardiac alert for standardized prehospital treatment, to identify sepsis patients. The prehospital sepsis screening tool included two components: (1) proper sepsis identification by first responders and (2) the initiation of sepsis treatment in the field. The primary objective of the pilot study was to explore if first responders could adequately identify patients who were at risk for sepsis.

Two months before the study began, 686 first responders participated in a two-hour education and training class.6 After the education and training class, first responders correctly identified and alerted the emergency room of 32 (47.8%) patients who had sepsis.6 However, the first responders did not identify 35 patients who were septic. Although not statistically significant, the researchers noted that septic patients identified by first responders received fluids sooner than non-identified patients and had a shorter hospital length of stay.6

Modified SIRS Criteria

In a retrospective cohort study, which took place from 2014 to 2015, Polito et al. (2015) explored all adult patients (18 years of age and older) who were transported to a hospital by EMS. The researchers used pre-defined criteria set to examine the risk of sepsis among all patients.7 The pre-defined criteria set, which was based on a predictive model and similar to the screenings used for stroke or heart attack, was triggered if patients had three symptoms. These three symptoms included: (1) a heart rate (HR) greater than 90 beats per minute, (2) a respiratory rate (RR) less than 20 breaths per minute, and (3) a systolic blood pressure (SBP) higher than 110mmHg.7

The criteria to establish if an individual was considered at-risk for sepsis was based on the systemic inflammatory response syndrome (SIRS) criteria. This tool has been generally used and studied on patients suspected of sepsis admitted to the hospital. Data was collected using abstracted patient charts. The primary outcome of Polito et al.’s (2015) research was measured if patients had an inpatient diagnosis of sepsis within 48 hours of hospital arrival. Of 66,439 EMS transports, 555 patients met the criteria for the study. Seventy-five patients (13.5%) had severe sepsis. Using these criteria, 14 of the 75 patients were identified by EMS.7

PRESEP Score

Bayer et al. (2015) completed a retrospective analysis of patients admitted to the emergency room after being transported by EMS. The researchers developed the Pre-hospital Early Sepsis Detection (PRESEP) score for EMS providers to utilize, screens for temperature, oxygen saturation, respiratory rate, heart rate, blood pressure, blood glucose level and Glasgow Coma Scale (GCS). Of the 375 patients who were included in this study, 93 patients had sepsis, 60 patients had severe sepsis, and 12 patients were in septic shock.8 Although the PRESEP score had a positive predictive value of 66%, the PRESEP score was not validated.

qSOFA Score

The PIs only located one study, which was carried out by Franchini and Duca (2016), that addressed the impact of the quick sepsis-related organ failure (qSOFA) score as a screening tool. The qSOFA score is a validated scoring tool used at a patient’s bedside to help providers identify if a patient is at risk for sepsis. Unfortunately, this scoring system does not screen patients with other conditions (e.g., heart failure, blood loss, pulmonary embolism).9

The qSOFA score has four criteria: (1) assigning one point for an alteration of one’s mental status, (2) using the Glasgow Coma Scale (GCS) for a score less than 15, (3) a systolic blood pressure less than or equal to 100 mmHg, and (4) respiratory rate greater than or equal to 22 per minute.10 The qSOFA, although reliable, is not validated for use in the prehospital setting.

BAS 90-30-90

The BAS 90-30-90 is a tool that utilizes an objective approach in screening for sepsis. The BAS 90-30-90 has been implemented internationally in prehospital settings. When using this tool, patients are considered septic if one or more of the three clinical indicators are positive. The three indicators include (1) an oxygen saturation level of less than 90%, (2) a respiratory rate greater than 30 breaths per minute, and (3) a systolic blood pressure less than 90.12 The BAS 90-30-90 has a 43% sensitivity in predicting sepsis.4

Robson Screening Tool

The Robson screening tool identifies and prioritizes patients in the prehospital setting who have sepsis. This tool allows for earlier intervention. Patients are considered to be septic if any of the two criteria are observed: (1) temperature greater than 38.3°C (100.9°F) or less than 36.0°C (96.8°F); (2) a heart rate greater than 90 beats per minute, (3) a respiratory rate higher than 20 breaths per minute, (4) an altered mental status (new and acute), and (5) serum glucose less than 120 mg/dL.11 While the Robson screening tool has a sensitivity score of 75%, in terms of predicting sepsis, many EMS systems are not equipped to support point of care lab testing in the prehospital setting.4

PRESS Score

The PRESS screening tool has an 86% sensitivity score and a 47% specificity score.7 This tool was developed using data collected from over 66,000 EMS transports that noted a diagnostic entry criterion of “severe sepsis.” Using univariable logistic regression analysis, Polito et al. (2015) indicated that the following findings were characteristic of sepsis: (1) temperature, (2) systolic blood pressure, (3) heart rate, (4) respiratory rate, (5) oxygen saturation, (6) glucose and (7) Glasgow Coma Scale.

The following modifications were made in the final tool description: (1) a heart rate higher than 90 beats per minute, (2) a respiratory rate higher than 20 beats per minute, and (3) a systolic blood pressure less than 110 mm/Hg. Since the PRESS scoring system is a novel tool and has only been internally studied, further research is needed to support the external validity of the findings.7

Guerra Protocol

The Guerra protocol is a sepsis alert protocol that utilizes point of care venous lactate samples. This protocol was derived from a pilot study, which investigated a prehospital sepsis screening tool’s feasibility. Through the use of quantitative evaluation, Guerra et al. (2013) screened patients as positive for sepsis if the following conditions were met: (1) if the patient was 18 years or older and was not pregnant, (2) if the patient had at least two systematic inflammatory response syndrome criteria (i.e., temperature greater than 38°C [100.4°F] or greater than 36°C [96.8°F], a pulse rate greater than 90 beats per minute, a respiratory rate greater than 20 breaths per minute or a mechanically ventilated respiratory rate), (3) a suspected or documented infection, and (4) hypoperfusion as manifested by one of the following criteria (systolic blood pressure less than 90 mm Hg, a mean arterial pressure less than 65 mm Hg, or lactate level greater than four mmol/; Guerra et al., 2013).

The study conducted by Guerra et al. (2013) was the first to use venous lactate measures to identify patients with severe sepsis. The lactate measures accurately identified patients with sepsis in 47.8% of cases. Despite the identification of patients with sepsis, through this measure, Guerra et al. (2013) noted that many EMS systems are not equipped for this level of testing.

Discussion

In the United States, sepsis is one of the leading causes of death, which requires timely identification and proper treatment (CDC, 2019; Guerra et al., 2020; Polito et al., 2015). Based upon a review of literature conducted from 2014 to 2018, the primary investigators could locate five prehospital EMS screening tools to assist EMS providers in identifying at-risk sepsis patients. The researchers explored how the modified SIRS and qSOFA scoring systems were used in hospital settings in addition to these five prehospital EMS screening tools.

The Bas 90-30-90, Guerra, PRESEP, PRESS, and Robson tools have overlapping screening protocol similarities. The PRESS score is a promising tool with an 86% sensitivity score; however, according to Polito et al. (2015), this tool needs to be duplicated and studied to validate externally. The Guerra protocol, which utilizes lactate testing, has a low sensitivity score (48%); thus, it is limiting since most EMS are not equipped with lactate testing capabilities.6 The Robson screening tool, which was adapted from the Surviving Sepsis Campaign diagnostic criteria, uses a modified system inflammatory response syndrome (SIRS) criterion.4

The Robson screening tool has a 93% sensitivity score, though it has yet to be further validated. While the BAS 90-30-90 has been used internationally, this tool lacks data and literature to support its application in a prehospital setting. Finally, the PRESEP score, derived from a retrospective analysis of septic patients, is promising; however, this tool needs prospective validity.8

Well-established sepsis screening tools, like the qSOFA score and SIRS criteria, are used in hospital-based settings. Currently, the qSOFA score is used at a patient’s bedside to identify a suspected sepsis infection and note if the patient is at risk for a poor outcome, such as organ failure or death. The SIRS criteria are used in response to a confirmed or suspected infection to identify sepsis if patients have at least two of the criteria (fever, hypothermia, tachycardia, tachypnea, leukocytosis, or leukopenia).12 The modified SIRS criteria, which was studied by Wallgren et al. (2014), did not show a promising impact. Furthermore, the Robson and Guerra protocols require instrumentation that not all EMS providers have available. A gap in the literature exists regarding an appropriate sepsis screening tool that can be utilized by EMS providers in the prehospital setting. Implementing a validated prehospital sepsis tool would provide first responders with the ability to quickly and easily assess patients in the prehospital setting for sepsis, thereby allowing providers to alert the destination point before arrival allowing for earlier intervention and treatment.

Interestingly, the qSOFA, Robson, PRESS, and PRESEP all include a mental status evaluation, evaluated using the GCS. Researchers have noted the benefits of utilizing the GCS to anticipate and detect sepsis.13–15 Applying the GCS, among other reliable findings (e.g., respiratory rate, temperature, and systolic blood pressure), could be promising in the prehospital setting. Although altered mental status can encompass many conditions, an acutely altered mental status may be a sign of infection and considered a sign of organ dysfunction (Barbara et al., 2018; Olander et al., 2019). Additionally, an altered mental status may be associated with adverse outcomes.16

Recommendations

Despite conducting a thorough literature review using peer-reviewed articles from 2014 to 2020, there is a dearth of literature evaluating prehospital sepsis screening. Prehospital sepsis screening is currently presumptive and based on clinical assessment (physical exam findings and vital signs). Notwithstanding the prevalence of sepsis, there are no gold-standard tests to screen individuals for sepsis in the prehospital setting. Further tool analysis and validation of the Robson screening tool and the PRESS score are necessary as they show promise for identifying patients at risk for sepsis in the prehospital setting.

Unfortunately, none of the tools discussed in this review have been validated for use in the prehospital setting. Additionally, because there is no validated tool, there is an opportunity to develop and study a new tool for prehospital sepsis screening by considering the predictors of sepsis. According to the CDC (2019), at least 1.7 million American adults develop sepsis annually, of which approximately 270,000 die from sepsis. Therefore, using a validated tool to screen for sepsis in the prehospital setting is critical.

A prehospital sepsis screening tool should rely on necessary assessment skills (physical exam and vital signs), should incorporate the use of equipment that is currently available to first responders (thus resulting in the affordable implementation of new processes), should be cost-effective for agencies, and be practical for use on emergency scenes.

References

  1. CDC. Data and Reports. Centers for Disease Control and Prevention. Published January 15, 2019. Accessed February 19, 2019. https://www.cdc.gov/sepsis/datareports/index.html
  2. CDC. Think Sepsis. Time Matters. Centers for Disease Control and Prevention. Published August 23, 2016. Accessed May 2, 2020. https://www.cdc.gov/vitalsigns/sepsis/index.html
  3. Femling J, Weiss S, Hauswald E, Tarby D. EMS patients and walk-in patients presenting with severe sepsis: Differences in management and outcome. Southern Medical Journal. 2014;107(12). doi:10.14423/SMJ.0000000000000206
  4. Wallgren UM, Castrén M, Svensson AEV, Kurland L. Identification of adult septic patients in the prehospital setting: a comparison of two screening tools and clinical judgment. European Journal of Emergency Medicine. 2014;21(4):260-265. doi:10.1097/MEJ.0000000000000084
  5. Smyth MA, Brace-McDonnell SJ, Perkins GD. Identification of adults with sepsis in the prehospital environment: a systematic review. BMJ Open. 2016;6(8):e011218. doi:10.1136/bmjopen-2016-011218
  6. Guerra WF, Mayfield TR, Meyers MS, Clouatre AE, Riccio JC. Early detection and treatment of patients with severe sepsis by prehospital personnel. The Journal of Emergency Medicine. 2013;44(6):1116-1125. doi:10.1016/j.jemermed.2012.11.003
  7. Polito CC, Isakov A, Yancey AH, et al. Prehospital recognition of severe sepsis: development and validation of a novel EMS screening tool. The American Journal of Emergency Medicine. 2015;33(9):1119-1125. doi:10.1016/j.ajem.2015.04.024
  8. Bayer O, Schwarzkopf D, Stumme C, et al. An early warning scoring system to identify septic patients in the prehospital setting: the PRESEP score. Academic Emergency Medicine. 2015;22(7):868-871. doi:10.1111/acem.12707
  9. Franchini S, Duca A. qSOFA should replace SIRS as the screening tool for sepsis. Critical Care. 2016;20(1). doi:10.1186/s13054-016-1562-4
  10. 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. Eckle T, ed. PLOS ONE. 2019;14(5):e0216560. doi:10.1371/journal.pone.0216560
  11. Widmeier K, Wesley K. Assessing & managing sepsis in the prehospital setting. Journal of Emergency Medical Services. 2015;39(3):9.
  12. Andaluz D, Ferrer R. SIRS, qSOFA, and organ failure for assessing sepsis at the emergency department. Journal of Thoracic Disease. 2017;9(6):1459-1462. doi:10.21037/jtd.2017.05.36
  13. Aljabran HAM, Alkhamri AM, Alwahbi AM. Glasgow coma scale in anticipation of sepsis and septic shock: review article. The Egyptian Journal of Hospital Medicine. 2017;69(6):2663-2666. doi:10.12816/0042245
  14. Freund Y, Lemachatti N, Krastinova E, et al. Prognostic accuracy of sepsis-3 criteria for on-hospital mortality among patients with suspected infection presenting to the emergency department. JAMA. 2017;317(3):301. doi:10.1001/jama.2016.20329
  15. Sheetrit E, Nissim N, Klimov D, Fuchs L, Elovici Y, Shahar Y. Temporal Pattern Discovery for Accurate Sepsis Diagnosis in ICU Patients. :10.
  16. Olander A, Andersson H, Sundler AJ, Bremer A, Ljungström L, Andersson Hagiwara M. Prehospital characteristics among patients with sepsis: a comparison between patients with or without adverse outcome. BMC Emergency Medicine. 2019;19(1):N.PAG-N.PAG. doi:10.1186/s12873-019-0255-0

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