Severe sepsis in pre-hospital emergency care: analysis of incidence, care, and outcome

Abstract

Rationale: Severe sepsis is common and highly morbid, yet the epidemiology of severe sepsis at the frontier of the health care system-pre-hospital emergency care-is unknown.

Objectives: We examined the epidemiology of pre-hospital severe sepsis among emergency medical services (EMS) encounters, relative to acute myocardial infarction and stroke.

Methods: Retrospective study using a community-based cohort of all nonarrest, nontrauma King County EMS encounters from 2000 to 2009 who were transported to a hospital.

Measurements and main results: Overall incidence rate of hospitalization with severe sepsis among EMS encounters, as well as pre-hospital characteristics, admission diagnosis, and outcomes. Among 407,176 EMS encounters, we identified 13,249 hospitalizations for severe sepsis, of whom 2,596 died in the hospital (19.6%). The crude incidence rate of severe sepsis was 3.3 per 100 EMS encounters, greater than for acute myocardial infarction or stroke (2.3 per 100 and 2.2 per 100 EMS encounters, respectively). More than 40% of all severe sepsis hospitalizations arrived at the emergency department after EMS transport, and 80% of cases were diagnosed on admission. Pre-hospital care intervals, on average, exceeded 45 minutes for those hospitalized with severe sepsis. One-half or fewer of patients with severe sepsis were transported by paramedics (n = 7,114; 54%) or received pre-hospital intravenous access (n = 4,842; 37%).

Conclusions: EMS personnel care for a substantial and increasing number of patients with severe sepsis, and spend considerable time on scene and during transport. Given the emphasis on rapid diagnosis and intervention for sepsis, the pre-hospital interval may represent an important opportunity for recognition and care of sepsis.

Figure 1.

Patient accrual diagram. EMS = emergency medical services.

Figure 2.

Temporal changes in the rates of hospitalizations with severe sepsis among emergency medical services (EMS) encounters, adjusted for age, sex, and receiving hospital. A comparison with acute myocardial infarction (AMI) and stroke is provided for context. Error bars represent 95% confidence intervals. Solid circles, severe sepsis; gray triangles, AMI; gray squares, stroke.

Figure 3.

(A) Absolute number of deaths and (B) adjusted case fatality rate among emergency medical services (EMS) encounters hospitalized with severe sepsis. Adjusted models include age, sex, Charlson Comorbidity Index, receiving hospital, and a pre-hospital clinical risk score for critical illness. A comparison with acute myocardial infarction and stroke is provided for context. Solid circles, severe sepsis; gray triangles, AMI; gray squares, stroke.