Impact of Prehospital Care on Outcomes in Sepsis

A Systematic Review

Michael A Smyth, MSc; Samantha J Brace-McDonnell, MSc; Gavin D Perkins, MD

Disclosures

Western J Emerg Med. 2016;17(4):427-437. 

In This Article

Abstract and Introduction

Abstract

Introduction: Sepsis is a common and potentially life-threatening response to an infection. International treatment guidelines for sepsis advocate that treatment be initiated at the earliest possible opportunity. It is not yet clear if very early intervention by ambulance clinicians prior to arrival at hospital leads to improved clinical outcomes among sepsis patients.

Methoda: We systematically searched the electronic databases MEDLINE, EMBASE, CINAHL, the Cochrane Library and PubMed up to June 2015. In addition, subject experts were contacted. We adopted the GRADE (grading recommendations assessment, development and evaluation) methodology to conduct the review and follow PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations to report findings.

Results: Nine studies met the eligibility criteria – one study was a randomized controlled trial while the remaining studies were observational in nature. There was considerable variation in the methodological approaches adopted and outcome measures reported across the studies. Because of these differences, the studies did not answer a unique research question and meta-analysis was not appropriate. A narrative approach to data synthesis was adopted.

Conclusion: There is little robust evidence addressing the impact of prehospital interventions on outcomes in sepsis. That which is available is of low quality and indicates that prehospital interventions have limited impact on outcomes in sepsis beyond improving process outcomes and expediting the patient's passage through the emergency care pathway. Evidence indicating that prehospital antibiotic therapy and fluid resuscitation improve patient outcomes is currently lacking.

Introduction

Sepsis is a common and potentially life-threatening response to an infection.[1] There are an estimated 150,000 cases of severe sepsis resulting in more than 44,000 deaths each year in the United Kingdom (UK).[2] It has been reported that over 70% of sepsis cases stem from the community[3] with one study suggesting two-thirds of severe sepsis cases are initially seen in the emergency department (ED).[2] Approximately half of all ED sepsis patients will arrive via emergency medical services (EMS).[5–10] Sepsis patients transported to the ED by EMS are likely to be sicker than those arriving by other means,[6,8–11] with up to 80% of severe sepsis patients admitted to intensive care from the ED having been transported by EMS.[7,12]

International treatment guidelines for sepsis advocate that treatment be initiated at the earliest possible opportunity.[1] It has been argued that early intervention by ambulance clinicians prior to arrival at the ED may lead to improved outcomes among sepsis patients[13] in the same manner as EMS intervention has helped to improve outcomes for other time critical, life-threatening conditions such as acute myocardial infarction,[14] stroke,[15] and major trauma.[16]

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