Impact of Prehospital Care on Outcomes in Sepsis

A Systematic Review

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


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

In This Article


Study Inclusion

Database searches yielded 4,366 citations. Duplicate citations were removed manually within EndNote® (version X7 Thompson Scientific, Carlsbad, CA) by a single reviewer (MAS) providing 2,958 unique citations. One citation was identified by contacting subject experts. After the first stage of screening 79 citations were retained and 2,880 citations were rejected. Inter-rater agreement for first stage screening, calculated using Cohens kappa statistic, was 0.87 (95% CI [0.81 to 0.92]). During the second stage of screening 79 manuscripts were reviewed; 70 were discarded following assessment and nine were retained for critical appraisal (Figure). Inter-rater agreement for second stage screening, calculated using Cohens Kappa, was 0.88 (95% CI [0.72 to 1.0]).

Figure 1.

PRISMA flow chart.
PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

No additional citations were identified by scrutinizing the reference lists of included manuscripts. One additional study,25 a manuscript pending publication (subsequently published), was identified by contacting subject experts. In total nine studies are included in the final analysis (Figure).

Characteristics Of Included Studies

Characteristics of included studies, comprising 3,470 patients in total, are summarised in the Table 1.

Risk Of Bias Findings

Risk of bias assessments are reported in Table 2 and Table 3.

Quality Of Evidence Findings

We identified very low quality evidence from one randomized controlled trial (downgraded for risk of bias, indirectness and imprecision), and very low quality evidence from eight observational studies (downgraded for risk of bias, indirectness and imprecision across studies, see supplementary information for evidence table with quality assessment.)

Data Synthesis

There was considerable variation in the methodological approach adopted across the studies as well the outcome measures reported. The majority of studies identified involve limited numbers of participants, without comparable control and intervention cohorts. Because of these differences, the studies did not answer a unique research question thus meta-analysis was not appropriate. A narrative approach to data synthesis was adopted.

Data Extraction

The data from included studies were extracted and entered into the evidence table (see Appendix A) and summary of findings table (Table 4) by a single reviewer (MAS) and verified by a second reviewer (SJBM).