Advertisement

The early chain of care in bacteraemia patients: Early suspicion, treatment and survival in prehospital emergency care

Published:April 05, 2018DOI:https://doi.org/10.1016/j.ajem.2018.04.004

      Abstract

      Introduction

      Bacteraemia is a first stage for patients risking conditions such as septic shock. The primary aim of this study is to describe factors in the early chain of care in bacteraemia, factors associated with increased chance of survival during the subsequent 28 days after admission to hospital. Furthermore, the long-term outcome was assessed.

      Methods

      This study has a quantitative design based on data from Emergency Medical Services (EMS) and hospital records.

      Results

      In all, 961 patients were included in the study. Of these patients, 13.5% died during the first 28 days. The EMS was more frequently used by non-survivors. Among patients who used the EMS, the suspicion of sepsis already on scene was more frequent in survivors. Similarly, EMS personnel noted the ESS code “fever, infection” more frequently for survivors upon arriving on scene. The delay time from call to the EMS and admission to hospital until start of antibiotics was similar in survivors and non-survivors. The five-year mortality rate was 50.8%. Five-year mortality was 62.6% among those who used the EMS and 29.5% among those who did not (p < 0.0001).

      Conclusion

      This study shows that among patients with bacteraemia who used the EMS, an early suspicion of sepsis or fever/infection was associated with improved early survival whereas the delay time from call to the EMS and admission to hospital until start of treatment with antibiotics was not. 50.8% of all patients were dead after five years.

      Keywords

      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Bone R.C.
        • Balk R.A.
        • Cerra F.B.
        • Dellinger R.P.
        • Fein A.M.
        • Knaus W.A.
        Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee.
        Chest. 1992; 101: 1644-1655
        • Seymour W.C.
        • Rea T.D.
        • Kahn J.M.
        • Walkey A.J.
        • Yealy D.M.
        • Angus D.C.
        Severe sepsis in pre-hospital emergency care. Analysis of incidence, care, and outcome.
        Am J Respir Crit Care Med. 2012; 186: 1264-1271
        • Singer M.
        • Deutschman C.S.
        • Seymour C.W.
        • Shankar-Hari M.
        • Annane D.
        • Bauer M.
        • et al.
        The third international consensus definitions for sepsis and septic shock (sepsis-3).
        JAMA. 2016; 315: 801-810
        • Wang H.E.
        • Weaverb M.D.
        • Shapiroc N.I.
        • Yealy D.M.
        Opportunities for emergency medical services care of sepsis.
        Resuscitation. 2010; 81: 193-197
        • Studnek J.R.
        • Artho M.R.
        • Garner C.L.
        • Jones A.E.
        The impact of emergency medical services on the ED care of severe sepsis.
        Am J Emerg Med. 2012; 30: 51-56
        • Andersson Hagiwara M.
        Development and evaluation of computerised decision support system for use in pre-hospital care.
        (Dissertation) Jönköping University, Jönköping2014
        • Edman-Wallér J.
        • Ljungström L.
        • Jacobsson G.
        • Andersson R.
        • Werner M.
        Systemic symptoms predict presence or development of severe sepsis and septic shock.
        Infect Dis. 2016; 48: 209-214
        • Robson W.
        • Nutbeam T.
        • Daniels R.
        Sepsis: a need for prehospital intervention?.
        Emerg Med J. 2009; 26: 535-538
        • Gårdlund B.
        • Cronqvist J.
        • Follin P.
        • Furebring M.
        • Gille-Johnson P.
        • Sjölin J.
        Severe sepsis and septic shock requires immediate care (in Swedish).
        Lakartidningen. 2011; 108: 271-275
        • Guerra W.F.
        • Mayfield T.R.
        • Meyers M.S.
        • Clouatre A.E.
        • Riccio J.C.
        Early detection and treatment of patients with severe sepsis by prehospital personnel.
        J Emerg Med. 2013; 44: 1116-1125
        • Ferrer R.
        • Martin-Loeches I.
        • Phillips G.
        • Osborn T.M.
        • Townsend S.
        • Dellinger R.P.
        • et al.
        Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program.
        Crit Care Med. 2014; 42: 1749-1755
        • Kumar A.
        • Roberts D.
        • Wood K.
        • Light B.
        • Parrillo J.
        • Sharma S.
        • et al.
        Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.
        Crit Care Med. 2006; 34: 1589-1596
        • Seymour C.W.
        • Gesten F.
        • Prescott H.C.
        • Friedrich M.E.
        • Iwashyna T.J.
        • Phillips G.S.
        • et al.
        Time to treatment and mortality during mandated emergency care for sepsis.
        N Engl J Med. 2017; 376: 2235-2244
        • Herlitz J.
        • Bång A.
        • Wireklint Sundström B.
        • Axelsson C.
        • Bremer A.
        • Hagiwara M.
        • et al.
        Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care.
        Scand J Trauma Resusc Emerg Med. 2012; 20: 42
        • Groenewoudt M.
        • Roest A.A.
        • Leijten F.
        • Stassen P.M.
        Septic patients arriving with emergency medical services: a seriously ill population.
        Eur J Emerg Med. 2014; 21: 330
        • Axelsson C.
        • Herlitz J.
        • Karlsson A.
        • Sjöberg H.
        • Jiménez-Herrera M.
        • Bång A.
        • et al.
        The early chain of care in patients with bacteraemia with the emphasis on the prehospital setting.
        Prehosp Disaster Med. 2016; 31: 272-277
        • Seymour C.W.
        • Band R.B.
        • Cooke C.R.
        • Mikkelsen M.E.
        • Hylton J.
        • Rea T.D.
        • et al.
        Out-of hospital characteristics and care of patients with severe sepsis: a cohort study.
        J Crit Care. 2010; 25: 553-562
        • Seymour C.W.
        • Carlbom D.
        • Engelberg R.A.
        • Larsen J.
        • Bulger E.M.
        • Copass M.K.
        • et al.
        Understanding of sepsis among emergency medical services: a survey study.
        J Emerg Med. 2012; 42: 666-677
        • Sjölin H.
        • Lindström V.
        • Hult H.
        • Kurland L.
        What an ambulance nurse needs to know: a content analysis of curricula in the specialist nursing programme in prehospital emergency care.
        Int Emerg Nurs. 2015; 23: 127-132
        • Suserud B.-J.
        A new profession in the pre-hospital care field- the ambulance nurse.
        Nurs Crit Care. 2005; 10: 269-271
        • The National Board of Health and Welfare
        Regulations on ambulance care (SOSFS 2009:10).
        (In Swedish) The National Board of Health and Welfare, Stockholm2009
        • Polito C.C.
        • Isakov A.
        • Yancey I.I.A.H.
        • Wilson D.K.
        • Anderson B.A.
        • Bloom I.
        • et al.
        Prehospital recognition of severe sepsis: development and validation of a novel EMS screening tool.
        Am J Emerg Med. 2015; 33: 1119-1125
        • Widgren B.
        RETTS - emergency care directly.
        (in Swedish) Lund, Studentlitteratur2012
        • Widgren B.R.
        • Jourak M.
        Medical emergency triage and treatment system (METTS): a new protocol in primary triage and secondary priority decision in emergency medicine.
        J Emerg Med. 2011; 40: 623-628
        • The National Archives
        The Swedish register of deaths.
        The National Archives, Stockholm2017
        • Mehl A.
        • Åsvold B.O.
        • Lydersen S.
        • Paulsen J.
        • Solligård E.
        • Damås J.K.
        • et al.
        Burden of bloodstream infection in an area of mid-Norway 2002–2013: a prospective population-based observational study.
        BMC Infect Dis. 2017; 17: 205
        • Roest A.A.
        • Stoffersa J.
        • Pijpersb E.
        • Jansenc J.
        • Stassena P.M.
        Ambulance patients with nondocumented sepsis have a high mortality risk: a retrospective study.
        Eur J Emerg Med. 2017; 24: 36-43
        • Band R.A.
        • Gaieski D.F.
        • Hylton J.H.
        • Shofer F.S.
        • Goyal M.
        • Meisel Z.F.
        Arriving by emergency medical services improves time to treatment endpoints for patients with severe sepsis or septic shock.
        Acad Emerg Med. 2011; 18: 934-940
        • Naghavi M.
        • Wang H.
        • Lozano R.
        • Davis A.
        • Liang X.
        • Zhou M.
        • et al.
        Global, regional, and national age sex specific all-cause and cause-specific mortality for 240 causes of death, 1990 2013: a systematic analysis for the Global Burden of Disease Study 2013.
        Lancet. 2015; 385: 117-171
        • Gotland N.
        • Uhre M.L.
        • Mejer N.
        • Skov R.
        • Petersen A.
        • Larsen A.R.
        • et al.
        Long-term mortality and causes of death associated with Staphylococcus aureus bacteremia. A matched cohort study.
        J Inf Secur. 2006; 73: 346-357
        • Nielsen S.L.
        • Lassen A.T.
        • G K.O.
        • Jensen T.G.
        • Kolmos H.J.
        • Hallas J.
        • et al.
        Bacteremia is associated with excess long-term mortality: a 12-year population-based cohort study.
        J Inf Secur. 2015; 70: 111-126
        • Weinstein M.P.
        • Towns M.L.
        • Quartey S.M.
        • Mirrett S.
        • Reimer L.G.
        • Parmigiani G.
        • et al.
        The clinical significance of positive blood cultures in the 1990s: a prospective comprehensive evaluation of the microbiology, epidemiology, and outcome of bacteremia and fungemia in adults.
        Clin Infect Dis. 1997; 24: 584-602
        • Sundén-Cullberg J.
        • Rylance R.
        • Svefors J.
        • Norrby-Teglund A.
        • Björk J.
        • Inghammar M.
        Fever in the emergency department predicts survival of patients with severe sepsis and septic shock admitted to the ICU.
        Crit Care Med. 2017; 45: 591-599
        • Bohm K.
        • Kurland L.
        • Bartholdson S.
        • Castrèn M.
        Descriptions and presentations of sepsis - a qualitative content analysis of emergency calls.
        Int Emerg Nurs. 2015; 23: 294-298
        • Wallgren U.M.
        • Bohm K.
        • Kurland L.
        Presentations of adult septic patients in the prehospital setting as recorded by emergency medical services: a mixed methods analysis.
        Scand J Trauma Resusc Emerg Med. 2017; 25: 23
        • Bayer O.
        • Schwarzkopf D.
        • Stumme C.
        • Stacke A.
        • Hartog C.S.
        • Hohenstein C.
        • et al.
        An early warning scoring system to identify septic patients in the prehospital setting: the PRESEP score.
        Acad Emerg Med. 2015; 22: 868-871
        • Lane D.
        • Ichelson R.
        • Drennan I.
        • Scales D.
        Prehospital management and identification of sepsis by emergency medical services: a systematic review.
        Emerg Med J. 2016; 33: 408-413
        • Chen N.-C.
        • Hsieh M.-J.
        • Tang S.-C.
        • Chiang W.-C.
        • Huang K.-Y.
        • Tsai L.-K.
        • et al.
        Factors associated with use of emergency medical services in patients with acute stroke.
        Am J Emerg Med. 2013; 31: 788-791
        • Robson W.
        • Newell J.
        Assessing, treating and managin patients with sepsis.
        Nurs Stand. 2005; 19: 56-64
        • Swedish EMS managers' organization
        National treatment guidelines for EMS services.
        (in Swedish) Swedish EMS managers' organization, Stockholm2011
        • Gilbert E.H.
        • Lowenstein S.R.
        • KozioI-McLain J.
        • Barta D.C.
        • Steiner J.
        Chart reviews in emergency medicine research: where are the methods?.
        Ann Emerg Med. 1996; 27: 305-308
        • Opal S.M.
        • Garber G.E.
        • LaRosa S.P.
        • Maki D.G.
        • Freebairn R.C.
        • Kinasewitz G.T.
        • et al.
        Systemic host responses in severe sepsis analyzed by causative microorganism and treatment effects of drotrecogin alfa (activated).
        Clin Infect Dis. 2003; 37: 50-58