Emergency Medical Services Care and Sepsis Trajectories

Abstract

Objective: Many sepsis patients receive initial care from prehospital Emergency Medical Services (EMS). While earlier sepsis care improves outcomes, the characteristics, care and outcomes of those treated by EMS versus those arriving directly to an emergency department (ED) are currently not detailed. We sought to determine differences in hospital presentation, course and outcomes between EMS and non-EMS patients enrolled in the Protocolized Care of Early Septic Shock (ProCESS) trial. Methods: We performed a secondary analysis of ProCESS, which studied ED patients with septic shock. EMS care was the primary exposure. We determined differences in demographics, clinical features, interventions and hospital course between EMS and non-EMS patients. Using mixed models, we determined the association between EMS care and 60-day mortality. Results: Among 1,341 patients, 826 (61.6%) received initial EMS care. EMS patients were older, more likely to be black (OR 1.49, 95% CI 1.14–1.95) or nursing home residents (5.57, 3.61–8.60), and more likely to have chronic respiratory disease (1.36, 1.04–1.78), cerebral vascular disease (1.56; 1.04–2.33), peripheral vascular disease (2.02; 1.29–3.16), and dementia (3.53; 2.04–6.10). EMS patients were more likely to present with coma (4.48; 2.53–7.96) or elevated lactate (1.30; 1.04–1.63), and to receive mechanical ventilation in the ED (7.16; 4.34–11.79). There were no differences in infection source or total intravenous fluids. Initial differences in vasopressor use (1.66; 1.22–2.26) resolved at 6 hours (1.18; 0.94–1.47). Initial differences in APACHE II (EMS 21.8 vs. non-EMS 19.0) narrowed by 48 hours (17.9 vs. 16.3, [EMS X time] interaction p = 0.003). Although EMS patients exhibited higher 60-day mortality, after adjustment for confounders, this association was not significant (1.09, 95% CI: 0.78–1.55). Conclusions: While EMS sepsis patients presented with worse chronic, nonmodifiable characteristics and higher acuity than non-EMS patients, differences in acuity narrowed after initial hospital care. Despite having higher illness burden, EMS patients did not have worse adjusted short-term mortality.