A comparison of screening tools for the early identification of sepsis among EMS patients transported to an urban safety net hospital Open Access

Abstract

BACKGROUND: Sepsis is a leading cause of death in the United States and is the most common cause of death in ICU patients. The majority of patients hospitalized for sepsis are admitted through emergency departments (EDs), and nearly half of those are transported to the hospital by emergency medical services (EMS). The purpose of this study is to determine if the Prehospital Severe Sepsis (PRESS) score and quick Sepsis-related Organ Failure Assessment (qSOFA) are useful for identifying septic patients in emergency settings.
STUDY POPULATION: The sample consisted of two cohorts of adult patients transported by EMS to Grady Memorial Hospital in Atlanta, GA between January 2011 and December 2012. Patients were excluded for cardiac arrest, trauma, toxic ingestion, pregnancy, or psychiatric emergency and were stratified into two groups at either high or low risk of sepsis. Patients whose EMS vitals included heart rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min, and systolic blood pressure less than 110 mm Hg were considered high-risk; all else were low-risk.
METHODS AND RESULTS: Thirty-one (27%) of high-risk patients and 12 (2.2%) of low-risk patients had sepsis (p-value <.0001), determined by inpatient diagnosis within 48 hours of hospital arrival. For both cohorts, patient vitals changed between the field and ED, though Glasgow Coma Scale scores did not change (p-values .42 and .81). We retrospectively screened patients with a modified version of PRESS in the field and qSOFA in the ED. Among high-risk patients, PRESS was 90% sensitive and 22% specific; in low-risk patients it was 83% sensitive and 17% specific. qSOFA was 41% sensitive and 88% specific in high-risk patients, and 17% sensitive and 98% specific in low-risk patients. Agreement between screening tools was low, but best for high-risk patients with sepsis (Kappa=0.15, p-value <.0001). Among patients misclassified by either tool, mean heart rate was the most common difference between those with and without sepsis.
CONCLUSION: Further studies are needed to validate PRESS and qSOFA for emergency sepsis screening. PRESS is limited by low specificity, and qSOFA may be unreliable in patients transported by EMS due to low sensitivity

Table of Contents

Table of Contents -- 1. Background/Literature Review…1 -- 1a. Introduction...1 -- 1b. Pathophysiology…2 -- 1c. Epidemiology and Public Health Impact...8 -- 1d. Definitions…11 -- e. Future Directions…15 -- 2. Abstract…16 -- 3. Introduction…17 -- 4. Methods…22 -- 5. Results…27 -- 6. Discussion…30 -- 7. Conclusion…32 -- 8. Tables and Figures…33 -- 9. References…42 -- 10. Summary, Implications, and Future Directions...49

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology
Keyword	sepsis Prehosital Severe Sepsis Score quick Sepsis-related Organ Failure Assessment
Committee Chair / Thesis Advisor	Marcus, Michele, Emory University
Committee Members	Polito, Carmen, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs Hospital or other health care provider

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