Emergency medical services care and sepsis outcomes in the protocolized care of early septic shock (PROCESS) trial
Liu R, Chaudhary N, Yealy DM, Wang HE, and Jayaprakash N. Emergency medical services care and sepsis outcomes in the protocolized care of early septic shock (PROCESS) trial. Acad Emerg Med 2019; 26:S45.
Acad Emerg Med
Background: Sepsis patients may receive initial care from Emergency Medical Services (EMS). While earlier sepsis care improves outcomes, the impact of EMS actions is unknown. We sought to determine the association of initial EMS care with hospital presentation, treatment and outcomes using the Protocolized Care of Early Septic Shock (ProCESS) trial. Methods: We performed a secondary analysis of ProCESS, which included Emergency Department (ED) patients with septic shock (suspected infection + [serum lactate ≥4.0 mg/dL or systolic blood pressure ≤90 mmHg]. We identified patients that did and did not receive initial EMS care. We determined differences between EMS and non-EMS patients, including demographics (age, race, comorbidities, nursing home residence, medical history), clinical characteristics (prehospital intravenous fluid, ED vital signs, source of infection), interventions (fluids and vasopressor use, mechanical ventilation), and course (APACHE II). Using mixed models, we determined the association between initial EMS care and 60-day mortality, adjusting for confounders. Results: Among 1,341 patients, 826 (61.6%) received initial EMS care. EMS patients were older (64 vs 57 years, p<0.001), were 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 were 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 (OR 4.48, 95% CI: 2.53-7.96) or lactate ≥4.0 mg/dL (1.30; 1.04-1.63), and to require early mechanical ventilation (7.16; 4.34-11.79). There were no differences in infection source. Initial differences in vasopressors use (EMS 19.6% vs non-EMS 12.8%, OR 1.66; 95% CI: 1.22-2.26) resolved at 6 hours (47.3 vs 43.3%, 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). Sixty-day mortality did not differ between EMS and non-EMS patients (22.6% vs. 14.0%, adjusted OR 1.09, 95% CI: 0.78-1.55). Conclusion: Despite presenting with higher acuity and comorbid features, sepsis patients receiving initial EMS care do not have worsened outcomes. EMS may play a key role in sepsis care.