These patients will need advanced pharmacological intervention that may include vasopressors, corticosteroids, anticoagulants and immune stimulants to maintain organ perfusion, reverse the inflammation cycle and avoid multiple organ failure. Even with rapid admission and treatment in the ICU, more than half these patients will continue into multiple organ failure and die.9
Sepsis can evolve rapidly. The first key to reducing mortality is identifying severe sepsis candidates early in the disease progression and initiating early goal-directed therapy. That's where prehospital caregivers come into play.
PREHOSPITAL ROLE IN EARLY RECOGNITION
When Christiana Care Health Services of Wilmington, DE, initiated a systemwide sepsis alert program focused on educating all caregivers in early recognition and rapid treatment of sepsis patients, leaders learned two important lessons. The first was that while medical providers throughout the facility received sepsis-recognition training, 85% of new sepsis patients were identified in the emergency room. The bulk of early sepsis recognition rested squarely on the shoulders of the facilities' emergency services.13
The second was that early goal-directed therapy could be remarkably effective. Since the program's implementation, Christiana has cut its severe sepsis mortality rate in half--from 61.7% to 30.2%. The program also achieved a 34% decrease in average length of stay and a 188% increase in the number of patients discharged directly home. Those results won the Joint Commission's prestigious Ernest Amory Codman award.13
Guerra was inspired by those results to try to take the concept even further. "We asked ourselves," he says, "if giving fluids early is so important in the treatment process, is there an opportunity to push that out even further into the field? Using the early goal-directed therapy concept used by [Dr. Emanuel] Rivers,14 could we use those criteria to identify patients with sepsis and institute the fluid bolus earlier? Would that make any change?"
Today, under the guidance of Riccio and Guerra, prehospital services like Colorado's South Metro Fire Rescue are implementing a field sepsis alert program that puts EMTs and paramedics at the front lines of early sepsis recognition and care.
The sepsis alert field criteria are similar to those used inside the receiving facilities. When patients meet the alert criteria, field providers activate the sepsis team prior to arrival, just like a stroke or cardiac alert program. But the reception at the hospital is markedly different.
"The patient goes to a room large enough to put in a central line," says Guerra. "They get a monitored room. Ultrasound will be there, with a physician, a nurse and a lab technician to draw cultures. A respiratory therapist will be there to help with the airway or run the stat venous lactate. And a nursing supervisor is there to help get us an ICU bed."
This team is ready to continue the early goal-directed therapy initiated by the field providers, who've already begun the most critical early steps, identification and aggressive fluid resuscitation. With this design, field providers are able to mobilize significant resources to benefit their patient. But none of it means anything if we can't identify the severe sepsis patient early in their presentation.
TUNING IN TO SEPSIS
Sepsis is not a simple process to identify. Early in the cycle, patients can look much like your run-of-the-mill sick person. Core temperatures can be high or low. The patient may be aware they're fighting an infection, but not always.
Whether or not your EMS system currently has a sepsis alert program, recognizing patients transitioning into severe sepsis is an important clinical skill. Here are some guidelines.