Prehospital sepsis care in Ireland: an audit

Study setting

The study population were patients attended by Dublin Fire Brigade's (DFB) fire-based EMS service. It operates one of the two public, government-funded ambulance services in Ireland. It serves the people of Dublin city and county, which have a total population of 1.2 million. DFB employs both paramedic and advanced paramedic practitioners, all of whom are registered with the Pre-Hospital Emergency Care Council (PHECC), the national regulator for prehospital care.

In Ireland, there are national prehospital clinical practice guidelines (CPGs) that emergency medical technicians, paramedics and advanced paramedics for statutory, voluntary and auxiliary agencies should follow so that all patients are treated to the same standard irrespective of the organisation providing care.

PHECC-registered paramedics undergo a 2-year training programme and can administer 26 medications. PHECC-registered advanced paramedics can deliver advanced life support (including intubation, intravenous (IV) or intraosseous cannulation) and administer 45 medications (PHECC, 2017).

PHECC's medical advisory committee, which comprises prehospital practitioners and medical doctors, devise the CPGs. The sepsis CPG for paramedics and advanced paramedics was devised in conjunction with Ireland's Health Service Executive's (HSE) sepsis steering committee (HSE, 2018) as part of an integrated national approach to sepsis recognition and management. CPGs are periodically reviewed and updated.

When a patient or bystander in Dublin city or county calls 999, 112 or 911, their call is answered by the DFB eastern regional control centre (ERCC) call-takers and dispatchers using a scripted medical priority dispatch system that codes the calls. DFB has been using the International Academy of Emergency Medical Dispatch (IAEMD) Advanced Medical Priority Dispatch System (AMPDS) as its call-management system since 2004. The ERCC has been accredited by the IAEMD since 2006 (IAEMD, 2020). AMPDS is supported by the PHECC's priority dispatch committee.

This call-management system both classifies the chief complaint of the call and allocates a call priority. The call is categorised by urgency of response required or call priority as an echo, delta, charlie, bravo, alpha or omega call. Echo and delta calls have the highest priority and alpha and omega calls are the lowest priority. In Ireland, the EMS response (which includes vehicle type, practitioner level and response time) is determined by the PHECC priority dispatch committee (Table 1). The nature of the patient's complaint is categorised into chief complaint call codes (Warner et al, 2014).

All patients consenting to transport are brought to an emergency department. There are six adult and three paediatric emergency departments in Dublin.

Treatment provided

Table 3 and Table 4 outline the care given to adult and paediatric patients, practitioner clinical level and pre-alert information. Where all the time points were accurately recorded (69% n=41), the median time from arrival on scene to hospital arrival was 22 minutes (range 9–44 minutes).

AMPDS call prioritisation

Interrogation of dispatch data showed that 28 patients (48%) were prioritised as delta (high priority), 19 (32%) were prioritised as alpha or omega (lowest priority) and, of the latter, 37% were classified as having ‘potential severe sepsis’ (Table 5).

AMPDS chief complaint

Further interrogation showed that the chief complaints most common in adults were ‘breathing problems’ and ‘sick person’ (33% and 26% respectively) and the incidence was higher in those with potential severe sepsis (40% and 33%) (Table 6). In children, convulsion/fitting was the predominant chief complaint (Table 7).

Sepsis recognition

Defining sepsis is complex. Sepsis is not a specific illness but a syndrome with a still-uncertain pathobiology. At present, it can be identified by a constellation of clinical signs and symptoms in a patient with suspected infection (Singer et al, 2016). The International Task Force on Sepsis recognises that sepsis is a syndrome without a validated criterion standard diagnostic test, and this key deficit that has led to major variations in reported incidence and mortality rates (Singer et al, 2016). The definitions of potential sepsis and potential severe sepsis used in this audit reflect the arbitrary nature of defining the sepsis spectrum.

The authors had to consider several variables to allow the accurate capture of potential sepsis from the PCR as, at the time of the audit, there was no option to record ‘sepsis’ as a ‘clinical impression’ on the PCR. This meant that the investigators had to consider data from several sources in deciding whether the patient had potential sepsis or potential severe sepsis. Patient follow-up to confirm the diagnosis was not practical as the patients were brought to nine hospitals and patients do not have individual health identifier numbers in Ireland. This was also outside the scope of an audit.

The recording of key vital signs on the PCR was high, with 95% of patients having four or more vital signs documented. This was in keeping with similar paramedic data from the UK and exceeded vital sign recording by GPs in the same study (NCEPOD, 2015). It differed from Dutch data, which showed that vital signs were not routinely assessed (Groenwoudt et al, 2014).

The free-text comments on the PCR (such as ‘SIRS response’, ‘severe sepsis’ and ‘at risk’) reflect the effectiveness of having specific clinical practice guidelines for sepsis and sepsis-specific paramedic training. This contrasts with the previously cited opinion that paramedic education programmes have not focused sufficient attention on sepsis (Smyth et al, 2016).

The difficulties in identifying patients with potential sepsis from the PCR was fed back to the PHECC by the study authors via the medical advisory committee. As a result of this, a revised edition of the PHECC's PCR clinical practice guidelines now includes sepsis as a clinical impression (PHECC, 2019). These changes may assist future research and audit.

Sepsis treatment

Once sepsis is recognised, the clinical practice guideline in Ireland focuses on the Give 3 element of the Sepsis Six bundle, that is, oxygen, antibiotics and IV fluids (Department of Health, 2014). This study demonstrated that 21% of adult patients received oxygen, none received antibiotics and 2% received IV fluids. Seymour et al's (2012) retrospective study of patients with severe sepsis showed that 37% had IV access and 72% were given oxygen. There was no reference to IV antibiotics. Casu and Häske's (2016) survey of medical directors of a physician-delivered EMS in Germany showed that 25.6% of respondents had antibiotics on EMS vehicles (most commonly ceftriaxone) and 10.3% of rescue districts had an algorithm for patients with sepsis. Groenewoudt et al's (2014) study of patients with sepsis arriving by EMS in the Netherlands showed treatment (oxygen and or IV fluids) was started in 43.6% of patients with no reference to antibiotic use.

For patients with septic shock, hospital evidence from large clinical trials shows that mortality increases with every hour delay in administering appropriate antibiotics (Kumar et al, 2006; Ferrer et al, 2014). If the goal of treatment in patients with septic shock is early antibiotics, then prehospital administration of antibiotics may reduce the time to antibiotics if prehospital on-scene times are prolonged. This would require that paramedics trained in IV cannulation and IV antibiotic administration be tasked to look after patients with potential sepsis.

Many of the patients with potentially severe sepsis in this audit did not receive IV fluids or antibiotics, although these were permitted by the clinical practice guidelines. Further interrogation of the data demonstrated that the majority of patients were treated by paramedics, not advanced paramedics, so these interventions were outside of their scope of practice. It can be argued that, because of the urban nature of work of DFB firefighter paramedics, prehospital IV antibiotics and fluids are less important because on-scene and travel times are short (the median total prehospital time is 22 minutes) which means sepsis treatment is prompt, usually starting within 60 minutes.

Seymour et al's (2012) study in King County in Washington State showed the average prehospital time was 45 minutes, including 12.6 minutes average travel time. Ideally, EMS systems would ensure the resources needed for patients with sepsis reflect the local organisation of EMS care and the communities they serve, to ensure timely administration of IV fluids and antibiotics whether in a prehospital or hospital setting.

One key step in this process is pre-alerting the receiving hospital to the incoming patient and this audit demonstrated that 14% of adults and no children had pre-alert messages. All emergency departments served by DFB can already accept pre-alert information. Since this audit was performed, national pre-alert criteria have been agreed and these include sepsis for pre-arrival notification.

Medical dispatch call prioritisation and classification

If IV fluids and antibiotics are to be administered prehospitally, medical dispatch systems should ideally recognise potential sepsis, allocate a high call priority and deploy practitioners who have the scope of practice to administer both of these.

UK data demonstrate that 51.9% of critically ill patients with sepsis are brought to hospital by ambulance (NCEPOD, 2015). Seymour et al (2012) calculated that 40% of all patients hospitalised with severe sepsis arrived in the emergency department by EMS transport. This audit of more than 1500 patients suggests an incidence of potential sepsis/severe sepsis of 3.7%, demonstrating that this illness forms a considerable volume of emergency ambulance calls in Dublin.

It is concerning that one-third of patients in this study had a low alpha or omega call priority and, within this cohort, 37% (7/19) were classified as having ‘potential severe sepsis’. This finding is in keeping with international practice; Groenewoudt (2014) found that half of EMS transports for sepsis were not considered urgent, even in the 34.6% of patients with septic shock and Seymour et al (2012) found that 30% of patients with severe sepsis were given a non-urgent call priority.

It is imperative that EMS call prioritisation systems consider sepsis if further improvements in sepsis morbidity and mortality are to be made. In the UK, NICE (2016) guidelines recommend that ‘all people with suspected sepsis outside acute hospital settings be referred to emergency medical care by the most appropriate means (usually 999 ambulance) if they have any high-risk criteria’. However, many international sepsis guidelines overlook the prehospital arena (NICE, 2016; Singer et al, 2016; HSE, 2017), and so are neglecting an area where considerable improvements in direct patient care could be made. It is incumbent on the prehospital community now to drive these changes.

Call-taking and dispatch systems can be medical priority dispatch system (MPDS), used mainly in Anglo-Saxon countries, or a criteria-based dispatch (CBD) used in Nordic and European countries (Bohm and Kurland, 2018). Recognition of sepsis and call prioritisation are challenges in both call-taking systems. Pedersen et al's (2017) observational study of dispatch and prehospital transport of acutely septic patients found that the Danish EMS CBD system did not have sepsis-specific descriptors available and patients with non-specific complaints were twice as likely as others to get a low-priority dispatch code. Polito et al (2015) showed that 40% of patients with sepsis had a chief complaint of sick person and 23% had breathing difficulties, similar to these audit findings. Smyth et al (2016) propose that validated criteria are needed at the call-taking stage of the patient journey to identify potential sepsis if a timely response with appropriately skilled practitioners is to be deployed.

A starting point may be a review of the determinant descriptors and priority symptoms. Frequent call codes in adults are breathing problems and sick person, and convulsion/fitting in children. The NICE (2016) sepsis guideline states that those particularly at risk of sepsis are infants and young children, immunocompromised people (including those being treated for cancer), people who have recently had surgery, those with indwelling medical lines or devices and women following childbirth. Polito et al's (2015) study on the prehospital recognition of sepsis recognised six EMS characteristics, four of which could be determined by call-takers.

The authors of this study propose that additional discriminators, such as those in the NICE (2016) guideline, may assist in recognising patients with sepsis (Box 1) and patients at the extremes of age should be allocated a higher call priority.

Call-taker determinants that indicate a high risk of sepsis