Prehospital advanced life support, but not basic life support only, care was associated with faster antibiotic initiation for patients with sepsis without hypotension, according to a study published in the Annals of the American Thoracic Society.

Sepsis is a common and costly condition encountered by prehospital and emergency department (ED) clinicians and accounts for at least 800,000 ED visits, 1.7 million hospitalizations with 16% mortality, and $24 billion in costs in the United States annually. Identifying sepsis, promptly followed by aggressive management, including early antibiotic initiation, reduces sepsis mortality and progression to septic shock.

However, less than half of patients with signs of sepsis that are present on arrival to the ED currently receive antibiotics within 1 hour, the goal recommended by international guidelines from the Surviving Sepsis Campaign. Factors likely to influence ED assessment and management of sepsis differ among patients who receive no prehospital care, basic life support care, or advanced life support care. Improved knowledge of these factors that support or impede prompt antibiotic initiation for sepsis will help in the creation of highly reliable sepsis care systems. In addition, integration of prehospital and in-hospital sepsis care may also aid in more rapid sepsis diagnoses and treatment initiation. Therefore, to aid in clarification of whether and how care from emergency medical services might influence door-to-antibiotic time for patients with sepsis, this retrospective cohort study investigated the relationship between prehospital level of care and ED door-to-antibiotic time for patients with sepsis.

Between 2009 and 2015, 361 patients with fluid-refractory sepsis or septic shock from the community to an academic ED were included in this study’s cohort. Transfer patients and those whose antibiotics began before ED arrival or after ED discharge were excluded. A multivariate regression was used to evaluate the association between the time from ED arrival to antibiotic initiation and prehospital level of care. Researchers defined prehospital care as the highest level of emergency medical services (EMS) received: none, basic life support ambulance, or advanced life support ambulance. Variation in this association when hypotension was or was not present by ED arrival was also measured.

Patients who received EMS care were administered antibiotics 33 to 36 minutes earlier than walk-in patients. Further, patients treated with advanced life support care received antibiotics faster than patients who did not receive prehospital care (median, 103 minutes vs 144 minutes, respectively; P <.001), as well as when compared with patients who received basic life support care (103 minutes vs 168 minutes; P <.001). After multivariate adjustment, this pattern was still present, in which advanced life support care (−43 minutes; P =.033) was associated with shorter time to antibiotic therapy initiation compared to patients who did not receive prehospital care, but basic life support only care (−4 minutes; P =.97) was not. Patients who received advanced life support care received antibiotics within an average of 3 hours of ED arrival (91%) compared with walk-in patients (62%; P =.015) or basic life support-treated patients (56%; P <.001). In addition, in the absence of hypotension on arrival at the ED, patients who received prehospital advanced life support were also administered antibiotics faster than walk-in patients (−41 min; P =.009), but not when hypotension was present (+25 min; P =.66).

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Overall, the study authors concluded that, “Our findings suggest possible opportunities to optimize ED care processes to aid delivery of high-quality sepsis care in the ED.”

Reference

Peltan ID, Mitchell KH, Rudd KE, et al. Prehospital care and emergency department door-to-antibiotic time in sepsis [published online August 28, 2018]. Annals ATS. doi: 10.1513/AnnalsATS.201803-199OC