The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–5, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.12.066
Selected Topics: Prehospital Care A SURVEY OF THE COMPETENCY OF AMBULANCE SERVICE PERSONNEL IN THE DIAGNOSIS AND MANAGEMENT OF SEPSIS Nobuaki Shime, MD, PHD Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan Reprint Address: Nobuaki Shime, MD, PHD, Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fushimi-ku, Kyoto 612-8555, Japan
, Abstract—Background: Few studies have evaluated the current status of knowledge of sepsis in ambulance service personnel. Objective: Our aim was to ascertain the levels of competency and proficiency of ambulance service personnel in the diagnosis and management of severe sepsis. Methods: A questionnaire was submitted to a sample of 208 participants in a professional ambulance service conference, and was recovered on site. The study probed eight areas of sepsis diagnosis and management based on modifications of a questionnaire used in a previous study. Results: The term sepsis in Japanese, Haiketsushou, was familiar to 99% of Japanese certified emergency life-saving technicians (ELST) (Group I) and to 92% of noncertified ambulance service personnel (Group II), although 15% of participants in Group I and 44% in Group II ignored the meaning of sepsis. The definition of sepsis as ‘‘body’s response to infection,’’ ‘‘blood poisoning,’’ or ‘‘shock due to bacteria in blood’’ were selected by 17%, 16%, and 37%, respectively, in Group I, and 4%, 6%, and 22%, respectively, in Group II. The mortality associated with sepsis was underestimated by 57% in Group I and 78% in Group II. Vital signs raising a suspicion for sepsis and their pertinent ranges were correctly chosen by only 50% of certified ELST. Hypothermia was prominently undervalued as a sign raising the suspicion of sepsis. Conclusions: Insufficient knowledge and perception for sepsis in Japanese ambulance services is revealed. A higher level of onsite or formal postgraduate education needs to be provided with a view to improve the prehospital management of sepsis. Ó 2015 Elsevier Inc.
INTRODUCTION Sepsis is a potentially life-threatening disorder, which, when it occurs out of the hospital, often requires emergency transport by ambulance (1). A recent study reported that > 40% of all patients hospitalized for severe sepsis had been transported by emergency services, with the number of cases increasing rapidly (1). However, it is not clear that the paramedical communities are thoroughly familiar with the various issues associated with the characteristics of sepsis and its management. The lack of knowledge might be a source of inaccurate and delayed initial recognition and diagnosis of sepsis, delay in the hospitalization and treatment of patients, and, ultimately, mediocre clinical outcomes (2). To the best of our knowledge, a single study, conducted in the United States (US), has focused on this issue (3). We developed the current survey to examine the level of knowledge and the perception of sepsis among Japanese ambulance service personnel. METHODS The survey was organized to examine knowledge and perceptions regarding sepsis during a continuing education conference for ambulance service personnel held in January 2014 in Kyoto, Japan. The ambulance service is staffed by certified emergency life-saving technicians (ELST) and other personnel. ELST in Japan were allowed
, Keywords—sepsis; medical education; ambulance service; emergency life-saving technician
RECEIVED: 23 July 2014; FINAL SUBMISSION RECEIVED: 30 November 2014; ACCEPTED: 22 December 2014 1
2
to tracheally intubate give electrical defibrillation, establish intravenous access, and administer adrenaline and fluids only for victims with cardiopulmonary arrest under the supervision of a medical commander, but not for victims with shock at the time of this survey. The printed questionnaire was distributed on site and gathered immediately after its completion by the conference participants. It included eight queries pertaining to sepsis, consisting in part of translations and modifications of a questionnaire used in earlier studies (4). In brief, the following questions were asked: 1. Have you heard of the term sepsis? 2. Have you heard of the term Haiketsushou? 3. Which, among the multiple choices listed below is the most accurate meaning of sepsis?3 , An allergy , Bacteria , Blood poisoning , Bacteria in blood , Shock due to bacteria in blood , Infection , Infection of a wound , Infection of a tissue , Inflammation , The body’s response to infection , Pus discharge , Other , Unknown 4. Where did you hear about sepsis? Several answers could be selected from multiple choices. , Biology lessons , At school , At college , At university , Friend/relative , Friend/relative has been affected , I have personally been affected , In the media , On the internet , Medical person/health professional in the family , I am a doctor/nurse/other health professional , Other , None of these , Do not know 5. Check the mortality associated with each condition? , Conditions B Ruptured abdominal aneurysm B Severe sepsis B Stroke B Acute myocardial infarction , Mortality B 2.7%–9.6% B 9.3%
N. Shime
28%–50% 50.0%–73.3%. 6. Have you ever told the command station ‘‘this patient is developing sepsis’’? 7. Which vital signs do you consider important when suspecting sepsis? Assign a ‘‘high’’ or ‘‘low’’ threshold to each sign. 8. Which of these interventions is (are) important in the management of sepsis? (select all that apply): , Fluid resuscitation , Antimicrobials , Steroids , Glucose infusion , Immunoglobulin , No opinion. B B
With this questionnaire, the investigator probed the awareness and proficiency of the technician with respect to the disease and pertinent terminology, definitions, use of vital signs, management and complications. The Ethics Committee of Kyoto Medical Center approved for this study. Informed consent of using the data was obtained from each participant when the survey was performed. The results are expressed as n (%) or median (range). RESULTS Out of the sample of 208 ambulance care personnel among 232 participants at the conference, 208 (100%) completed the questionnaire, 94 (45%) of them were board-certified ELST (Group I) and 114 (55%) were noncertified ambulance service personnel and students (Group II). The responses to the questionnaire are summarized in the Table 1.
Table 1. Familiarity With Sepsis and its Complications Group I (n = 94) Participant familiar with the term sepsis Participant familiar with the term Haiketsushou Source of information from school Sepsis means the response of the body to infection Sepsis means identification of bacteria in blood Sepsis means blood poisoning Sepsis means shock due to bacteria in blood Do not know the meaning of sepsis Mortality associated with severe sepsis is 28%–50% Mortality associated with severe sepsis is 2.7%–9.6% or 9.3% Data are presented as n (%).
Group II (n = 114)
11 (12) 93 (99)
5 (4) 105 (92)
34 (37) 16 (17)
32 (28) 4 (4)
35 (37)
23 (21)
15 (16) 35 (37)
7 (6) 25 (22)
14 (15) 11/77 (14)
50 (44) 12/91 (13)
44/77 (57)
71/91 (78)
Competency of Ambulance Service for Sepsis
3
Table 2. Vital Sign Thresholds Prompting the Suspicion of Severe Sepsis Vital Signs
Threshold
Observations, n (%)
Threshold, Median (Range)
Systolic blood pressure, mm Hg
High Low High Low High Low High Low High Low
14 (15) 51 (54) 57 (61) 6 (6) 48 (51) 8 (9) 3 (3) 38 (41) 48 (51) 5 (6)
180 (120 200) 90 (50 100) 120 (90 200) 50 (30 80) 30 (20 40) 10 (9 12) — 90 (70 95) 38 (37 42) 35 (31 36)
Heart rate, beats/min Respiratory rate, breaths/min Arterial oxygen saturation, % Body temperature, C
Terms and Definitions
Management of Sepsis
Haiketsushou, which means ‘‘sepsis’’ in Japanese, was a term familiar to 99% of study participants in Group I and to 92% in Group II. However, only 11% of participants in Group I and 4% in Group II knew the meaning of the English word sepsis. The most frequent source of information was a school, in 37% and 28% of participants in Group I and in Group II, respectively. Only 17% in Group I and 4% in Group II knew that sepsis means ‘‘body’s response to infection,’’ while 37% and 21%, respectively, incorrectly thought that sepsis meant ‘‘bacteria in blood’’ (i.e., bacteremia). Sixteen percent and 6% thought that sepsis meant ‘‘blood poisoning’’ and 37% and 22% thought that sepsis meant ‘‘shock due to bacteria in blood’’ in Group I and II, respectively (Table 1). Fifteen percent in Group I and 47% in Group II, respectively, responded that they did not know the meaning of sepsis.
Among the choices of treatments, ‘‘antimicrobials’’ was most often selected in Group I (n = 43 [51%)] and in Group II (n = 15 [13%]), while only 20% and 12%, respectively, chose fluid resuscitation. Steroids or immunoglobulins were chosen by 17% and 28%, and 4% and 5% in Group I and II, respectively. Twenty-one percent in Group I and 57% in Group II, respectively, had no opinion.
Mortality Associated with Sepsis Only 14% and 13% of participants in Groups I and II, respectively, knew that the mortality associated with severe sepsis was 28%–50%, while 57% and 78%, respectively, thought that the mortality was < 10% (Table 1). Diagnosis Only 7 of 91 certified ELST (8%) indicated that they had ever communicated to the command center that ‘‘this patient may be having sepsis.’’ The vital signs raising a suspicion of severe sepsis and assigned threshold were analyzed in Group I and are shown in Table 2. The most often selected sign (61%) was tachycardia, followed by low blood pressure, low arterial oxygen saturation, and tachypnea. It is noteworthy that only 5 certified ELST chose hypothermia as a sign of sepsis. The selection rates of any sign in Group II were too low to allow meaningful analyses (data not shown).
DISCUSSION The Japanese term Haiketsushou was familiar to nearly all Japanese providers of emergency services. The aptitude level was similar to the 96% measured among US emergency medical technicians, or 100% among Japanese physicians, nurses, and medical and nursing students or paramedics in the United States (3,5). However, the correct perception of sepsis is suboptimal, as observed in earlier studies evaluating the fund of knowledge of emergency medical services (3,6). High proportions of participants in Groups I and II thought that sepsis was identical to bacteremia, and few respondents knew that the correct definition of sepsis is ‘‘a systemic inflammatory response to an infection.’’ In addition, mortality was markedly underestimated, which is concordant with the results of previous surveys in nurses and medical and nursing students (4,5). This misunderstanding of sepsis and the misperception of its pathophysiology and gravity could be the sources of delays in its diagnosis and treatment, as well as the cause of unfavorable clinical outcomes. These observations indicate that a higher level of education on the topic of sepsis should be offered to certified Japanese ELST and to nonccertified emergency medical personnel. Seymour et al. validated a thresholds of vital signs to determine the acuity of an illness in the out-of-hospital setting; a systolic blood pressure < 90 mm Hg, a respiratory rate of < 12 breaths/min or $ 36 breaths/min, a heart
4
rate $ 120 beats/min, and a blood oxygen saturation # 87% (7). The vital signs and the thresholds that the ELST viewed as indicative of severe sepsis in our survey were concordant with these earlier observations. However, only approximately 50% of the study participants in Group I identified a pertinent vital sign in this survey. In addition, very few certified ELST had alerted a command center of an incoming case of sepsis. A study in the United States also found that < 50% of cases of severe sepsis were identified by emergency care providers (8). Finally, we were surprised by the low proportion of certified ELST who were alerted by a low body temperature. A recent study has suggested the increased mortality of patients presenting with severe sepsis and a body temperature < 36.5 C (8). A greater awareness of the importance of hypothermia as a manifestation of severe sepsis with poor outcome needs to be promoted. Volume resuscitation, a key therapeutic measure in severe sepsis and septic shock was markedly underrecognized. Its recommendation as a treatment by only 20% of the group I study participants was markedly lower than the 40%–50% by American emergency medical services (3). The absence of venous access and insufficient fluid administration has been observed in another US survey (9). Although fluid administration for shock victims was not allowed for ELST at the time of this survey, it has just been certified by the administrator. This suggests the increasing contribution of ELST in the management of community-aquired sepsis. The dispensation of evidence-based education and appropriate goal-directed therapy should therefore be facilitated in future training of ELST. Limitations Because the selection of our study groups may have been biased, the results of this study are not universally applicable. We chose our study groups among the participants to a local continuing education conference to facilitate the recruitment by the investigators. This might have introduced selection biases, resulting in the collection of data from particularly motivated groups, or from individuals who had identified personal deficiencies in their understanding of sepsis. Finally, the role played by ambulance systems and the professional qualifications of
N. Shime
board-certified ELST in Japan versus other countries may differ markedly. CONCLUSIONS Our study identified areas of prehospital care of sepsis by emergency service providers in need of higher education and knowledge. National educational programs with the contributions of critical care experts should be organized to improve the knowledge, and ultimately, to improve outcomes for septic patients identified in out-of-hospital settings (9,10). Acknowledgments—The authors thank all of the participants in this survey and the committee of chiefs of the Kyoto prefectural ambulance service.
REFERENCES 1. Seymour CW, Rea TD, Kahn JM, et al. Severe sepsis in pre-hospital emergency care: analysis of incidence, care, and outcome. Am J Respir Crit Care Med 2012;186:1264–71. 2. Poeze M, Ramsay G, Gerlach H, et al. An international sepsis survey: a study of doctors’ knowledge and perception about sepsis. Crit Care 2004;8:R409–13. 3. Seymour CW, Carlbom D, Engelberg RA, et al. Understanding of sepsis among emergency medical services: a survey study. J Emerg Med 2012;42:666–77. 4. Rubulotta FM, Ramsay G, Parker MM, et al. Surviving Sepsis Campaign Steering Committee; European Society of Intensive Care Medicine; Society of Critical Care Medicine. An international survey: public awareness and perception of sepsis. Crit Care Med 2009;37:167–70. 5. Shime N, Shinohara T, Shigemi K, et al. Knowledge and perception about sepsis: a survey in Japan. Anaesth Intensive Care 2012;40: 737–8. 6. Guerra WF, Mayfield TR, Meyers MS, et al. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med 2013;44:1116–25. 7. Seymour CW, Kahn JM, Cooke CR, et al. Prediction of critical illness during out-of-hospital emergency care. JAMA 2010;304: 747–54. 8. Kushimoto S, Gando S, Saitoh D, et al. JAAM Sepsis Registry (JAAMSR) Study Group. The impact of body temperature abnormalities on the disease severity and outcome in patients with severe sepsis: an analysis from a multicenter, prospective survey of severe sepsis. Crit Care 2013;17:R271. 9. Seymour CW, Cooke CR, Mikkelsen ME, et al. Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department. Prehosp Emerg Care 2010;14:145–52. 10. Brice JH, Evenson KR, Lellis JC, et al. Emergency medical services education, community outreach, and protocols for stroke and chest pain in North Carolina. Prehosp Emerg Care 2008;12:366–71.
Competency of Ambulance Service for Sepsis
ARTICLE SUMMARY 1. Why is this topic important? It is important to reveal if the paramedical communities are familiar with the characteristics of sepsis and its management, as this knowledge might be associated with optimal care of septic patients in out-of-hospital settings. 2. What does this study attempt to show? This study attempted to examine the level of knowledge and the perception of sepsis among ambulance service personnel. 3. What are the key findings? Our study identified areas of prehospital care of sepsis by emergency service providers in need of higher education and knowledge. 4. How is patient care impacted? Attempts to improve the knowledge could ultimately help to improve outcomes for septic patients identified in out-of-hospital settings.
5
http://dx.doi.org/10.1016/j.jemermed.2014.12.066
Selected Topics: Prehospital Care A SURVEY OF THE COMPETENCY OF AMBULANCE SERVICE PERSONNEL IN THE DIAGNOSIS AND MANAGEMENT OF SEPSIS Nobuaki Shime, MD, PHD Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan Reprint Address: Nobuaki Shime, MD, PHD, Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fushimi-ku, Kyoto 612-8555, Japan
, Abstract—Background: Few studies have evaluated the current status of knowledge of sepsis in ambulance service personnel. Objective: Our aim was to ascertain the levels of competency and proficiency of ambulance service personnel in the diagnosis and management of severe sepsis. Methods: A questionnaire was submitted to a sample of 208 participants in a professional ambulance service conference, and was recovered on site. The study probed eight areas of sepsis diagnosis and management based on modifications of a questionnaire used in a previous study. Results: The term sepsis in Japanese, Haiketsushou, was familiar to 99% of Japanese certified emergency life-saving technicians (ELST) (Group I) and to 92% of noncertified ambulance service personnel (Group II), although 15% of participants in Group I and 44% in Group II ignored the meaning of sepsis. The definition of sepsis as ‘‘body’s response to infection,’’ ‘‘blood poisoning,’’ or ‘‘shock due to bacteria in blood’’ were selected by 17%, 16%, and 37%, respectively, in Group I, and 4%, 6%, and 22%, respectively, in Group II. The mortality associated with sepsis was underestimated by 57% in Group I and 78% in Group II. Vital signs raising a suspicion for sepsis and their pertinent ranges were correctly chosen by only 50% of certified ELST. Hypothermia was prominently undervalued as a sign raising the suspicion of sepsis. Conclusions: Insufficient knowledge and perception for sepsis in Japanese ambulance services is revealed. A higher level of onsite or formal postgraduate education needs to be provided with a view to improve the prehospital management of sepsis. Ó 2015 Elsevier Inc.
INTRODUCTION Sepsis is a potentially life-threatening disorder, which, when it occurs out of the hospital, often requires emergency transport by ambulance (1). A recent study reported that > 40% of all patients hospitalized for severe sepsis had been transported by emergency services, with the number of cases increasing rapidly (1). However, it is not clear that the paramedical communities are thoroughly familiar with the various issues associated with the characteristics of sepsis and its management. The lack of knowledge might be a source of inaccurate and delayed initial recognition and diagnosis of sepsis, delay in the hospitalization and treatment of patients, and, ultimately, mediocre clinical outcomes (2). To the best of our knowledge, a single study, conducted in the United States (US), has focused on this issue (3). We developed the current survey to examine the level of knowledge and the perception of sepsis among Japanese ambulance service personnel. METHODS The survey was organized to examine knowledge and perceptions regarding sepsis during a continuing education conference for ambulance service personnel held in January 2014 in Kyoto, Japan. The ambulance service is staffed by certified emergency life-saving technicians (ELST) and other personnel. ELST in Japan were allowed
, Keywords—sepsis; medical education; ambulance service; emergency life-saving technician
RECEIVED: 23 July 2014; FINAL SUBMISSION RECEIVED: 30 November 2014; ACCEPTED: 22 December 2014 1
2
to tracheally intubate give electrical defibrillation, establish intravenous access, and administer adrenaline and fluids only for victims with cardiopulmonary arrest under the supervision of a medical commander, but not for victims with shock at the time of this survey. The printed questionnaire was distributed on site and gathered immediately after its completion by the conference participants. It included eight queries pertaining to sepsis, consisting in part of translations and modifications of a questionnaire used in earlier studies (4). In brief, the following questions were asked: 1. Have you heard of the term sepsis? 2. Have you heard of the term Haiketsushou? 3. Which, among the multiple choices listed below is the most accurate meaning of sepsis?3 , An allergy , Bacteria , Blood poisoning , Bacteria in blood , Shock due to bacteria in blood , Infection , Infection of a wound , Infection of a tissue , Inflammation , The body’s response to infection , Pus discharge , Other , Unknown 4. Where did you hear about sepsis? Several answers could be selected from multiple choices. , Biology lessons , At school , At college , At university , Friend/relative , Friend/relative has been affected , I have personally been affected , In the media , On the internet , Medical person/health professional in the family , I am a doctor/nurse/other health professional , Other , None of these , Do not know 5. Check the mortality associated with each condition? , Conditions B Ruptured abdominal aneurysm B Severe sepsis B Stroke B Acute myocardial infarction , Mortality B 2.7%–9.6% B 9.3%
N. Shime
28%–50% 50.0%–73.3%. 6. Have you ever told the command station ‘‘this patient is developing sepsis’’? 7. Which vital signs do you consider important when suspecting sepsis? Assign a ‘‘high’’ or ‘‘low’’ threshold to each sign. 8. Which of these interventions is (are) important in the management of sepsis? (select all that apply): , Fluid resuscitation , Antimicrobials , Steroids , Glucose infusion , Immunoglobulin , No opinion. B B
With this questionnaire, the investigator probed the awareness and proficiency of the technician with respect to the disease and pertinent terminology, definitions, use of vital signs, management and complications. The Ethics Committee of Kyoto Medical Center approved for this study. Informed consent of using the data was obtained from each participant when the survey was performed. The results are expressed as n (%) or median (range). RESULTS Out of the sample of 208 ambulance care personnel among 232 participants at the conference, 208 (100%) completed the questionnaire, 94 (45%) of them were board-certified ELST (Group I) and 114 (55%) were noncertified ambulance service personnel and students (Group II). The responses to the questionnaire are summarized in the Table 1.
Table 1. Familiarity With Sepsis and its Complications Group I (n = 94) Participant familiar with the term sepsis Participant familiar with the term Haiketsushou Source of information from school Sepsis means the response of the body to infection Sepsis means identification of bacteria in blood Sepsis means blood poisoning Sepsis means shock due to bacteria in blood Do not know the meaning of sepsis Mortality associated with severe sepsis is 28%–50% Mortality associated with severe sepsis is 2.7%–9.6% or 9.3% Data are presented as n (%).
Group II (n = 114)
11 (12) 93 (99)
5 (4) 105 (92)
34 (37) 16 (17)
32 (28) 4 (4)
35 (37)
23 (21)
15 (16) 35 (37)
7 (6) 25 (22)
14 (15) 11/77 (14)
50 (44) 12/91 (13)
44/77 (57)
71/91 (78)
Competency of Ambulance Service for Sepsis
3
Table 2. Vital Sign Thresholds Prompting the Suspicion of Severe Sepsis Vital Signs
Threshold
Observations, n (%)
Threshold, Median (Range)
Systolic blood pressure, mm Hg
High Low High Low High Low High Low High Low
14 (15) 51 (54) 57 (61) 6 (6) 48 (51) 8 (9) 3 (3) 38 (41) 48 (51) 5 (6)
180 (120 200) 90 (50 100) 120 (90 200) 50 (30 80) 30 (20 40) 10 (9 12) — 90 (70 95) 38 (37 42) 35 (31 36)
Heart rate, beats/min Respiratory rate, breaths/min Arterial oxygen saturation, % Body temperature, C
Terms and Definitions
Management of Sepsis
Haiketsushou, which means ‘‘sepsis’’ in Japanese, was a term familiar to 99% of study participants in Group I and to 92% in Group II. However, only 11% of participants in Group I and 4% in Group II knew the meaning of the English word sepsis. The most frequent source of information was a school, in 37% and 28% of participants in Group I and in Group II, respectively. Only 17% in Group I and 4% in Group II knew that sepsis means ‘‘body’s response to infection,’’ while 37% and 21%, respectively, incorrectly thought that sepsis meant ‘‘bacteria in blood’’ (i.e., bacteremia). Sixteen percent and 6% thought that sepsis meant ‘‘blood poisoning’’ and 37% and 22% thought that sepsis meant ‘‘shock due to bacteria in blood’’ in Group I and II, respectively (Table 1). Fifteen percent in Group I and 47% in Group II, respectively, responded that they did not know the meaning of sepsis.
Among the choices of treatments, ‘‘antimicrobials’’ was most often selected in Group I (n = 43 [51%)] and in Group II (n = 15 [13%]), while only 20% and 12%, respectively, chose fluid resuscitation. Steroids or immunoglobulins were chosen by 17% and 28%, and 4% and 5% in Group I and II, respectively. Twenty-one percent in Group I and 57% in Group II, respectively, had no opinion.
Mortality Associated with Sepsis Only 14% and 13% of participants in Groups I and II, respectively, knew that the mortality associated with severe sepsis was 28%–50%, while 57% and 78%, respectively, thought that the mortality was < 10% (Table 1). Diagnosis Only 7 of 91 certified ELST (8%) indicated that they had ever communicated to the command center that ‘‘this patient may be having sepsis.’’ The vital signs raising a suspicion of severe sepsis and assigned threshold were analyzed in Group I and are shown in Table 2. The most often selected sign (61%) was tachycardia, followed by low blood pressure, low arterial oxygen saturation, and tachypnea. It is noteworthy that only 5 certified ELST chose hypothermia as a sign of sepsis. The selection rates of any sign in Group II were too low to allow meaningful analyses (data not shown).
DISCUSSION The Japanese term Haiketsushou was familiar to nearly all Japanese providers of emergency services. The aptitude level was similar to the 96% measured among US emergency medical technicians, or 100% among Japanese physicians, nurses, and medical and nursing students or paramedics in the United States (3,5). However, the correct perception of sepsis is suboptimal, as observed in earlier studies evaluating the fund of knowledge of emergency medical services (3,6). High proportions of participants in Groups I and II thought that sepsis was identical to bacteremia, and few respondents knew that the correct definition of sepsis is ‘‘a systemic inflammatory response to an infection.’’ In addition, mortality was markedly underestimated, which is concordant with the results of previous surveys in nurses and medical and nursing students (4,5). This misunderstanding of sepsis and the misperception of its pathophysiology and gravity could be the sources of delays in its diagnosis and treatment, as well as the cause of unfavorable clinical outcomes. These observations indicate that a higher level of education on the topic of sepsis should be offered to certified Japanese ELST and to nonccertified emergency medical personnel. Seymour et al. validated a thresholds of vital signs to determine the acuity of an illness in the out-of-hospital setting; a systolic blood pressure < 90 mm Hg, a respiratory rate of < 12 breaths/min or $ 36 breaths/min, a heart
4
rate $ 120 beats/min, and a blood oxygen saturation # 87% (7). The vital signs and the thresholds that the ELST viewed as indicative of severe sepsis in our survey were concordant with these earlier observations. However, only approximately 50% of the study participants in Group I identified a pertinent vital sign in this survey. In addition, very few certified ELST had alerted a command center of an incoming case of sepsis. A study in the United States also found that < 50% of cases of severe sepsis were identified by emergency care providers (8). Finally, we were surprised by the low proportion of certified ELST who were alerted by a low body temperature. A recent study has suggested the increased mortality of patients presenting with severe sepsis and a body temperature < 36.5 C (8). A greater awareness of the importance of hypothermia as a manifestation of severe sepsis with poor outcome needs to be promoted. Volume resuscitation, a key therapeutic measure in severe sepsis and septic shock was markedly underrecognized. Its recommendation as a treatment by only 20% of the group I study participants was markedly lower than the 40%–50% by American emergency medical services (3). The absence of venous access and insufficient fluid administration has been observed in another US survey (9). Although fluid administration for shock victims was not allowed for ELST at the time of this survey, it has just been certified by the administrator. This suggests the increasing contribution of ELST in the management of community-aquired sepsis. The dispensation of evidence-based education and appropriate goal-directed therapy should therefore be facilitated in future training of ELST. Limitations Because the selection of our study groups may have been biased, the results of this study are not universally applicable. We chose our study groups among the participants to a local continuing education conference to facilitate the recruitment by the investigators. This might have introduced selection biases, resulting in the collection of data from particularly motivated groups, or from individuals who had identified personal deficiencies in their understanding of sepsis. Finally, the role played by ambulance systems and the professional qualifications of
N. Shime
board-certified ELST in Japan versus other countries may differ markedly. CONCLUSIONS Our study identified areas of prehospital care of sepsis by emergency service providers in need of higher education and knowledge. National educational programs with the contributions of critical care experts should be organized to improve the knowledge, and ultimately, to improve outcomes for septic patients identified in out-of-hospital settings (9,10). Acknowledgments—The authors thank all of the participants in this survey and the committee of chiefs of the Kyoto prefectural ambulance service.
REFERENCES 1. Seymour CW, Rea TD, Kahn JM, et al. Severe sepsis in pre-hospital emergency care: analysis of incidence, care, and outcome. Am J Respir Crit Care Med 2012;186:1264–71. 2. Poeze M, Ramsay G, Gerlach H, et al. An international sepsis survey: a study of doctors’ knowledge and perception about sepsis. Crit Care 2004;8:R409–13. 3. Seymour CW, Carlbom D, Engelberg RA, et al. Understanding of sepsis among emergency medical services: a survey study. J Emerg Med 2012;42:666–77. 4. Rubulotta FM, Ramsay G, Parker MM, et al. Surviving Sepsis Campaign Steering Committee; European Society of Intensive Care Medicine; Society of Critical Care Medicine. An international survey: public awareness and perception of sepsis. Crit Care Med 2009;37:167–70. 5. Shime N, Shinohara T, Shigemi K, et al. Knowledge and perception about sepsis: a survey in Japan. Anaesth Intensive Care 2012;40: 737–8. 6. Guerra WF, Mayfield TR, Meyers MS, et al. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med 2013;44:1116–25. 7. Seymour CW, Kahn JM, Cooke CR, et al. Prediction of critical illness during out-of-hospital emergency care. JAMA 2010;304: 747–54. 8. Kushimoto S, Gando S, Saitoh D, et al. JAAM Sepsis Registry (JAAMSR) Study Group. The impact of body temperature abnormalities on the disease severity and outcome in patients with severe sepsis: an analysis from a multicenter, prospective survey of severe sepsis. Crit Care 2013;17:R271. 9. Seymour CW, Cooke CR, Mikkelsen ME, et al. Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department. Prehosp Emerg Care 2010;14:145–52. 10. Brice JH, Evenson KR, Lellis JC, et al. Emergency medical services education, community outreach, and protocols for stroke and chest pain in North Carolina. Prehosp Emerg Care 2008;12:366–71.
Competency of Ambulance Service for Sepsis
ARTICLE SUMMARY 1. Why is this topic important? It is important to reveal if the paramedical communities are familiar with the characteristics of sepsis and its management, as this knowledge might be associated with optimal care of septic patients in out-of-hospital settings. 2. What does this study attempt to show? This study attempted to examine the level of knowledge and the perception of sepsis among ambulance service personnel. 3. What are the key findings? Our study identified areas of prehospital care of sepsis by emergency service providers in need of higher education and knowledge. 4. How is patient care impacted? Attempts to improve the knowledge could ultimately help to improve outcomes for septic patients identified in out-of-hospital settings.
5
