Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
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Objective: Identifying patients with sepsis in the prehospital setting is an important opportunity to increase timely care. When assessing clinical tools designed for paramedic sepsis identification, predicted risk may provide more useful information to support decision-making, compared to traditional estimates of classification accuracy (i.e., sensitivity and specificity). We sought to contrast classification accuracy versus predicted risk of a modified version of the Systemic Inflammatory Response Syndrome score (i.e., excluding white blood cell measure which is often unavailable to paramedics; mSIRS) and quick Sepsis Related Organ Failure Assessment (qSOFA) for determining mortality risk among patients with infection transported by paramedics. ⋯ The mSIRS score had higher sensitivity estimates than qSOFA for classifying hospital mortality at all thresholds (mSIRS ≥ 1: 0.83 vs. qSOFA≥ 1: 0.80, mSIRS ≥ 3: 0.11 vs. qSOFA ≥ 3: 0.08), but the qSOFA score had better discrimination (C-statistic qSOFA: 0.72 vs. mSIRS: 0.63) and calibration. The risk of hospital mortality predicted by the mSIRS score ranged from 8.0 to 19% across score values, whereas the risk predicted by the qSOFA score ranged from 10 to 51%. Conclusion: Assessing the predicted risk for the mSIRS and qSOFA scores instead of classification accuracy reveals that the qSOFA score provides more information to clinicians about a patient's mortality risk, supporting its use in clinical decision-making.
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Comment Letter
Challenges of being prepared for pediatric emergencies.
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Background: Patients with acute illness who receive intravenous (IV) fluids prior to hospital arrival may have a lower in-hospital mortality. To better understand whether this is a direct treatment effect or epiphenomenon of downstream care, we tested the association between a prehospital fluid bolus and the change in inflammatory cytokines measured at prehospital and emergency department timepoints in a sample of non-trauma, non-cardiac arrest patients at risk for critical illness. Methods: In a prospective cohort study, we screened 4,013 non-trauma, non-cardiac arrest encounters transported by City of Pittsburgh Emergency Medical Services (EMS) to 2 hospitals from August 2013 to February 2014. ⋯ Prehospital IL-10 and TNF were similar in both groups (IL-10: 3.5 [IQR 2.2-25.6] vs. 3.0 [IQR 1.9-9.0]; TNF: 7.5 [IQR 6.4-10.4] vs. 6.9 [IQR 6.0-8.3]). After adjustment for demographics, illness severity, and prehospital transport time, we observed a relative decrease in IL-6 at hospital arrival in those receiving a prehospital fluid bolus (adjusted β = -10.0, 95% CI: -19.4, -0.6, p = 0.04), but we did not detect a significant change in IL-10 (p = 0.34) or TNF (p = 0.53). Conclusions: Among non-trauma, non-cardiac arrest patients at risk for critical illness, a prehospital IV fluid bolus was associated with a relative decrease in IL-6, but not IL-10 or TNF.
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Background: Advance care planning documents, including Physician Orders for Life-Sustaining Treatment (POLST), are intended to guide care near end of life, particularly in emergency situations. Yet, research on POLST during emergency care is sparse. Methods: A total of 7,055 injured patients age ≥ 65 years were transported by 8 emergency medical services (EMS) agencies to 23 hospitals in Oregon. ⋯ Conclusions: Among injured older adults transported by ambulance in Oregon, one in 5 had an active POLST form at the time of 9-1-1 contact, the prevalence of which increased over the following year. Mortality differences by POLST status were evident at 30 days and large by one year. This information could help emergency, trauma, surgical, inpatient, and outpatient clinicians understand how to guide patients through acute injury episodes of care and post-injury follow up.
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Introduction: Emergency Medical Services (EMS) are the first healthcare contact for the majority of severely ill patients. Physiologic measures collected by EMS, when incorporated into a prognostic score, may provide important information on patient illness severity. This study compares the predictive ability of 3 common prognostic scores for predicting clinical outcomes in EMS patients. ⋯ Overall, the CIP score had the best discrimination, good calibration, and the greatest range of predicted probabilities (0.01 at a CIP score of 0 to 0.92 at a CIP score of 8) for hospital mortality. Conclusions: Prognostic scores using physiologic measures assessed by paramedics have good predictive ability for hospital mortality. These scores, particularly the CIP score, may be considered as a tool for mortality risk stratification or as a general measure of illness severity for patients included in EMS studies.