Introduction

Sepsis and septic shock are frequent diseases with high mortality rates [1,2,3]; the survival probability decreases with every hour that adequate therapy is delayed [4, 5]. The first contact between patients with sepsis or septic shock and emergency medical services (EMS) is associated with improved in-hospital processes for the care of these critically ill patients, provided that early diagnosis is made and that the EMS initiated adequate organizational and therapeutic consequences [6, 7].

In 1991, the clinical definition of sepsis emerged from the consensus conference sponsored by the American College of Chest Physicians and the Society of Critical Care Medicine. This definition included the systemic inflammatory response syndrome (SIRS) criteria (Table 1) as the basis for the clinical diagnosis of sepsis. However, in prehospital emergency management, SIRS criteria cannot be completely recorded.

Table 1 Systemic inflammatory response syndrome (SIRS) criteria. In addition to vital signs, there is a laboratory parameter (white blood cell count). Two or more SIRS criteria need to be positive to diagnose sepsis
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Recently, new definitions were published in February 2016 by the Sepsis-3 taskforce within the framework of the third international consensus definitions for sepsis and septic shock [8]. In general, sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. To detect organ dysfunction, vital signs still play a key role in the emergency management. In the prehospital setting, the quick Sepsis Organ Failure Assessment (qSOFA) score is a new screening tool to detect sepsis, raising the alarm if two of the three criteria are present in case of a suspected infection (Table 2).

Table 2 Quick Sepsis Organ Failure Assessment (qSOFA): Two or more criteria need to be positive to suspect sepsis
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Alternative scores and screening tools are also used in the prehospital emergency setting (e. g., the Robson Prehospital Severe Sepsis Screening Tool, the Prehospital Early Sepsis Detection Score [PRESEP], and the Modified Early Warning Score [9,10,11]). All of these use vital signs, such as body temperature, heart, and respiratory rates or blood pressure to evaluate the patients’ condition. Remarkably, body temperature is not part of the qSOFA criteria, since temperature is a sign of infection but not organ dysfunction.

Regardless of discussions about the best sepsis screening tool in the prehospital emergency medicine setting, the best sepsis score will not be helpful if the applied single criteria are not measured regularly and completely in case of suspected sepsis, thereby initiating immediate treatment in prehospital sepsis care [12]. Recently, sepsis has been included as one of the six time-critical tracer diagnoses, thus requiring EMS to foster stronger awareness in the prehospital setting [13].

This retrospective study was initiated to analyze whether EMS regularly document vital signs associated with organ dysfunction in the presence of suspected infection.

Methods

During the analyzed period from January 1, 2013, to December 31, 2014, no specific prehospital infection or sepsis protocol was established. The analyzed data were derived from an EMS district in Hesse (Germany). This EMS district provided five rescue stations and three emergency physician stations in a suburban setting with a population of 1000 people per km2 and a total number of 230,000 inhabitants.

Under the supervision of a medical director, EMS is performed by different agencies pursuant to the legal mission. All EMS operations must be documented by the EMS and stored in a central register of the dispatching centers of the districts. For the present study, only pseudonymized data were made available, so that no traceability was possible through the patient’s name, address, location, or date of birth. To determine age, the date of birth was given as month and year. The investigation was approved by the Ethics Committee of the Faculty of Medicine at the Goethe University in Frankfurt/Main. The pseudonymized data usage is also permitted by law by the Hessian Rescue Services Act (HRDG) § 17 (Privacy) and § 19 (quality assurance); those responsible are even encouraged by law to analyze the data for medical quality assurance so that analysis can lead to improvements in emergency service law.

The diagnoses pneumonia, meningitis, and septic shock with unknown focus were chosen as representative for prehospital suspected infections in the prehospital setting. In total, 68,798 operation protocols from the years 2013 and 2014 were analyzed. Any missing data for nonvital parameters were interpreted as not evaluated. For statistical analysis, because the data were not normally distributed, we used the Mann–Whitney U‑test for continuous variables and the χ2 test for categorical variables. The Kruskal–Wallis test was used to compare the three independent groups. A two-tailed p-value < 0.05 was considered statistically significant. All data were analyzed using SPSS statistical software (Version 24.0, IBM Inc.). For continuous variables, data are shown as the mean ± standard deviation. For categorical variables, percentages are presented.

Results

In total, 1390 of 68,798 protocols were identified with prehospital diagnoses of pneumonia, meningitis or septic shock without known focus. The average age of patients was 73 ± 18 years, 59.0% (n = 820) were female. Most (96.4%, n = 1338) had suspected pneumonia, 2.7% (n = 37) had suspected meningitis, and 0.9% (n = 13) had septic shock with an unknown focus.

Table 3 shows the number of measurements in the different groups. Body temperature (26.2%) and respiratory rate (31.5%) were least documented. When comparing the documentation of different vital signs, the rates of measurement of respiratory rate, temperature, and Glasgow Coma Scale (GCS) did not differ significantly.

Table 3 Number of measurements between the different diagnoses. Caution is required in the interpretation due to the small sample size
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The points on the Glasgow Coma Scale, saturation of peripheral oxygen (SpO2), heart rate and systolic blood pressure did differ significantly between groups, as shown in Table 4.

Table 4 Vital signs in the different diagnostic groups. Values are mean ± standard deviation (SD with min–max)
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In this study, 28.8% (n = 401) of the patients were transported only by paramedics. As shown in Fig. 1, there seem to be differences in measurements between emergency physicians and paramedics. In particular, for paramedics, the respiratory rate was documented in 38% of cases, which is significantly more often than by emergency physicians (16%, p < 0.001). However, the measured values for heart rate (99.4% versus 95.5%, p = 0.001) and blood pressure (98.2% versus 94.8%, p = 0.013) were significantly better documented by the emergency physicians.

Fig. 1
figure 1

Measurement behavior of emergency physicians and paramedics. P-value indicates significance between both groups in measuring the vital sign. GCS Glasgow Coma Scale

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Discussion

The SIRS criteria were fundamental for the diagnosis of sepsis and septic shock at the time of data collection [14]. Today, the Sepsis-3 definition qSOFA should be used to screen for suspected sepsis and septic shock [8].

This study shows that documentation of the vital parameter in case of severe infection and possible sepsis in the prehospital setting is low, primarily because the respiratory rate and temperature are rarely measured.

In Germany, every ambulance can use thermometers so that body temperature can be evaluated as a standard vital parameter. Considering this, it is surprising that body temperature and respiration rate were so poorly documented. This might be because heart rate is measured automatically with ECG, which is usually used for every emergency patient and further action is unnecessary to evaluate heart rate, in contrast to using a thermometer to measure body temperature or manually counting the respiration rate.

There is a need to demonstrate whether a gapless measurement of respiratory rate and temperature would have relevant consequences for the prehospital management of patients with sepsis and septic shock. There could be a change in management with oxygen, infusion therapy, and transportation management and handover procedure in relation to time management and destination hospital. However, in Germany, there are only a few rescue districts with rescue vehicles carrying antibiotics with them in the prehospital setting, so the therapeutic consequence in prehospital antibiotic treatment does not seem to be realistic, at least not yet [12].

The differences in stringencies in the collection of relevant measurements by paramedics versus emergency physicians were most pronounced in the respiratory rate. However, why these deviations existed cannot be explained.

In conclusion, our results show a lack of documentation of body temperature and respiratory rate in case of suspected sepsis. Only the heart rate was evaluated regularly. EMS personnel have to be trained to document these parameters in case of severe infections.