A new retrospective chart-review study comparing two prehospital sepsis screening tools entitled Identification of adult septic patients in the prehospital setting: a comparison of two screening tools and clinical judgment has just been published ahead of print in the European Journal of Emergency Medicine.(1) The authors did a retrospective study comparing a previously-unvalidated sepsis screening protocol published by Robson, et. Al in 2009, an also previously unvalidated sepsis screening protocol in use in Sweden, referred to as “BAS 90-30-90,” and provider clinical judgement, which was defined as when a prehospital practitioner recorded a clinical impression of sepsis or a similar term. The authors looked at a retrospective cross-section of 353 patients, and found that the Robson tool would identify 75% of patients later found to be sepsis, BAS 90-30-90 would have caught about 43%, and practitioner clinical impressions only caught about 12% of septic patients.
This study makes the Robson criteria look like a very nice option for prehospital sepsis detection. According to the current authors’ adaptation of that tool, whenever any of the following are present in a patient with a history suggestive of infection, a patient may be considered septic:*
- Temperature > 38.3º or < 36.0º
- Heart rate > 90 bpm
- Respiratory rate > 20 breaths/min
- Acutely altered mental status
- Plasma glucose > 6.6 mmol/l (119 mg/dl) unless diabetic
The 75% detection rate found with the Robson criteria even puts it ahead of Guerra et. al’s tool, which required point-of-care lactate testing.(2) Those are impressive numbers, and they don’t even require a fancy new toy. I also like that this tool includes hyperglycemia as a criteria: that’s one of the canonical signs of sepsis according to the international consensus criteria,(3) but even though we all carry glucometers it’s a sepsis sign we usually overlook in the prehospital environment.
The finding that prehospital practitioners aren’t good at identifying sepsis is unfortunately not surprising, given the research that shows we as a profession don’t have a very good understanding of what sepsis is,(4) but it is fairly disturbing to see numbers this low. It indicates a crying need for EMS practitioners to have more education on this topic. Can you imagine if EMS only picked up on 12% of CVAs or AMIs in the field?
* The authors of the current study include a fairly heavy-handed statement with their adaptation of the Robson criteria that “to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.” However, I believe my recounting it here is an insubstantial infringement, and even if it were found to be a substantial infringement by a court I believe that this blog article, which is a critical review of the authors’ article, would be protected as fair dealing under the copyright laws of Canada, where this blog resides, the UK, where the European Journal of Emergency Medicine is published, and/or as fair use in the United States, where the European Journal of Emergency Medicine’s website resides.
1. Wallgren UM, Castrén M, Svensson AEV, Kurland L. Identification of adult septic patients in the prehospital setting: a comparison of two screening tools and clinical judgment. Eur J Emerg Med Off J Eur Soc Emerg Med. 2013 Sep 30;
2. Guerra WF, Mayfield TR, Meyers MS, Clouatre AE, Riccio JC. Early Detection And Treatment Of Patients With Severe Sepsis By Prehospital Personnel. J Emerg Med [Internet]. 2013 Jan [cited 2013 Jan 14]; Available from: http://www.jem-journal.com/article/PIIS0736467912014412/abstract?rss=yes
3. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003 Apr;31(4):1250–6.
4. Báez AA, Hanudel P, Perez MT, Giraldez EM, Wilcox SR. Prehospital Sepsis Project (PSP): Knowledge and Attitudes of United States Advanced Out-of-Hospital Care Providers. Prehospital Disaster Med. 2012;FirstView:1–3.
Last updated: October 6, 2013 at 22:30 pm