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18 AUGUST 2017 | EMSWORLD.com T his month's article is dedicated to EMS innovation. There are a ton of topics we could have covered that fall into the innovation category, but one has been discussed more and more in our field: prehospital sepsis care. Not only has EMS research indicated that we see a lot of sepsis patients prehospitally, but this appears to be an area of prehospital patient care in which we can truly make a positive, empirically verified impact on patient mor- bidity and mortality. One thing to keep in mind with sepsis care is that it can require medications that historically have not been given in the pre- hospital environment. It can also require new patient assessment skills, blood draws, cul- tures, etc. Many in our field don't routinely perform these interventions. So it may be reasonable to ask whether EMS can suc- cessfully assess and manage sepsis patients. Fortunately, Jason Walchok—currently the stroke, STEMI and sepsis coordinator for the South Carolina Bureau of EMS—and coauthors recently published a manuscript titled "Paramedic-Initiated CMS Sepsis Core Measure Bundle Prior to Hospital Arrival: A Stepwise Approach." The study objective was to determine whether paramedics can reliably initiate the CMS sepsis core measure bundle in the prehospital environment. The study was performed in a single EMS agency that examined all adult 9-1-1 patients who triggered a sepsis alert in their system. The study period spanned from November 2014 to February 2016. This system used a prehospital sepsis assessment tool based on the 2012 Surviving Sepsis guidelines. This tool evaluated four systemic inflammatory response syndrome (SIRS) criteria. These included a heart rate greater than 90 bpm, respiratory rate greater than 20 or mechani- cal ventilation, and a body temperature of greater than 38 degrees Celsius or less than 36 degrees Celsius. If the patient had at least two of these signs as well as a known or sus- pected source of infection, the paramedic was required to initiate a sepsis alert. Preliminary Work Prior to beginning the study, every para- medic in the EMS agency received 12 hours of sepsis education and skills training. Training included didactic, simulation and skills stations. To complete it, paramedics were required to obtain 90% on a written exam and verify critical blood culture col- lection competency using a high-fidelity simulation manikin. All 120 paramedics successfully completed this training. This study required a significant amount of preliminary work. Not only did this EMS agency have to petition the state EMS office to add antibiotics to the state medication for- mulary, they also had to develop a prehospi- tal sepsis care protocol in conjunction with a local established EMS sepsis committee. This protocol dictated that after calling the sepsis alert into the receiving facility, the paramedic would gain IV access, obtain blood cultures as well as a venous blood sample for lactate analysis, begin fluid resuscitation at 3mg/kg, and screen for penicillin allergy. As discussed above, a substantial amount of red tape needed to be cut through for this study. The addition of antibiotics to the state formulary was not approved until a few months into the study. Once they were approved, paramedics initiated antibiotics in the field following a screen for allergies. Each assessment and intervention was implemented using a stepwise approach in which each area of the CMS bundle was incorporated into the prehospital setting and evaluated for success prior to the implemen- tation of the next step. The study outcomes of interest included the evaluation of agreement of the para- medics' sepsis identification and the ICD-9/ ICD-10 discharge diagnosis codes for sepsis, severe sepsis and septic shock. The authors also evaluated blood culture contamina- tion and received feedback from the receiv- ing hospitals' sepsis coordinator regarding adverse effects. Encouraging Results With the background, red tape and study methods having been discussed, we are ready to dive into the results. During the study period over 57,000 EMS patients were seen and a total of 1,185 sepsis alerts were triggered. There was almost an equal distribution of males and females (50.3% male) and the average patient age for those who triggered a sepsis alert was 70 years. As is common with most research, there was some missing data. There were 31 patients who did not have a complete ICD-9/ICD-10 discharge diagnosis. How- ever, for those who did have complete data, the results are encouraging. In total, 73.5% of the sepsis alert patients had a diagnosis code consistent with sepsis. Almost 83% of the patients who had a sepsis diagnosis code had blood successfully collected for lactate analysis. Among all the 1,185 sep- sis alert patients, 946 had a blood culture collected and over 95% of these were not contaminated during collection. There were also 571 patients who received prehospital antibiotics following authorization to add antibiotics to the formulary. In 94.1% of sep- Look for PCRF research podcasts based on the topics featured in this column at www.pcrfpodcast.org. I m p r o v i n g P r e h o s p i t a l S e p s i s C a r e REVIEWED THIS MONTH Paramedic-Initiated CMS Sepsis Core Measure Bundle Prior to Hospital Arrival: A Stepwise Approach Authors: Walchok JG, Pirrallo RG, Furmanek D, Lutz M, Shope C, Giles B, Gue G, Dix A. Published in: Prehosp Emerg Care, 2017 May–Jun 21(3):291–300. Can paramedics reliably initiate the new CMS core measure bundle? By Antonio R. Fernandez, PhD, NRP, FAHA THE TRIP REPORT: TURNING RESEARCH INTO PRACTICE