Keywords reflecting sepsis presentation based on mode of emergency department arrival: a retrospective cross-sectional study

Background Current sepsis screening tools are predominantly based on vital signs. However, patients with serious infections frequently present with normal vital signs and there has been an increased interest to include other variables such as symptoms in screening tools to detect sepsis. The majority of patients with sepsis arrive to the emergency department by emergency medical services. Our hypothesis was that the presentation of sepsis, including symptoms, may differ between patients arriving to the emergency department by emergency medical services and patients arriving by other means. This information is of interest to adapt future sepsis screening tools to the population in which they will be implemented. The aim of the current study was to compare the prevalence of keywords reflecting the clinical presentation of sepsis based on mode of arrival among septic patients presenting to the emergency department. Methods Retrospective cross-sectional study of 479 adult septic patients. Keywords reflecting sepsis presentation upon emergency department arrival were quantified and analyzed based on mode of arrival, i.e., by emergency medical services or by other means. We adjusted for multiple comparisons by applying Bonferroni-adjusted significance levels for all comparisons. Adjustments for age, gender, and sepsis severity were performed by stratification. All patients were admitted to the emergency department of Södersjukhuset, Stockholm, and discharged with an ICD-10 code compatible with sepsis between January 1, and December 31, 2013. Results “Abnormal breathing” (51.8% vs 20.5%, p value < 0.001), “abnormal circulation” (38.4% vs 21.3%, p value < 0.001), “acute altered mental status” (31.1% vs 13.1%, p value < 0.001), and “decreased mobility” (26.1% vs 10.7%, p value < 0.001) were more common among patients arriving by emergency medical services, while “pain” (71.3% vs 40.1%, p value < 0.001) and “risk factors for sepsis” (50.8% vs 30.8%, p value < 0.001) were more common among patients arriving by other means. Conclusions The distribution of most keywords related to sepsis presentation was similar irrespective of mode of arrival; however, some differences were present. This information may be useful in clinical decision tools or sepsis screening tools.

Association Between Duration of Return of Spontaneous Circulation and Favorable Outcomes After Out-of-Hospital Cardiac Arrest

Background: Return of spontaneous circulation (ROSC) is a core outcome element of cardiopulmonary resuscitation (CPR), but the definition or criterion of ROSC is disputed and varies in resuscitation for out-of-hospital cardiac arrest (OHCA).Methods: In this retrospective observational study from a single center in Beijing, we analyzed the records of 126 OHCA patients who achieved ROSC between January 1, 2020, and December 31, 2020. ROSC duration was defined as the entire time of ROSC from heartbeat or pulse present upon arrival at hospital or arrest again during CPR. The primary outcome was survival at 30 days with favorable neurological outcome. The probability of survival after OHCA as related to CPR duration time was further analyzed using the Probability Density Function (PDF) and the empirical Cumulative Density Functions (CDFs), and compared with ROSC sustained until emergency department arrival and ROSC sustained at least 20 minutes. Results: Among all 126 OHCA patients who achieved ROSC, the median ROSC duration time was 13.6 minutes. There were no significant differences between ROSC sustained until emergency department arrival and sustained at least 20 minutes in the 24-hour survival rate (31.3% [31/99] vs. 35.7% [10/30]; P=0.835), 30-day survival rate (23.2% [23/99] vs. 25.0% [7/30]; P=0.991), or survival at 30 days with cerebral performance category (CPC) 1–2 (18.2% [18/99] vs. 10.7% [3/30]; P=0.435). The Kolmogorov-Smirnov test values from the empirical CDFs with ROSC sustained until hospital arrival and ROSC at least 20 minutes were 0.4444, 0.2000, and 0.2353 for CPC 1 or 2, CPC 3 or 4, and CPC 5 respectively.Conclusions: ROSC duration was directly associated with 24-hour survival, 30-day survival and 30-day survival with favorable neurological outcomes after OHCA. ROSC as a core outcome element of CPR should be defined as sustained at least 20 minutes or until arrival at the emergency department, and as a basic standard for evaluating resuscitation success after OHCA.

Keywords Reflecting Sepsis Presentation and Mode of Emergency Department Arrival: A Retrospective Cross-sectional Study

Background: Current sepsis screening tools rely predominantly on vital signs. Since patients with serious infections frequently present with normal vital signs there is a need for other variables to be included to detect sepsis. As a first step, it is essential to understand the clinical presentation of septic patients. The aim was to compare the prevalence of keywords reflecting the clinical presentation of sepsis and mode of arrival, among septic patients presenting to the emergency department. Methods: Retrospective cross-sectional study of 479 adult septic patients. Keywords reflecting sepsis presentation upon emergency department arrival were quantified and analyzed based on mode of arrival, i.e. by emergency medical services or by other means. We adjusted for multiple comparisons by applying Bonferroni-adjusted significance levels for all comparisons. Adjustments for age, gender and sepsis severity were performed by stratification. All patients were admitted to the emergency department of Södersjukhuset, Stockholm, and discharged with an ICD-10 code compatible with sepsis between January 1stand December 31st, 2013. Results: “Abnormal breathing” (51.8% vs 20.5%, p-value <0.001), “abnormal circulation” (38.4% vs 21.3%, p-value <0.001), “acute altered mental status” (31.1% vs 13.1%, p-value <0.001) and “decreased mobility” (26.1% vs 10.7%, p-value <0.001) were more common among patients arriving by emergency medical services, while “pain” (71.3% vs 40.1%, p-value <0.001) and “risk factors for sepsis” (50.8% vs 30.8%, p-value <0.001) were more common among patients arriving by other means.Conclusions: The distribution of most keywords related to sepsis presentation was similar irrespective of mode of arrival, however, some differences were present. This information may be useful in clinical decision tools or sepsis screening tools.

Paramedic Global Impression of Change During Prehospital Evaluation and Transport for Acute Stroke

Background and Purpose— The prehospital setting is a promising site for therapeutic intervention in stroke, but current stroke screening tools do not account for the evolution of neurological symptoms in this early period. We developed and validated the Paramedic Global Impression of Change (PGIC) Scale in a large, prospective, randomized trial. Methods— In the prehospital FAST-MAG (Field Administration of Stroke Therapy-Magnesium) randomized trial conducted from 2005 to 2013, EMS providers were asked to complete the PGIC Scale (5-point Likert scale values: 1-much improved, 2-mildly improved, 3-unchanged, 4-mildly worsened, 5-much worsened) for neurological symptom change during transport for consecutive patients transported by ambulance within 2 hours of onset. We analyzed PGIC concurrent validity (compared with change in Glasgow Coma Scale, Los Angeles Motor Scale), convergent validity (compared with National Institutes of Health Stroke Scale severity measure performed in the emergency department), and predictive validity (of neurological deterioration after hospital arrival and of final 90-day functional outcome). We used PGIC to characterize differential prehospital course among stroke subtypes. Results— Paramedics completed the PGIC in 1691 of 1700 subjects (99.5%), among whom 635 (37.5%) had neurological deficit evolution (32% improvement, 5.5% worsening) during a median prehospital care period of 33 (IQR, 27–39) minutes. Improvement was associated with diagnosis of cerebral ischemia rather than intracranial hemorrhage, milder stroke deficits on emergency department arrival, and more frequent nondisabled and independent 3-month outcomes. Conversely, worsening on the PGIC was associated with intracranial hemorrhage, more severe neurological deficits on emergency department arrival, more frequent treatment with thrombolytic therapy, and poor disability outcome at 3 months. Conclusions— The PGIC scale is a simple, validated measure of prehospital patient course that has the potential to provide information useful to emergency department decision-making. Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT00059332.

Abstract TP353: Long-term Outcomes in Patients With Intracerebral Hemorrhage and Delayed Hospital Presentation

Background: Delays in medical care are known to be associated with worse outcomes in ischemic stroke, but outcomes in patients with intracerebral hemorrhage (ICH) and delayed presentation are unclear. We aimed to determine factors associated with prolonged delays from ICH symptom onset to hospital presentation and implications for long-term outcomes. Methods: We performed a single-center cohort study using data from consecutive ICH patients over 12 months. ICH characteristics and outcomes were prospectively collected, while time of symptom onset (or last-known-well) and emergency department arrival were retrospectively abstracted. We calculated time-to-arrival and defined prolonged delay as >24 hours. Using multivariable logistic regression, we determined factors associated with prolonged delays to presentation, then determined associations with unfavorable 3-month outcomes (modified Rankin Scale [mRS] 4-6) after adjusting for demographics and ICH severity. Results: Of 299 patients with out-of-hospital ICH, 21% (n=62) presented >24 hours from symptom onset; median time-to-arrival was 5.5 hours (IQR 1.2-17.8). There were not significant differences in age (mean 71.9±14.0 vs. 70.4±16.0, p=0.50), sex (48% vs. 50% male, p=0.80), race (89% vs. 82% white, p=0.22), or ICH size (mean 15.5±23.2 vs. 20.5±27.4cc, p=0.19) between patients presenting >24 hours and <24 hours from symptom onset, though patients with prolonged delays were less likely to have initial GCS <13 (16% vs. 34%, p=0.02) and therefore had modestly lower ICH scores (median 1 [0-2] vs. 1 [1-2], p=0.02). Patients with prolonged delays had lower 3-month mRS scores than patients who presented earlier (median 3 [1.5-4] vs. 4 [3-6], p=0.002), and lower odds of unfavorable 3-month outcome in adjusted models (OR 0.46, 95% CI 0.22-0.97). Conclusions: Outcomes in ICH patients with prolonged delays to presentation differ from those who present earlier. ICH severity in such patients may not be accurately captured by established predictors, and prognostication models should therefore account for inherent survivorship bias.