title: Out-of-hospital characteristics and care of patients with severe sepsis: a cohort study.
abstract: OBJECTIVE
  Early recognition and treatment in severe sepsis improve outcomes. However, out-of-hospital patient characteristics and emergency medical services (EMS) care in severe sepsis is understudied. Our goals were to describe out-of-hospital characteristics and EMS care in patients with severe sepsis and to evaluate associations between out-of-hospital characteristics and severity of organ dysfunction in the emergency department (ED).
  
  
  METHODS
  We performed a secondary data analysis of existing data from patients with severe sepsis transported by EMS to an academic medical center. We constructed multivariable linear regression models to determine if out-of-hospital factors are associated with serum lactate and sequential organ failure assessment (SOFA) in the ED.
  
  
  RESULTS
  Two hundred sixteen patients with severe sepsis arrived by EMS. Median serum lactate in the ED was 3.0 mmol/L (interquartile range, 2.0-5.0) and median SOFA score was 4 (interquartile range, 2-6). Sixty-three percent (135) of patients were transported by advanced life support providers and 30% (62) received intravenous fluid. Lower out-of-hospital Glasgow Coma Scale score was independently associated with elevated serum lactate (P < .01). Out-of-hospital hypotension, greater respiratory rate, and lower Glasgow Coma Scale score were associated with greater SOFA (P < .01).
  
  
  CONCLUSIONS
  Out-of-hospital fluid resuscitation occurred in less than one third of patients with severe sepsis, and routinely measured out-of-hospital variables were associated with greater serum lactate and SOFA in the ED.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA 98104, USA. seymoc@u.washington.edu
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Seymour
authors.forename: Roger A
authors.initials: RA
authors.lastname: Band
authors.forename: Colin R
authors.initials: CR
authors.lastname: Cooke
authors.forename: Mark E
authors.initials: ME
authors.lastname: Mikkelsen
authors.forename: Julie
authors.initials: J
authors.lastname: Hylton
authors.forename: Tom D
authors.initials: TD
authors.lastname: Rea
authors.forename: Christopher H
authors.initials: CH
authors.lastname: Goss
authors.forename: David F
authors.initials: DF
authors.lastname: Gaieski
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D019344:Lactic Acid / Q000097:blood*; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure; D010043:Outcome and Process Assessment, Health Care; D012044:Regression Analysis; D012189:Retrospective Studies; D018805:Sepsis / Q000628:therapy*; D012772:Shock, Septic
chemical_list: D019344:Lactic Acid
references.citation: J Emerg Med. 2010 Jun;38(5):578-81
references.pmid: 18614319
references.citation: Crit Care Med. 2001 Jul;29(7):1303-10
references.pmid: 11445675
references.citation: Crit Care Med. 2000 Aug;28(8):2793-8
references.pmid: 10966252
references.citation: J Trauma. 2003 Nov;55(5):860-3
references.pmid: 14608157
references.citation: Anaesth Intensive Care. 2008 Jan;36(1):51-9
references.pmid: 18326132
references.citation: Chest. 1992 Jun;101(6):1644-55
references.pmid: 1303622
references.citation: N Engl J Med. 2003 Apr 17;348(16):1546-54
references.pmid: 12700374
references.citation: Intensive Care Med. 2000 Aug;26(8):1037-45
references.pmid: 11030159
references.citation: Eur J Emerg Med. 1994 Jun;1(2):62-8
references.pmid: 9422140
references.citation: N Engl J Med. 2001 Nov 8;345(19):1368-77
references.pmid: 11794169
references.citation: Crit Care Med. 2009 May;37(5):1670-7
references.pmid: 19325467
references.citation: Crit Care Med. 2006 Apr;34(4):1025-32
references.pmid: 16484890
references.citation: J Trauma. 1999 Apr;46(4):565-79; discussion 579-81
references.pmid: 10217218
references.citation: Crit Care Med. 2003 Jun;31(6):1737-41
references.pmid: 12794413
references.citation: Crit Care Med. 2007 Sep;35(9):2016-24
references.pmid: 17855815
references.citation: Am J Physiol. 1984 Mar;246(3 Pt 2):H344-50
references.pmid: 6367487
references.citation: CMAJ. 2008 Apr 22;178(9):1141-52
references.pmid: 18427089
references.citation: Intensive Care Med. 2004 Apr;30(4):536-55
references.pmid: 14997291
references.citation: Crit Care Med. 2009 May;37(5):1649-54
references.pmid: 19325482
references.citation: Crit Care Med. 2008 May;36(5):1518-22
references.pmid: 18434908
references.citation: Acad Emerg Med. 2005 Apr;12(4):352-9
references.pmid: 15805328
references.citation: Clin Res Cardiol. 2008 Oct;97(10):748-52
references.pmid: 18483691
references.citation: Crit Care. 2008;12(6):R160
references.pmid: 19091118
references.citation: N Engl J Med. 2004 Aug 12;351(7):647-56
references.pmid: 15306666
references.citation: Intensive Care Med. 2003 Apr;29(4):530-8
references.pmid: 12664219
references.citation: Ann Emerg Med. 1999 Jan;33(1):44-50
references.pmid: 9867885
references.citation: JAMA. 1996 Feb 14;275(6):470-3
references.pmid: 8627969
references.citation: Acad Emerg Med. 2004 Mar;11(3):237-43
references.pmid: 15001402
references.citation: Intensive Care Med. 2008 Dec;34(12):2210-7
references.pmid: 18594793
references.citation: Crit Care Med. 2005 Oct;33(10):2194-201
references.pmid: 16215369
references.citation: Stroke. 1995 Jun;26(6):937-41
references.pmid: 7762041
references.citation: Am J Cardiol. 2008 Jan 15;101(2):158-61
references.pmid: 18178399
references.citation: Am J Public Health. 1989 Mar;79(3):340-9
references.pmid: 2916724
references.citation: Crit Care Med. 2007 Apr;35(4):1105-12
references.pmid: 17334251
references.citation: Crit Care Med. 1981 Aug;9(8):591-7
references.pmid: 7261642
references.citation: Crit Care Med. 1998 Nov;26(11):1793-800
references.pmid: 9824069
references.citation: Crit Care Med. 2006 Jun;34(6):1589-96
references.pmid: 16625125
references.citation: Chest. 2006 Nov;130(5):1579-95
references.pmid: 17099041
references.citation: Am J Emerg Med. 1994 Nov;12(6):617-20
references.pmid: 7945600
references.citation: Prehosp Emerg Care. 2006 Apr-Jun;10(2):198-206
references.pmid: 16531377
references.citation: Ann Emerg Med. 2006 Sep;48(3):326-31, 331.e1-3
references.pmid: 16934654
references.citation: Crit Care Med. 2004 Jan;32(1):256-62
references.pmid: 14707589
references.citation: Crit Care Med. 2008 Jan;36(1):296-327
references.pmid: 18158437
references.citation: Ann Emerg Med. 2004 Jan;43(1):106-13
references.pmid: 14707949
references.citation: Crit Care Med. 2004 Aug;32(8):1637-42
references.pmid: 15286537
references.citation: J Trauma. 1998 Sep;45(3):545-9
references.pmid: 9751548
references.citation: N Engl J Med. 2007 May 24;356(21):2156-64
references.pmid: 17522399
references.citation: J Trauma. 2003 Aug;55(2):355-61
references.pmid: 12913649
references.citation: Intensive Care Med. 1999 Jul;25(7):686-96
references.pmid: 10470572
references.citation: Prehosp Emerg Care. 2010 Apr-Jun;14(2):145-52
references.pmid: 20199228
references.citation: JAMA. 2001 Oct 10;286(14):1754-8
references.pmid: 11594901
references.citation: Shock. 2004 Aug;22(2):145-50
references.pmid: 15257087
references.citation: J Trauma. 1997 Apr;42(4):723-9
references.pmid: 9137264
references.citation: JAMA. 1995 Jul 26;274(4):338-45
references.pmid: 7609265
references.citation: Ann Emerg Med. 2006 Jul;48(1):28-54
references.pmid: 16781920
references.citation: Stroke. 2007 Oct;38(10):2765-70
references.pmid: 17717317