title: Arriving by emergency medical services improves time to treatment endpoints for patients with severe sepsis or septic shock.
abstract: OBJECTIVE
  The objective was to evaluate the effect of arrival to the emergency department (ED) by emergency medical services (EMS) on time to initiation of antibiotics, time to initiation of intravenous fluids (IVF), and in-hospital mortality in patients with severe sepsis and septic shock.
  
  
  METHODS
  The authors performed an evaluation of prospectively collected registry data of patients with a diagnosis of severe sepsis or septic shock who presented to an urban academic ED during a 2-year period from January 1, 2005, to December 31, 2006. Descriptive and multivariate analytic methods were used to analyze the data. Using unadjusted and adjusted models, out-of-hospital patients who presented to the ED by ambulance (EMS) were compared to control patients who arrived by alternative means (non-EMS). Primary outcomes measured were ED time to initiation of antibiotics, ED time to initiation of IVF, and in-hospital mortality.
  
  
  RESULTS
  A total of 963 severe sepsis patients were enrolled in the registry. Median time to antibiotics was 116 minutes for EMS (interquartile range [IQR] = 66 to 199) vs. 152 minutes for non-EMS (IQR = 92 to 252, p ≤ 0.001). Median time to initiation of IVF was 34 minutes for EMS (IQR = 10 to 88) and 68 minutes for non-EMS (IQR = 25 to 121, p ≤ 0.001). After adjustment for the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, age, and initial serum lactate level, no significant differences in hospital mortality were seen (adjusted relative risk [aRR] for EMS vs. non EMS = 1.24, 95% confidence interval [CI] = 0.92 to 1.66, p = 0.16). The Cox proportional hazard ratio (HR) comparing EMS to non-EMS care after similar adjustment was HR = 1.27 for IVF (95% CI = 1.10 to 1.47, p = 0.004) and HR = 1.25 for antibiotics (95% CI = 1.08 to 1.44, p = 0.003).
  
  
  CONCLUSIONS
  Out-of-hospital care was associated with improved in-hospital processes for the care of critically ill patients. Despite shortened ED treatment times for septic patients who arrive by EMS, a mortality benefit could not be demonstrated.
authors: Department of Emergency Medicine, University of Pennsylvania, Philadelphia, USA. roger.band@uphs.upenn.edu
authors: Roger A
authors: RA
authors: Band
authors: David F
authors: DF
authors: Gaieski
authors: Julie H
authors: JH
authors: Hylton
authors: Frances S
authors: FS
authors: Shofer
authors: Munish
authors: M
authors: Goyal
authors: Zachary F
authors: ZF
authors: Meisel
mesh_terms: D018806:APACHE; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D004638:Emergency Treatment; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007262:Infusions, Intravenous; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D018805:Sepsis / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D012720:Severity of Illness Index; D012772:Shock, Septic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents