title: EMS patients and walk-in patients presenting with severe sepsis: differences in management and outcome.
abstract: OBJECTIVE
  Sepsis is a significant problem. The differences between patients with sepsis who walk into the emergency department (ED) and those who are transported via emergency medical services (EMS) have not been clarified. The aim of the study was to determine whether there was a difference in outcome between patients arriving by EMS and those presenting directly to the ED.
  
  
  METHODS
  We prospectively collected and reviewed a cohort of all cases of severe sepsis and septic shock admitted to the medical intensive care unit from the ED from November 2009 to March 2012. Extracted data were basic demographic information (including mode of ED arrival), clinical data, and treatments. We calculated Systemic Inflammatory Response Syndrome criteria, Acute Physiology and Chronic Health Evaluation II scores, and Sequential Organ Failure Assessment (SOFA) scores. The primary outcome was mortality in severely ill patients with sepsis.
  
  
  RESULTS
  A total of 378 subjects (78%) presented by EMS and 107 subjects were walk-in patients (22%). Patients transported via EMS were older (P < 0.01), had fewer lactates >4 (P < 0.02), a more altered mental status (P < 0.01), and higher respiratory rates (P < 0.05) than did walk-in patients. Patients transported by EMS had worse disease severity when measured by an Acute Physiology and Chronic Health Evaluation II score (P < 0.01) but not by SOFA score. EMS patients had a shorter time to receiving antibiotics (P = 0.02) and central line placement (P < 0.01) than did walk-in patients. In a logistic model, mortality was associated with increasing age (adjusted odds ratio 1.3; 95% confidence interval [CI] 1.2-1.4), higher first-measured ED lactates (1.2; 95% CI 1.1-1.2), and increased initial SOFA score (adjusted odds ratio 1.2; 95% CI 1.1-1.3) but not EMS arrival or prehospital fluids.
  
  
  CONCLUSIONS
  Neither arrival by EMS nor fluid administration by EMS is associated with decreased mortality in severe sepsis.
authors.affiliation: From the Department of Emergency Medicine, University of New Mexico, Albuquerque.
authors.forename: Jon
authors.initials: J
authors.lastname: Femling
authors.affiliation: From the Department of Emergency Medicine, University of New Mexico, Albuquerque.
authors.forename: Steven
authors.initials: S
authors.lastname: Weiss
authors.affiliation: From the Department of Emergency Medicine, University of New Mexico, Albuquerque.
authors.forename: Eric
authors.initials: E
authors.lastname: Hauswald
authors.affiliation: From the Department of Emergency Medicine, University of New Mexico, Albuquerque.
authors.forename: David
authors.initials: D
authors.lastname: Tarby
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004632:Emergency Medical Services / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D018805:Sepsis / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D012720:Severity of Illness Index; D012772:Shock, Septic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D014187:Transportation of Patients / Q000706:statistics & numerical data