title: Presentations of adult septic patients in the prehospital setting as recorded by emergency medical services: a mixed methods analysis.
abstract: BACKGROUND
  Current sepsis screening tools rely on vital parameters which are, however, normal in one third of patients with serious infections. Therefore, there is a need to include other variables than vital parameters to identify septic patients. Our primary aim was to identify and quantify keywords related to the septic patients' symptom presentation in the prehospital setting. The secondary aims were to compare keywords in relation to in-hospital mortality and the distribution of keywords in relation to age categories, survivors/ deceased and severe/ non-severe sepsis.
  
  
  METHODS
  A mixed methods analysis using a sequential exploratory design was performed, starting with a content analysis of presentations of septic patients as documented in Emergency Medical Services (EMS) records (n = 80) from 2012, to identify keywords related to sepsis presentation. Thereafter, the identified keywords were quantified among 359 septic patients from 2013. All patients were adults, admitted to Södersjukhuset and discharged with an ICD-10-code (International Classification of Diseases, Tenth Revision) compatible with sepsis.
  
  
  RESULTS
  The most common keywords related to septic patients' symptom presentation were: abnormal/ suspected abnormal temperature (64.1.%), pain (38.4%), acute altered mental status (38.2%), weakness of the legs (35.1%), breathing difficulties (30.4%), loss of energy (26.2%) and gastrointestinal symptoms (24.0%). There was an association between keywords and in-hospital mortality. Symptoms varied between age categories, survivors/ deceased and severe/ non-severe sepsis.
  
  
  CONCLUSIONS
  This is, to the best of our knowledge, the first study exploring the symptom presentation as documented by EMS, of septic patients in the prehospital setting. Keywords related to patients´ symptom presentation recurred in the EMS records of septic patients, so that a pattern was discernible. In addition, certain symptom presentations were associated with increased in-hospital mortality CONCLUSIONS: Information relating to symptom presentation is not included in current sepsis screening tools. We suggest that keywords related to patients´ symptom presentation could be integrated into screening tools and may thus increase the identification of sepsis, and potentially also identify high-risk patients. However, as a first step, the specificity of these keywords, with respect to sepsis, needs to be examined.
authors.affiliation: Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sjukhusbacken 10, SE 118 83, Stockholm, Sweden. ulrika.wallgren@sll.se.|Fisksätra Vårdcentral (Primary Health Care Center), Fisksätra torg 20, SE 133 41, Saltsjöbaden, Sweden. ulrika.wallgren@sll.se.
authors.forename: Ulrika Margareta
authors.initials: UM
authors.lastname: Wallgren
authors.affiliation: Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sjukhusbacken 10, SE 118 83, Stockholm, Sweden.
authors.forename: Katarina Eva Margareta
authors.initials: KEM
authors.lastname: Bohm
authors.affiliation: Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sjukhusbacken 10, SE 118 83, Stockholm, Sweden.|Department of Medical Sciences, Örebro University, SE 701 82, Örebro, Sweden.
authors.forename: Lisa
authors.initials: L
authors.lastname: Kurland
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D004632:Emergency Medical Services; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D012772:Shock, Septic / Q000175:diagnosis* / Q000503:physiopathology*
keywords: Emergency Care; Emergency Medical Services; Prehospital; Sepsis