What are the guidelines for prehospital recognition and treatment of sepsis?

Prehospital Sepsis Recognition and Treatment Guidelines

Prehospital providers should use the National Early Warning Score 2 (NEWS2) to identify patients with suspected sepsis and administer antibiotics within one hour for high-risk patients when transfer time to hospital exceeds one hour. 1

Recognition of Sepsis in Prehospital Settings

Screening Tools

• Use NEWS2 as the standardized screening tool for sepsis risk stratification 1
• NEWS2 score interpretation for risk of severe illness or death from sepsis:
  • Score 0: Very low risk
  • Score 1-4: Low risk
  • Score 5-6: Moderate risk
  • Score ≥7: High risk

Key Clinical Parameters to Assess

• Respiratory rate (breaths per minute)
• Oxygen saturation (SpO2)
• Systolic blood pressure (mmHg)
• Pulse rate (beats per minute)
• Level of consciousness (AVPU scale)
• Temperature (°C)
• Use of supplemental oxygen

Additional High-Risk Indicators

Consider evaluating risk as higher than suggested by NEWS2 score if any of the following are present 1:

• Mottled or ashen appearance
• Non-blanching petechial or purpuric rash
• Cyanosis of skin, lips, or tongue
• Clinical deterioration since previous assessment

Prehospital Management Algorithm

Step 1: Initial Assessment

• Calculate NEWS2 score within 15 minutes of patient contact
• Obtain history of suspected infection
• Document vital signs and mental status

Step 2: Risk Stratification

Based on NEWS2 score, categorize patient as:

• High risk (NEWS2 ≥7)
• Moderate risk (NEWS2 5-6)
• Low risk (NEWS2 1-4)
• Very low risk (NEWS2 0)

Step 3: Management Based on Risk Level and Transfer Time

For High-Risk Patients (NEWS2 ≥7):

• If transfer time to hospital >1 hour:

  • Administer antibiotics according to local guidelines 1
  • Alert receiving hospital about high-risk sepsis patient
  • Reassess NEWS2 every 30 minutes
  • Establish IV access and collect blood cultures if possible before antibiotic administration 1

• If transfer time to hospital <1 hour:

  • Alert receiving hospital about high-risk sepsis patient
  • Expedite transfer
  • Reassess NEWS2 every 30 minutes

For Moderate-Risk Patients (NEWS2 5-6):

• Alert receiving hospital about moderate-risk sepsis patient
• Reassess NEWS2 every hour
• Follow local protocols regarding antibiotic administration
• Consider antibiotics if transfer time >3 hours 1

For Low-Risk Patients (NEWS2 1-4):

• Reassess NEWS2 every 4-6 hours
• Monitor for clinical deterioration
• Transport to appropriate facility

Antibiotic Administration Guidelines

When to Administer Antibiotics

• High-risk patients (NEWS2 ≥7) with transfer time >1 hour: Administer within 1 hour 1
• Moderate-risk patients (NEWS2 5-6) with transfer time >3 hours: Consider antibiotics 1
• Follow local guidelines for antibiotic selection

Antibiotic Administration Procedure

• Collect blood cultures before antibiotic administration if possible (do not delay antibiotics >45 minutes for cultures) 1
• Use broad-spectrum antibiotics according to local protocols
• Document time of antibiotic administration
• Communicate antibiotic administration to receiving facility

Implementation Considerations

Training Requirements

• Train paramedics in:
  • NEWS2 calculation and interpretation
  • Sepsis recognition
  • Aseptic blood culture collection techniques
  • Antibiotic administration protocols

Quality Improvement

• Implement performance improvement programs for sepsis 1
• Monitor compliance with sepsis screening protocols
• Track time to antibiotic administration for high-risk patients
• Review outcomes and adjust protocols as needed

Common Pitfalls to Avoid

1. Delayed recognition: Failure to calculate NEWS2 promptly can delay treatment
2. Over-reliance on single parameters: Interpret NEWS2 in context of patient's baseline physiology and comorbidities 1
3. Failure to reassess: Sepsis can rapidly progress; regular reassessment is critical
4. Inappropriate antibiotic use: Balance between early treatment and antimicrobial stewardship
5. Poor communication: Ensure clear handover to receiving facility about sepsis suspicion and treatments given

Special Considerations

Rural and Remote Settings

• In remote locations, patients assessed as high risk should receive antibiotics outside of hospital according to local guidelines 1
• Consider local resources and transport times when making treatment decisions

Mental Health Settings

• For patients in acute mental health settings at high risk of sepsis, follow local emergency protocols for treatment and ambulance transfer 1

Documentation Requirements

• Document NEWS2 scores and times calculated
• Record all interventions and times administered
• Document rationale for treatment decisions
• Ensure comprehensive handover to receiving facility

By implementing these guidelines, prehospital providers can significantly improve early recognition and treatment of sepsis, potentially reducing morbidity and mortality through timely intervention.