Original Article

EMS Patients and Walk-In Patients Presenting With Severe Sepsis: Differences in Management and Outcome

Authors: Jon Femling, MD, PhD, Steven Weiss, MD, Eric Hauswald, BA, David Tarby, MD


Objectives: 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.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Rivers EP, Katranji M, Jaehne KA, et al. Early interventions in severe sepsis and septic shock: a review of the evidence one decade later. Minerva Anestesiol 2012;78:712-724. .
2. Perman SM, Goyal M, Gaieski DF. Initial emergency department diagnosis and management of adult patients with severe sepsis and septic shock. Scand J Trauma Resusc Emerg Med 2012;20:41.
3. Kethireddy S, Kumar A. Mortality due to septic shock following early, appropriate antibiotic therapy: can we do better?* Crit Care Med 2012;40:2228-2229.
4. Nguyen HB, Lynch EL, Mou JA, et al. The utility of a quality improvement bundle in bridging the gap between research and standard care in the management of severe sepsis and septic shock in the emergency department. Acad Emerg Med 2007;14:1079-1086.
5. Puskarich MA, Trzeciak S, Shapiro NI, et al. Prognostic value and agreement of achieving lactate clearance or central venous oxygen saturation goals during early sepsis resuscitation. Acad Emerg Med 2012;19:252-258.
6. Jones AE, Shapiro NI, Trzeciak S, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA 2010;303:739-746.
7. Goyal M, Pines JM, Drumheller BC, et al. Point-of-care testing at triage decreases time to lactate level in septic patients. J Emerg Med 2010;38:578-581.
8. Puskarich MA, Kline JA, Summers RL, et al. Prognostic value of incremental lactate elevations in emergency department patients with suspected infection. Acad Emerg Med 2012;19:983-985.
9. Band RA, Gaieski DF, Hylton JH, et al. Arriving by emergency medical services improves time to treatment endpoints for patients with severe sepsis or septic shock. Acad Emerg Med 2011;18:934-940.
10. Studnek JR, Artho MR, Garner CL Jr, et al. The impact of emergency medical services on the ED care of severe sepsis. Am J Emerg Med 2012;30:51-56.
11. Seymour CW, Band RA, Cooke CR, et al. Out-of-hospital characteristics and care of patients with severe sepsis: a cohort study. J Crit Care 2010;25:553-562.
12. Seymour CW, Cooke CR, Mikkelsen ME, et al. Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department. Prehosp Emerg Care 2010;14:145-152.
13. Wang HE, Weaver MD, Shapiro NI, et al. Opportunities for emergency medical services care of sepsis. Resuscitation 2010;81:193-197.
14. Guerra WF, Mayfield TR, Meyers MS, et al. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med 2013;44:1116-1125.
15. Seymour CW, Rea TD, Kahn JM, et al. Severe sepsis in pre-hospital emergency care: analysis of incidence, care, and outcome. Am J Respir Crit Care Med 2012;186:1264-1271.
16. Herlitz J, Bang A, Wireklint-Sundstrom B, et al. Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care. Scand J Trauma Resusc Emerg Med 2012;20:42.
17. Brown JP, Mahmud E, Dunford JV, et al. Effect of prehospital 12-lead electrocardiogram on activation of the cardiac catheterization laboratory and door-to-balloon time in ST-segment elevation acute myocardial infarction. Am J Cardiol 2008;101:158-161.
18. Mosley I, Nicol M, Donnan G, et al. The impact of ambulance practice on acute stroke care. Stroke 2007;38:2765-2770.
19. Hartl R, Gerber LM, Iacono L, et al. Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury. J Trauma 2006;60:1250-1256.
20. Institute for Healthcare improvement. http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis. Accessed November 14, 2009.
21. Nguyen HB, Van Ginkel C, Batech M, et al. Comparison of Predisposition, Insult/Infection, Response, and Organ dysfunction, Acute Physiology And Chronic Health Evaluation II, and Mortality in Emergency Department Sepsis in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. J Crit Care 2012;27:362-369.
22. Jones AE, Trzeciak S, Kline JA. The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Crit Care Med 2009;37:1649-1654.
23. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-1377.
24. Nguyen HB, Banta JE, Cho TW, et al. Mortality predictions using current physiologic scoring systems in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. Shock 2008;30:23-28.
25. Vincent JL, de Mendonc¸a A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on ‘‘sepsis-related problems’’ of the European Society of Intensive Care Medicine. Crit Care Med 1998;26:1793-1800.