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Sepsis Syndrome

Date Last Search Run: Oct 01, 2021
Table last updated: Oct 25, 2021
Data last added: Oct 25, 2021

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)      
2 (fair evidence exists)  
3 (weak evidence exists)      


Interventions

Early Goal Directed Therapy
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) In-Hospital Mortality Patient ED-MD Rivers E., et al. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. N Engl J Med 2001; 345(19):1368-77. Medline
I Neutral (Yellow) 90 day mortality Patient ED-MD ARISE Investigators, ANZICS Clinical Trials Group, Peake SL, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014; 371(16):1496-1506. Medline
I Neutral (Yellow) All-cause mortality Patient Jiang LB., Zhang M., Jiang SY., Ma YF. Early goal-directed resuscitation for patients with severe sepsis and septic shock: a meta-analysis and trial sequential analysis. Scand J Trauma Resusc Emerg Med 2016; 24:23-016-0214-7. Medline
I Neutral (Yellow) All-cause 90 day mortality Patient ED-MD Mouncey P., Osborn T., Power GS., et al. Protocolised Management In Sepsis (ProMISe): a multicentre randomised controlled trial of the clinical effectiveness and cost-effectiveness of early, goal-directed, protocolised resuscitation for emerging septic shock. Health Technology Assessment 2015; 19:97. Medline
I Neutral (Yellow) Mortality Patient ED-MD ProCESS Investigators, Yealy DM., Kellum JA., et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014; 370(18):1683-93. Medline
I Neutral (Yellow) 90 day mortality Patient ED-MD The PRISM Investigators*. Early, Goal-Directed Therapy for Septic Shock— A Patient-Level Meta-Analysis. N Engl J Med 2017; 376(23):2223-2234. Medline
I Neutral (Yellow) 28 day mortality Patient ED-MD Yu H., Chi D., Wang S., Liu B. Effect of early goal-directed therapy on mortality in patients with severe sepsis or septic shock: a meta-analysis of randomised controlled trials. BMJ Open 2016; 6(3):e008330-2015-008330. Medline
II Supportive (Green) In-Hospital Mortality Patient ED-MD El KC, Abou DG, Chami A., Bou CR, Amoun T., Bachir R., et al. The Impact of EGDT on Sepsis Mortality in a Single Tertiary Care Center in Lebanon. Emergency medicine international 2019; 8747282. Medline
II Supportive (Green) Mortality Patient ED-MD El Solh AA., Akinnusi ME., Alsawalha LN., Pineda LA. Outcome of Septic Shock in Older Adults After Implementation of the Sepsis Bundle. J Am Geriatr Soc 2008; 56:272-8. Medline
II Supportive (Green) Time to antibiotics Process ED-MD Francis M., Rich T., Williamson T., Peterson D. Effect of an emergency department sepsis protocol on time to antibiotics in severe sepsis. CJEM 2010; 12(4):303-10. Medline
II Supportive (Green) 28 day in-hospital mortality Patient ED-MD Hanzelka KM., Yeung SC., Chisholm G., et al. Implementation of modified early-goal directed therapy for sepsis in the emergency center of a comprehensive cancer center. Support Care Cancer 2013; 21(3):727-34. Medline
II Supportive (Green) In-hospital mortality Patient ED-MD Jones AE., Focht A., Horton JM., Kline JA. Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock. Chest 2007; 132(2):425-32. Medline
II Supportive (Green) Feasibility of implementation Process ED-MD Nguyen HB., Corbett SW., Steele R., et al. Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med 2007; 35(4):1105-12. Medline
II Supportive (Green) 28 day mortality Patient ED-MD Permpikul C., Sringam P., Tongyoo S. Therapeutic goal achievements during severe sepsis and septic shock resuscitation and their association with patients' outcomes. J Med Assoc Thai 2014; 97(S3):S176-83. Medline
II Supportive (Green) In-hospital mortality Patient ED-MD Prasad PA, Shea ER, Shiboski S, Sullivan MC, Gonzales R, Shimabukuro D. Relationship Between a Sepsis Intervention Bundle and In-Hospital Mortality Among Hospitalized Patients: A Retrospective Analysis of Real-World Data. Anesth Analg 2017; 125(2):507-13. Medline
II Supportive (Green) Mortality at 1 year Patient ED-MD Puskarich MA., Marchick MR., Kline JA., Steuerwald MT., Jones AE. One year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study. Crit Care 2009; 13(5):R167. Medline
II Supportive (Green) In-hospital mortality rate Patient ED-MD Sivayoham N., Rhodes A., Jaiganesh T., van Zyl Smit N., Elkhodhair S., Krishnanandan S. Outcomes from implementing early goal-directed therapy for severe sepsis and septic shock : A 4-year observational cohort study. Eur J Emerg Med 2012; 19(4):235-240. Medline
II Supportive (Green) Time to initiation of antibiotics in ED Process ED-MD Studnek JR., Artho MR., Garner CL., Jr, Jones AE. The impact of emergency medical services on the ED care of severe sepsis. Am J Emerg Med 2012; 30(1):51-56. Medline
II Neutral (Yellow) Mortality Patient ED-MD Crowe CA., Mistry CD., Rzechula K., Kulstad CE. Evaluation of a modified early goal-directed therapy protocol. Am J Emerg Med 2010; 28(6):689-93. Medline
II Neutral (Yellow) Mortality Patient ED-MD Focht A., Jones AE., Lowe TJ. Early goal-directed therapy: Improving mortality and morbidity of sepsis in the emergency department. Jt Comm J Qual Patient Saf 2009; 35(4):186-91. Medline
II Neutral (Yellow) Achievement of EGDT benchmarks Process ED-MD Worapratya P., Wanjaroenchaisuk A., Joraluck J., Wuthisuthimethawee P. Success of applying early goal-directed therapy for septic shock patients in the emergency department. Open Access Emerg Med 2016; 8:1-6. Medline
II Opposes (Red) Mortality Patient ED-MD Ho BC., Bellomo R., McGain F., et al. The incidence and outcome of septic shock patients in the absence of early-goal directed therapy. Crit Care 2006; 10(3):R80. Medline
III Supportive (Green) Feasibility Process PH-Paramedic Walchok JG., Pirrallo RG., Furmanek D., Lutz M., Shope C., Giles B., et al. Paramedic-Initiated CMS Sepsis Core Measure Bundle Prior to Hospital Arrival: A Stepwise Approach. Prehosp Emerg Care 2016; 05:1-10. Medline

Identification tools (other)
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Prediction of severe sepsis Process ED-MD Askim Ã., Moser F., Gustad LT., Stene H., Gundersen M., Ãsvold BO., et al. Poor performance of quick-SOFA (qSOFA) score in predicting severe sepsis and mortality - a prospective study of patients admitted with infection to the emergency department. Scandinavian journal of trauma, resuscitation and emergency medicine 2017; 25(1):56. Medline
II Supportive (Green) Bundle compliance Process PH-Paramedic Borrelli G, Koch E, Sterk E, Lovett S, Rech MA. Early recognition of sepsis through emergency medical services pre-hospital screening. Am J Emerg Med 2018. Medline
II Supportive (Green) Prediction of mortality Process ED-MD Brink A, Alsma J, Verdonschot RJCG, Rood PPM, Zietse R, Lingsma HF, et al. (2019) Predicting mortality in patients with suspected sepsis at the Emergency Department; A retrospective cohort study comparing qSOFA, SIRS and National Early Warning Score. PLoS ONE 14(1): e0211133 Medline
II Supportive (Green) Prediction of in-hospital mortality Process ED-MD Cag Y., Karabay O., Sipahi OR., Aksoy F., Durmus G., Batirel A., et al. Development and validation of a modified quick SOFA scale for risk assessment in sepsis syndrome. PloS one 2018; 13(9):e0204608. Medline
II Supportive (Green) Time to triage Process ED-MD Carberry M., Harden J. A collaborative improvement project by an NHS Emergency Department and Scottish Ambulance Paramedics to improve the identification and delivery of sepsis 6. BMJ Qual Improv Rep 2016; 5(1):u212670.w5049. Medline
II Supportive (Green) Prediction of Mortality Process ED-MD Chang SH., Hsieh CH., Weng YM., Hsieh MS., Goh ZNL., Chen HY., et al. Performance Assessment of the Mortality in Emergency Department Sepsis Score, Modified Early Warning Score, Rapid Emergency Medicine Score, and Rapid Acute Physiology Score in Predicting Survival Outcomes of Adult Renal Abscess Patients in the Emergency Department. BioMed research international 2018; 2018:6983568. Medline
II Supportive (Green) In-hospital mortality prediction Process ED-MD Chen KF, Liu SH, Li CH, Wu CC, Chaou CH, Tzeng IS, et al. Development and validation of a parsimonious and pragmatic CHARM score to predict mortality in patients with suspected sepsis. Am J Emerg Med 2017; 35(4):640-6. Medline
II Supportive (Green) Prediction of sepsis Process ED-MD Gilbert BW, Faires L, Meister A, Huffman J, Faber RK. Comparison of Sepsis-3 Criteria Versus SIRS Criteria in Screening Patients for Sepsis in the Emergency Department. Advanced emergency nursing journal 2018; 40(2):138-43. Medline
II Supportive (Green) 30-day mortality. Patient ED-MD González del Castillo J, Escobar-Curbelo L, Martínez-Ortíz de Zárate F, García-Lamberechts J, Moreno-Cuervo Ã, et al. GYM score: 30-day mortality predictive model in elderly patients attended in the emergency department with infection. European journal of emergency medicine: official journal of the European Society for Emergency Medicine 2017; 24(3):183-8. Medline
II Supportive (Green) Prediction of 30-day mortality Process González del Castillo J, Julian-Jiménez A, González-Martínez F, Álvarez-Manzanares J, Piñera P, Navarro-Bustos C, et al. Prognostic accuracy of SIRS criteria, qSOFA score and GYM score for 30-day-mortality in older non-severely dependent infected patients attended in the emergency department. European journal of clinical microbiology & infectious diseases: official publication of the European Society of Clinical Microbiology 2017; 36(12):2361-9. Medline
II Supportive (Green) EMS identification of sepsis Process PH-Paramedic Guerra WF., Mayfield TR., Meyers MS., Clouatre AE., Riccio JC. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med 2013; 44(6):1116-25. Medline
II Supportive (Green) Mortality Patient Hunter C., Silvestri S., Ralls G., Stone A., Walker A., Mangalat N., et al. Comparing Quick Sequential Organ Failure Assessment Scores to End-tidal Carbon Dioxide as Mortality Predictors in Prehospital Patients with Suspected Sepsis. WestJEM 2018; 19(3):446–51.  Medline
II Supportive (Green) Sepsis and severe sepsis in-hospital mortality Patient PH-Paramedic Hunter CL., Silvestri S., Ralls G., Stone A., Walker A., Papa L. A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis. Am J Emerg Med 2016; 34(5):813-9. Medline
II Supportive (Green) % receiving antibiotics within 60 minutes of triage Process ED-MD Idrees M., Macdonald SP., Kodali K. Sepsis Early Alert Tool: Early recognition and timely management in the emergency department. Emerg Med Australas 2016; 28(4):399-403. Medline
II Supportive (Green) Prediction of 28 day mortality Process ED-MD Innocenti F., Tozzi C., Donnini C., De Villa E., Conti A., Zanobetti M., et al. SOFA score in septic patients: incremental prognostic value over age, comorbidities, and parameters of sepsis severity. Intern Emerg Med 2018; 13(3):405-412. Medline
II Supportive (Green) Prediction of admission Process ED-MD Jiang L., Caputo ND., Chang BP. Respiratory adjusted shock index for identifying occult shock and level of Care in Sepsis Patients. Am J Emerg Med 2019; 37(3):506-9. Medline
II Supportive (Green) Prediction of ICU admission Process PH-Paramedic Jouffroy R., Saade A., Ellouze S., Carpentier A., Michaloux M., Carli P., et al. Prehospital triage of septic patients at the SAMU regulation: Comparison of qSOFA, MRST, MEWS and PRESEP scores. Am J Emerg Med 2018; 36(5):820-4. Medline
II Supportive (Green) Accuracy of prehospital identification Process PH-Paramedic Lane D., Ichelson R., Drennan I., Scales D. Prehospital management and identification of sepsis by emergency medical services: a systematic review. Emerg Med J 2016; 33:408–413. Medline
II Supportive (Green) Area under the receiver operating characteristic (AUROC) curve for detection and prediction of sepsis, severe sepsis and septic shock Process Mao Q, Jay M, Hoffman JL, Calvert J, Barton C, Shimabukuro D, et al. Multicentre validation of a sepsis prediction algorithm using only vital sign data in the emergency department, general ward and ICU. BMJ open 2018; 8(1):e017833. Medline
II Supportive (Green) Time to treatment Process ED-MD McDonald CM., West S., Dushenski D., Lapinsky SE., Soong C., van den BK, et al. Sepsis now a priority: a quality improvement initiative for early sepsis recognition and care. International journal for quality in health care 2018; 30(10):802-9. Medline
II Supportive (Green) Prediction of direct ICU admission Process ED-MD Quinten VM., van MM, Wolffensperger AE., Ter MJ, Ligtenberg JJM. Sepsis patients in the emergency department: stratification using the Clinical Impression Score, Predisposition, Infection, Response and Organ dysfunction score or quick Sequential Organ Failure Assessment score? European journal of emergency medicine 2018; 25(5):328-34. Medline
II Supportive (Green) all-cause in-hospital mortality Patient ED-MD Ranzani OT, Prina E, Menéndez R, Ceccato A, Cilloniz C, et al. New Sepsis Definition (Sepsis-3) and Community-acquired Pneumonia Mortality. A Validation and Clinical Decision-Making Study. American journal of respiratory and critical care medicine 2017; 196(10):1287-97. Medline
II Supportive (Green) Time to antibiotics Process Rosenqvist M., Fagerstrand E., Lanbeck P., Melander O., Akesson P. Sepsis Alert - a triage model that reduces time to antibiotics and length of hospital stay. Infect Dis (Lond) 2017; 49(7):507-13. Medline
II Supportive (Green) Prediction of 28 day mortality Process ED-MD Saeed K., Wilson DC., Bloos F., Schuetz P., van der DY, Melander O., et al. The early identification of disease progression in patients with suspected infection presenting to the emergency department: a multi-centre derivation and validation study. Crit Care 2019; 23(1):40. Medline
II Supportive (Green) Prediction of 30 in-hospital mortality Process Samsudin MI, Liu N, Prabhakar SM, Chong SL, Kit LW, Koh ZX, et al. A novel heart rate variability based risk prediction model for septic patients presenting to the emergency department. Medicine 2018; 97(23):e10866. Medline
II Neutral (Yellow) Predicting sepsis Process ED-MD Filbin MR., Thorsen JE., Lynch J., Gillingham TD., Pasakarnis CL., Capp R., et al. Challenges and Opportunities for Emergency Department Sepsis Screening at Triage. Scientific reports 2018; 8(1):11059. Medline
II Neutral (Yellow) Sepsis identification Process PH-Paramedic Green R., Travers A., Cain E., et al. Paramedic Recognition of Sepsis in the Prehospital Setting: A Prospective Observational Study. Emerg Med Int 2016; 2016:6717261 Medline
II Neutral (Yellow) Bundle compliance Process ED-MD Shah T., Sterk E., Rech MA. Emergency department sepsis screening tool decreases time to antibiotics in patients with sepsis. Am J Emerg Med 2018; 36(10):1745-8. Medline
II Neutral (Yellow) Prediction of sepsis Process ED-MD Shetty AL., Brown T., Booth T., Van KL., Dor-Shiffer DE., Vaghasiya MR., et al. Systemic inflammatory response syndrome-based severe sepsis screening algorithms in emergency department patients with suspected sepsis. Emerg Med Australas 2016; 28(3):287-294. Medline
II Neutral (Yellow) ICU admission within 48 h Process PH-Paramedic Silcock DJ, Corfield AR, Rooney KD, Staines H. Superior performance of National Early Warning Score compared with quick Sepsis-related Organ Failure Assessment Score in predicting adverse outcomes: a retrospective observational study of patients in the prehospital setting. European journal of emergency medicine: official journal of the European Society for Emergency Medicine 2018. Medline
III Supportive (Green) Diagnosis of sepsis Process ED-MD Althunayyan SM., Alsofayan YM., Khan AA. Shock index and modified shock index as triage screening tools for sepsis. Journal of infection and public health 2019; 12(6):822-6. Medline
III Supportive (Green) All-cause mortality Patient In-Patient Henning DJ, Puskarich MA, Self WH, Howell MD, Donnino MW, Yealy DM, et al. An Emergency Department Validation of the SEP-3 Sepsis and Septic Shock Definitions and Comparison With 1992 Consensus Definitions. Ann Emerg Med 2017; 70(4):544-52.e5. Medline
III Supportive (Green) Sepsis identification Process PH-Paramedic Lane DJ, Wunsch H, Saskin R, et al. Screening strategies to identify sepsis in the prehospital setting: a validation study. CMAJ. 2020;192(10):E230–E239. doi:10.1503/cmaj.190966 Medline
III Supportive (Green) Detection of sepsis Process PH-Paramedic Smyth MA., Brace-McDonnell SJ., Perkins GD. Identification of adults with sepsis in the prehospital environment: a systematic review. BMJ Open 2016; 6(8):e011218-2016-011218. Medline
III Supportive (Green) Predicting critical illness Process PH-Paramedic Smyth MA., Gallacher D., Kimani PK., Ragoo M., Ward M., Perkins GD. Derivation and internal validation of the screening to enhance prehospital identification of sepsis (SEPSIS) score in adults on arrival at the emergency department. Scandinavian journal of trauma, resuscitation and emergency medicine 2019; 27(1):67. Medline
III Supportive (Green) Prediction of sepsis Process PH-Paramedic Wallgren UM., Bohm KEM., Kurland L. Presentations of adult septic patients in the prehospital setting as recorded by emergency medical services: a mixed methods analysis. Scand J Trauma Resusc Emerg Med 2017; 25(1):23. Medline
III Supportive (Green) Time to diagnosis Process ED-MD Westphal GA., Pereira AB., Fachin SM., Sperotto G., Gonçalves M., Albino L., et al. An electronic warning system helps reduce the time to diagnosis of sepsis. Revista Brasileira de terapia intensive 2018; 30(4):414-22. Medline
III Neutral (Yellow) Prediction of sepsis Process PH-Paramedic Baez AA., Cochon L. Acute Care Diagnostics Collaboration: Assessment of a Bayesian clinical decision model integrating the Prehospital Sepsis Score and point-of-care lactate. Am J Emerg Med 2016; 34(2):193-6. Medline
III Opposes (Red) Prediction of sepsis Process ED-MD Gräff I, Goldschmidt B, Glien P, Dolscheid-Pommerich RC, Fimmers R, Grigutsch D. Validity of the Manchester Triage System in patients with sepsis presenting at the ED: a first assessment. Emergency medicine journal: EMJ 2017; 34(4):212-8. Medline
X Not Yet Graded (White) - Martín-Rodríguez F, Sanz-García A, del Poza Vegas C, Ortega GJ, Castro Villamor MA, López-Izquierdo R. Time for a prehospital-modified sequential organ failure assessment score: An ambulance-Based cohort study. Am J Emerg Med 2021; 49:331–7. Medline

Identification tools- qSOFA
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Prediction of sepsis Process ED-MD April MD., Aguirre J., Tannenbaum LI., Moore T., Pingree A., Thaxton RE., et al. Sepsis Clinical Criteria in Emergency Department Patients Admitted to an Intensive Care Unit: An External Validation Study of Quick Sequential Organ Failure Assessment. J Emerg Med 2017; 52(5):622-31. Medline
II Supportive (Green) Prediction of mortality Process ED-MD Brink A, Alsma J, Verdonschot RJCG, Rood PPM, Zietse R, Lingsma HF, et al. (2019) Predicting mortality in patients with suspected sepsis at the Emergency Department; A retrospective cohort study comparing qSOFA, SIRS and National Early Warning Score. PLoS ONE 14(1): e0211133 Medline
II Supportive (Green) Prediction of in-hospital mortality Process ED-MD Cag Y., Karabay O., Sipahi OR., Aksoy F., Durmus G., Batirel A., et al. Development and validation of a modified quick SOFA scale for risk assessment in sepsis syndrome. PloS one 2018; 13(9):e0204608. Medline
II Supportive (Green) Prediction of 30-day mortality Process González del Castillo J, Julian-Jiménez A, González-Martínez F, Álvarez-Manzanares J, Piñera P, Navarro-Bustos C, et al. Prognostic accuracy of SIRS criteria, qSOFA score and GYM score for 30-day-mortality in older non-severely dependent infected patients attended in the emergency department. European journal of clinical microbiology & infectious diseases: official publication of the European Society of Clinical Microbiology 2017; 36(12):2361-9. Medline
II Supportive (Green) Prediction of in-hospital mortality Process PH-Paramedic Harada M., Takahashi T., Haga Y., Nishikawa T. Comparative study on quick sequential organ failure assessment, systemic inflammatory response syndrome and the shock index in prehospital emergency patients: single-site retrospective study. Acute medicine & surgery 2019; 6(2):131-7. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Hunter C., Silvestri S., Ralls G., Stone A., Walker A., Mangalat N., et al. Comparing Quick Sequential Organ Failure Assessment Scores to End-tidal Carbon Dioxide as Mortality Predictors in Prehospital Patients with Suspected Sepsis. WestJEM 2018; 19(3):446–51.  Medline
II Supportive (Green) Prediction of 28 day mortality Process ED-MD Innocenti F., Tozzi C., Donnini C., De Villa E., Conti A., Zanobetti M., et al. SOFA score in septic patients: incremental prognostic value over age, comorbidities, and parameters of sepsis severity. Intern Emerg Med 2018; 13(3):405-412. Medline
II Supportive (Green) Prediction of mortality Process ED-MD Kwak H., Suh GJ., Kim T., Kwon WY., Kim KS., Jung YS., et al. Prognostic performance of Emergency Severity Index (ESI) combined with qSOFA score. Am J Emerg Med 2018; 36(10):1784-8. Medline
II Supportive (Green) Prediction of in-hospital mortality Process Other Miyamoto K., Shibata N., Nakashima T., Kato S. Prehospital quick sequential organ failure assessment as a tool to predict in-hospital mortality. Am J Emerg Med 2018; 36(10) 1832-6. Medline
II Supportive (Green) Prediction of organ failure Process ED-MD Park HK, Kim WY, Kim MC, Jung W, Ko BS. Quick sequential organ failure assessment compared to systemic inflammatory response syndrome for predicting sepsis in emergency department. J Crit Care 2017; 42:12-7. Medline
II Supportive (Green) Prediction of direct ICU admission Process ED-MD Quinten VM., van MM, Wolffensperger AE., Ter MJ, Ligtenberg JJM. Sepsis patients in the emergency department: stratification using the Clinical Impression Score, Predisposition, Infection, Response and Organ dysfunction score or quick Sequential Organ Failure Assessment score? European journal of emergency medicine 2018; 25(5):328-34. Medline
II Supportive (Green) Prediction of critical illness Process ED-MD Rodriguez RM, Greenwood JC, Nuckton TJ, Darger B, Shofer FS, Troeger D, et al. Comparison of qSOFA with current emergency department tools for screening of patients with sepsis for critical illness. Emergency medicine journal: EMJ 2018; 35(6):350-6. Medline
II Supportive (Green) Prediction of 28 day mortality Process ED-MD Saeed K., Wilson DC., Bloos F., Schuetz P., van der DY, Melander O., et al. The early identification of disease progression in patients with suspected infection presenting to the emergency department: a multi-centre derivation and validation study. Crit Care 2019; 23(1):40. Medline
II Supportive (Green) Prediction of 30 day mortality Process ED-MD Samsudin MI., Liu N., Prabhakar SM., Chong SL., Kit LW, Koh ZX., et al. A novel heart rate variability based risk prediction model for septic patients presenting to the emergency department. Medicine 2018; 97(23):e10866. Medline
II Supportive (Green) Prediction of sepsis Patient PH-Paramedic Shu E, Ives TC, Frye W, Boyajian JG, Farshidpour L, Young M, et al. Pre-hospital qSOFA as a predictor of sepsis and mortality. Am J Emerg Med 2018. Medline
II Supportive (Green) Prediction of 28-day mortality Process PH-Paramedic Usul E, Korkut S, Kayipmaz AE, Halici A, Kavalci C. The role of the quick sequential organ failure assessment score (qSOFA) and modified early warning score (MEWS) in the pre-hospitalization prediction of sepsis prognosis. Am J Emerg Med 2021; 41:158-62. Medline
II Supportive (Green) Prediction of 30 day mortality Process ED-MD Williams JM., Greenslade JH., McKenzie JV., Chu K., Brown AFT., Lipman J. Systemic Inflammatory Response Syndrome, Quick Sequential Organ Function Assessment, and Organ Dysfunction: Insights From a Prospective Database of ED Patients With Infection. Chest 2017; 151(3):586-96. Medline
II Neutral (Yellow) Prediction of severe sepsis Process ED-MD Askim Ã., Moser F., Gustad LT., Stene H., Gundersen M., Ãsvold BO., et al. Poor performance of quick-SOFA (qSOFA) score in predicting severe sepsis and mortality - a prospective study of patients admitted with infection to the emergency department. Scandinavian journal of trauma, resuscitation and emergency medicine 2017; 25(1):56. Medline
II Neutral (Yellow) Prediction of 28 day mortality Process ED-MD Boulos D., Shehabi Y., Moghaddas JA., Birrell M., Choy A., Giang V., et al. Predictive value of quick Sepsis-Related Organ Failure Scores following sepsis-related Medical Emergency Team calls: a retrospective cohort study. Anaesth Intensive Care 2017; 45(6):688-94. Medline
II Neutral (Yellow) Prediction of 28 day mortality Process ED-MD Churpek MM., Snyder A., Han X., Sokol S., Pettit N., Howell MD., et al. Quick Sepsis-related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores for Detecting Clinical Deterioration in Infected Patients outside the Intensive Care Unit. American journal of respiratory and critical care medicine 2017; 195(7):906-11. Medline
II Neutral (Yellow) Prediction of 28 day mortality Patient In-Patient Fernando SM, Tran A, Taljaard M, Cheng W, Rochwerg B, Seely AJE, et al. Prognostic Accuracy of the Quick Sequential Organ Failure Assessment for Mortality in Patients With Suspected Infection: A Systematic Review and Meta-analysis. Ann Intern Med 2018; 168(4):266-75. Medline
II Neutral (Yellow) Predicting sepsis Process ED-MD Filbin MR., Thorsen JE., Lynch J., Gillingham TD., Pasakarnis CL., Capp R., et al. Challenges and Opportunities for Emergency Department Sepsis Screening at Triage. Scientific reports 2018; 8(1):11059. Medline
II Neutral (Yellow) Prediction of sepsis Process ED-MD Haydar S., Spanier M., Weems P., Wood S., Strout T. Comparison of QSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis. Am J Emerg Med 2017; 35(11):1730-3. Medline
II Neutral (Yellow) Prediction of ICU admission Process Jouffroy R., Saade A., Carpentier A., Ellouze S., Philippe P., Idialisoa R., et al. Triage of Septic Patients Using qSOFA Criteria at the SAMU Regulation: A Retrospective Analysis. Prehospital Emergency Care 2018; 22(1):84-90. Medline
II Neutral (Yellow) Prediction of ICU admission Process PH-Paramedic Jouffroy R., Saade A., Ellouze S., Carpentier A., Michaloux M., Carli P., et al. Prehospital triage of septic patients at the SAMU regulation: Comparison of qSOFA, MRST, MEWS and PRESEP scores. Am J Emerg Med 2018; 36(5):820-4. Medline
II Neutral (Yellow) ICU admission with 48 hours Process PH-Paramedic Silcock DJ, Corfield AR, Rooney KD, Staines H. Superior performance of National Early Warning Score compared with quick Sepsis-related Organ Failure Assessment Score in predicting adverse outcomes: a retrospective observational study of patients in the prehospital setting. European journal of emergency medicine: official journal of the European Society for Emergency Medicine 2018. Medline
II Neutral (Yellow) Prediction of ICU admission Process PH-Paramedic Tusgul S., Carron PN., Yersin B., Calandra T., Dami F. Low sensitivity of qSOFA, SIRS criteria and sepsis definition to identify infected patients at risk of complication in the prehospital setting and at the emergency department triage. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2017; 25(1):108. Medline
II Neutral (Yellow) In-hospital mortality (28 day) Patient PH-MD & CCT Vaittinada AP, Delay M, Avondo A, Duchateau FX, Nadiras P, Lapostolle F, et al. Prognostic value of prehospital quick sequential organ failure assessment score among patients with suspected infection. European journal of emergency medicine: official journal of the European Society for Emergency Medicine 2018. Medline
II Opposes (Red) Prediction of 28 day mortality Process ED-MD Hwang SY, Jo IJ, Lee SU, Lee TR, Yoon H, Cha WC, et al. Low Accuracy of Positive qSOFA Criteria for Predicting 28-Day Mortality in Critically Ill Septic Patients During the Early Period After Emergency Department Presentation. Ann Emerg Med 2018; 71(1):1-9.e2. Medline
III Supportive (Green) Prediction of sepsis Process PH-Paramedic Barbara P., Graziano C., Caputo W., Litvak I., Battinelli D., Hahn B. The quick sequential organ failure assessment (qSOFA) identifies septic patients in the out-of-hospital setting. Am J Emerg Med 2018. Medline
III Supportive (Green) Prediction of in-hospital mortality Process ED-MD Canet E., Taylor DM., Khor R., Krishnan V., Bellomo R. qSOFA as predictor of mortality and prolonged ICU admission in Emergency Department patients with suspected infection. J Crit Care 2018; 48:118-23. Medline
III Supportive (Green) Prediction of in-hospital mortality Process ED-MD Chang SH., Yeh CC., Chen YA., Hsu CC., Chen JH., Chen WL., et al. Quick-SOFA score to predict mortality among geriatric patients with influenza in the emergency department. Medicine 2019; 98(23):e15966. Medline
III Supportive (Green) Prediction of in-hospital mortality Process PH-Paramedic Koyama S., Yamaguchi Y., Gibo K., Nakayama I., Ueda S. Use of prehospital qSOFA in predicting in-hospital mortality in patients with suspected infection: A retrospective cohort study. PloS one 2019; 14(5):e0216560. Medline
III Supportive (Green) Sepsis identification Process PH-Paramedic Lane DJ, Wunsch H, Saskin R, et al. Screening strategies to identify sepsis in the prehospital setting: a validation study. CMAJ. 2020;192(10):E230–E239. doi:10.1503/cmaj.190966 Medline
III Neutral (Yellow) Prediction of sepsis Process PH-Paramedic Dorsett M., Kroll M., Smith CS., Asaro P., Liang SY., Moy HP. qSOFA Has Poor Sensitivity for Prehospital Identification of Severe Sepsis and Septic Shock. Prehosp Emerg Care 2017; 21(4):489-97. Medline
X Not Yet Graded (White) - Mignot-Evers L, Raaijmakers V, Buunk G, Brouns S, Romano L, T van H, et al. Comparison of SIRS criteria and qSOFA score for identifying culture-positive sepsis in the emergency department: a prospective cross-sectional multicentre study. BMJ Open 2021; 11(6):e041024. Medline

Identification tools-SIRS
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Prediction of sepsis Process ED-MD April MD., Aguirre J., Tannenbaum LI., Moore T., Pingree A., Thaxton RE., et al. Sepsis Clinical Criteria in Emergency Department Patients Admitted to an Intensive Care Unit: An External Validation Study of Quick Sequential Organ Failure Assessment. J Emerg Med 2017; 52(5):622-31. Medline
II Supportive (Green) Prediction of severe sepsis Process ED-MD Askim Ã., Moser F., Gustad LT., Stene H., Gundersen M., Ãsvold BO., et al. Poor performance of quick-SOFA (qSOFA) score in predicting severe sepsis and mortality - a prospective study of patients admitted with infection to the emergency department. Scandinavian journal of trauma, resuscitation and emergency medicine 2017; 25(1):56. Medline
II Supportive (Green) Prediction of mortality Process ED-MD Brink A, Alsma J, Verdonschot RJCG, Rood PPM, Zietse R, Lingsma HF, et al. (2019) Predicting mortality in patients with suspected sepsis at the Emergency Department; A retrospective cohort study comparing qSOFA, SIRS and National Early Warning Score. PLoS ONE 14(1): e0211133 Medline
II Supportive (Green) Prediction of 30-day mortality Process González del Castillo J, Julian-Jiménez A, González-Martínez F, Álvarez-Manzanares J, Piñera P, Navarro-Bustos C, et al. Prognostic accuracy of SIRS criteria, qSOFA score and GYM score for 30-day-mortality in older non-severely dependent infected patients attended in the emergency department. European journal of clinical microbiology & infectious diseases: official publication of the European Society of Clinical Microbiology 2017; 36(12):2361-9. Medline
II Supportive (Green) Prediction of sepsis Process ED-MD Haydar S., Spanier M., Weems P., Wood S., Strout T. Comparison of QSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis. Am J Emerg Med 2017; 35(11):1730-3. Medline
II Supportive (Green) Accuracy of prehospital identification Process PH-Paramedic Lane D., Ichelson R., Drennan I., Scales D. Prehospital management and identification of sepsis by emergency medical services: a systematic review. Emerg Med J 2016; 33:408–413. Medline
II Supportive (Green) Prediction of 28 day mortality Process ED-MD Saeed K., Wilson DC., Bloos F., Schuetz P., van der DY, Melander O., et al. The early identification of disease progression in patients with suspected infection presenting to the emergency department: a multi-centre derivation and validation study. Crit Care 2019; 23(1):40. Medline
II Supportive (Green) Prediction of mortality Process ED-MD Tai HC., Yeh CC., Chen YA., Hsu CC., Chen JH., Chen WL., et al. Utilization of systemic inflammatory response syndrome criteria in predicting mortality among geriatric patients with influenza in the emergency department. BMC infectious diseases 2019; 19(1):639. Medline
II Supportive (Green) Prediction of 30 day mortality Process ED-MD Williams JM., Greenslade JH., McKenzie JV., Chu K., Brown AFT., Lipman J. Systemic Inflammatory Response Syndrome, Quick Sequential Organ Function Assessment, and Organ Dysfunction: Insights From a Prospective Database of ED Patients With Infection. Chest 2017; 151(3):586-96. Medline
II Neutral (Yellow) Prediction of 28 day mortality Process ED-MD Boulos D., Shehabi Y., Moghaddas JA., Birrell M., Choy A., Giang V., et al. Predictive value of quick Sepsis-Related Organ Failure Scores following sepsis-related Medical Emergency Team calls: a retrospective cohort study. Anaesth Intensive Care 2017; 45(6):688-94. Medline
II Neutral (Yellow) Prediction of 28 day mortality Process ED-MD Churpek MM., Snyder A., Han X., Sokol S., Pettit N., Howell MD., et al. Quick Sepsis-related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores for Detecting Clinical Deterioration in Infected Patients outside the Intensive Care Unit. American journal of respiratory and critical care medicine 2017; 195(7):906-11. Medline
II Neutral (Yellow) Prediction of sepsis or septic shock Process In-Patient Gilbert BW, Faires L, Meister A, Huffman J, Faber RK. Comparison of Sepsis-3 Criteria Versus SIRS Criteria in Screening Patients for Sepsis in the Emergency Department. Advanced emergency nursing journal 2018; 40(2):138-43. Medline
II Neutral (Yellow) Prediction of in-hospital mortality Process PH-Paramedic Harada M., Takahashi T., Haga Y., Nishikawa T. Comparative study on quick sequential organ failure assessment, systemic inflammatory response syndrome and the shock index in prehospital emergency patients: single-site retrospective study. Acute medicine & surgery 2019; 6(2):131-7. Medline
II Neutral (Yellow) Prediction of ICU admission Process ED-MD Jouffroy R., Saade A., Carpentier A., Ellouze S., Philippe P., Idialisoa R., et al. Triage of Septic Patients Using qSOFA Criteria at the SAMU Regulation: A Retrospective Analysis. Prehospital Emergency Care 2018; 22(1):84-90. Medline
II Neutral (Yellow) Sensitivity and specificity to identify sepsis Process PH-Paramedic Lane DJ, Wunsch H, Saskin R, et al. Screening strategies to identify sepsis in the prehospital setting: a validation study. CMAJ. 2020;192(10):E230–E239. doi:10.1503/cmaj.190966 Medline
II Neutral (Yellow) Prediction of critical illness Process ED-MD Rodriguez RM, Greenwood JC, Nuckton TJ, Darger B, Shofer FS, Troeger D, et al. Comparison of qSOFA with current emergency department tools for screening of patients with sepsis for critical illness. Emergency medicine journal: EMJ 2018; 35(6):350-6. Medline
II Neutral (Yellow) Prediction of ICU admission Process PH-Paramedic Tusgul S., Carron PN., Yersin B., Calandra T., Dami F. Low sensitivity of qSOFA, SIRS criteria and sepsis definition to identify infected patients at risk of complication in the prehospital setting and at the emergency department triage. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2017; 25(1):108. Medline
III Supportive (Green) Prediction of mortality Process ED-MD Asayama K., Aikawa N. Evaluation of systemic inflammatory response syndrome criteria as a predictor of mortality in emergency patients transported by ambulance. Keio J Med 1998;47:19–27. Medline
III Supportive (Green) Detection of sepsis Process PH-Paramedic Smyth MA., Brace-McDonnell SJ., Perkins GD. Identification of adults with sepsis in the prehospital environment: a systematic review. BMJ Open 2016; 6(8):e011218-2016-011218. Medline
III Neutral (Yellow) Accuracy compared to bacterial cultures Process ED-MD Minderhoud TC., Spruyt C., Huisman S., Oskam E., Schuit SCE., Levin MD. Microbiological outcomes and antibiotic overuse in Emergency Department patients with suspected sepsis. Neth J Med 2017; 75(5):196-203. Medline
III Neutral (Yellow) Detection of sepsis Process ED-MD Morr M., Lukasz A., Rabig E., Pavenstdt H., Kampers P. Sepsis recognition in the emergency department - impact on quality of care and outcome? BMC Emergency Medicine 2017; 17(1):11. Medline
X Not Yet Graded (White) - Mignot-Evers L, Raaijmakers V, Buunk G, Brouns S, Romano L, T van H, et al. Comparison of SIRS criteria and qSOFA score for identifying culture-positive sepsis in the emergency department: a prospective cross-sectional multicentre study. BMJ Open 2021; 11(6):e041024. Medline

Oxygen-high flow
Level Direction Primary Outcome Patient/Process Setting Reference
II Opposes (Red) 28 day mortality Patient ED-MD Jouffroy R., Saade A., Pegat-Toquet A., Philippe P., Carli P., Vivien B. Pre-hospital mechanical ventilation in septic shock patients. Am J Emerg Med 2019. Medline
II Opposes (Red) Mortality at day 28 Patient PH-Paramedic Jouffroy R., Saade A., Saint ML., Philippe P., Carli P., Vivien B. Prognosis value of partial arterial oxygen pressure in patients with septic shock subjected to pre-hospital invasive ventilation. Am J Emerg Med. 2018; S0735-6757(18)30332-2 Medline
II Opposes (Red) In-hospital mortality Patient ED-MD Pope JV., Jones AE., Gaieski DF., et al. Multicenter study of central venous oxygen saturation (ScvO(2)) as a predictor of mortality in patients with sepsis. Ann Emerg Med 2010; 55(1):40-6. Medline
III Neutral (Yellow) Hypoxia Patient ED-MD Stolmeijer R., Ter Maaten JC., Zijlstra JG., Ligtenberg JJ. Oxygen therapy for sepsis patients in the emergency department: a little less? Eur J Emerg Med 2014; 21(3):233-5. Medline

Oxygen-titrated
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) 28 day mortality Patient ED-MD Jouffroy R., Saade A., Pegat-Toquet A., Philippe P., Carli P., Vivien B. Pre-hospital mechanical ventilation in septic shock patients. Am J Emerg Med 2019. Medline
II Supportive (Green) Mortality at day 28 Patient PH-Paramedic Jouffroy R., Saade A., Saint ML., Philippe P., Carli P., Vivien B. Prognosis value of partial arterial oxygen pressure in patients with septic shock subjected to pre-hospital invasive ventilation. Am J Emerg Med. 2018; S0735-6757(18)30332-2 Medline
II Supportive (Green) In-hospital mortality Patient PH-Paramedic Pope JV., Jones AE., Gaieski DF., et al. Multicenter study of central venous oxygen saturation (ScvO(2)) as a predictor of mortality in patients with sepsis. Ann Emerg Med 2010; 55(1):40-6. Medline
III Neutral (Yellow) Hypoxia Patient ED-MD Stolmeijer R., Ter Maaten JC., Zijlstra JG., Ligtenberg JJ. Oxygen therapy for sepsis patients in the emergency department: a little less? Eur J Emerg Med 2014; 21(3):233-5. Medline

Point of Care Lactate
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Prediction of severe sepsis Process ED-MD Contenti J., Corraze H., Lemoel F., Levraut J. Effectiveness of arterial, venous, and capillary blood lactate as a sepsis triage tool in ED patients. Am J Emerg Med 2015; 33(2):167-72. Medline
II Supportive (Green) EMS identification of sepsis Process PH-Paramedic Guerra WF., Mayfield TR., Meyers MS., Clouatre AE., Riccio JC. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med 2013; 44(6):1116-25. Medline
II Supportive (Green) Mortality prediction Process Other Jouffroy R, Léguillier T, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, et al. Prehospital lactate clearance is associated with reduced mortality in patients with septic shock. Am J Emerg Med 2020. Medline
II Supportive (Green) recognition and treatment of septic shock Process ICU Larsen GY, Mecham N, Greenberg R. An emergency department septic shock protocol and care guideline for children initiated at triage. Pediatrics. 2011;127(6):e1585–e1592. Medline
II Supportive (Green) Mortality Patient ED-MD Morris E, McCartney D, Lasserson D, Van den BA, Fisher R, Hayward G. Point-of-care lactate testing for sepsis at presentation to health care: a systematic review of patient outcomes. The British journal of general practice: the journal of the Royal College of General Practitioners 2017; 67(665):e859-70. Medline
II Supportive (Green) Prediction of 30- day Mortality or ICU admission Process ED-MD Purcarea A., Bourgarit A., Sovaila A., Ghiura C., Diemunsch P., Andres E. Brief report: Serial capillary lactate measurement predict the evolution of early sepsis. J Med Life 2016; 9(1):74-8. Medline
II Supportive (Green) Time from ED triage to IV fluids and time to antibiotic administration Process ED-MD Singer AJ, Taylor M, LeBlanc D, et al. ED bedside point-of-care lactate in patients with suspected sepsis is associated with reduced time to IV fluids and mortality. Am J Emerg Med. 2014;32(9):1120–1124. Medline
II Supportive (Green) mortality Process Other Swan KL, Avard BJ, Keene T. The relationship between elevated prehospital point-of-care lactate measurements, intensive care unit admission, and mortality: A retrospective review of adult patients. Aust Crit Care 2018. Medline
II Neutral (Yellow) Absolute and relative diagnostic gains Process ED-MD Báez AA, López O, Martínez MDP, Libell N, Cochón L, Nicolás JM. Clinical validation demonstrates concordance of qSOFA and POC lactate Bayesian model: Results from the ACDC Phase-2 program. Am J Emerg Med 2020. Medline
II Neutral (Yellow) Correlation to ED lactate Process PH-Paramedic Boland LL., Hokanson JS., Fernstrom KM., Kinzy TG., Lick CJ., Satterlee PA., et al. Prehospital Lactate Measurement by Emergency Medical Services in Patients Meeting Sepsis Criteria. West J Emerg Med 2016; 17(5):648-55. Medline
II Neutral (Yellow) Agreement with serum lactate value Process PH-Paramedic Swan KL., Keene T., Avard BJ. A 12-Month Clinical Audit Comparing Point-of-Care Lactate Measurements Tested by Paramedics with In-Hospital Serum Lactate Measurements. Prehosp Disaster Med 2018; 33(1):36-42. Medline
III Supportive (Green) Feasibility Process PH-Paramedic Walchok JG., Pirrallo RG., Furmanek D., Lutz M., Shope C., Giles B., et al. Paramedic-Initiated CMS Sepsis Core Measure Bundle Prior to Hospital Arrival: A Stepwise Approach. Prehosp Emerg Care 2016; 05:1-10. Medline
III Neutral (Yellow) Prediction of sepsis Process PH-Paramedic Baez AA., Cochon L. Acute Care Diagnostics Collaboration: Assessment of a Bayesian clinical decision model integrating the Prehospital Sepsis Score and point-of-care lactate. Am J Emerg Med 2016; 34(2):193-6. Medline
III Neutral (Yellow) Predictive value of POC lactate for mortality Patient Mullen M, Cerri G, Murray R, et al. Use of point-of-care lactate in the prehospital aeromedical environment. Prehosp Disaster Med. 2014;29(2):200–203. Medline

Prehospital Antibiotics
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) 28-day mortality Patient PH-Paramedic Alam N, Oskam E, Stassen PM, Exter PV, van de VP, Haak HR, et al. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. The Lancet Respiratory medicine 2018; 6(1):40-50. Medline
I Neutral (Yellow) Mortality Patient ED-MD Sterling SA., Miller WR., Pryor J., Puskarich MA., Jones AE. The impact of timing of antibiotics on outcomes in severe sepsis and septic shock: A systematic review and meta-analysis. Crit Care Med 2015; 43(9):1907-1915. Medline
II Supportive (Green) Adequate antibiotic coverage Patient ED-MD Flaherty SK., Weber RL., Chase M., et al. Septic shock and adequacy of early empiric antibiotics in the emergency department. J Emerg Med 2014; 47(5):601-7. Medline
II Supportive (Green) Mortality Patient ED-MD Gaieski DF., Mikkelsen ME., Band RA., Pines JM., Massone R., Furia FF., et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med 2010; 38(4):1045-53. Medline
II Supportive (Green) order-to-antibiotic time Process ED-MD Hitti EA., Lewin JJ,3rd., Lopez J., Hansen J., Pipkin M., Itani T., et al. Improving door-to-antibiotic time in severely septic emergency department patients. J Emerg Med 2012; 42(4):462-9. Medline
II Supportive (Green) Sepsis-related death or discharge Patient ED-MD Jalili M., Barzegari H., Pourtabatabaei N., et al. Effect of door-to-antibiotic time on mortality of patients with sepsis in emergency department: A prospective cohort study. Acta Med Iran 2013; 51(7):454-60. Medline
II Supportive (Green) Mortality Patient ED-MD Johnston AN., Park J., Doi SA., Sharman V., Clark J., Robinson J., et al. Effect of Immediate Administration of Antibiotics in Patients With Sepsis in Tertiary Care: A Systematic Review and Meta-analysis. Clin Ther 2017; 39(1):190-202. Medline
II Supportive (Green) 30 day mortality Patient PH-Paramedic & MD Jouffroy R, Gilbert B, JP T, Bloch-Laine E, Ecollan P, Bounes V, Boularan J, Léguillier T, Gueye-Ngalgou, P, Vivien, B. Impact of Prehospital Antibiotic Therapy on Septic Shock Mortality. Prehosp Emerg Care 2021; 25(3): 317–24. Medline
II Supportive (Green) In-hospital Mortality Patient PH-Paramedic Seymour C., Kahn J., Martin-Gill C., Callaway C., Yealy D., Scales D., Angus D., Delays From First Medical Contact to Antibiotic Administration for Sepsis. Critical Care Medicine 2017; 45(5):759–765. Medline
II Supportive (Green) Mortality (most common outcome of included studies) Patient ED-MD Sherwin R, Winters ME, Vilke GM, Wardi G. Does Early and Appropriate Antibiotic Administration Improve Mortality in Emergency Department Patients with Severe Sepsis or Septic Shock? J Emerg Med 2017; 53(4):588-95. Medline
III Supportive (Green) In-hospital mortality Patient ED-MD Liu VX., Fielding-Singh V., Greene JD., Baker JM., Iwashyna TJ., Bhattacharya J., et al. The Timing of Early Antibiotics and Hospital Mortality in Sepsis. American Journal of Respiratory and Critical Care Medicine 2017; 196(7):856-63. Medline
III Supportive (Green) Survival Patient ED-MD Siddiqui S., Salahuddin N., Raza A., Razzak J. How early do antibiotics have to be to impact mortality in severe sepsis? A prospective, observational study from an emergency department. J Ayub Med Coll Abbottabad 2009; 21(4):106-110. Medline
III Supportive (Green) Feasibility Process PH-Paramedic Walchok JG., Pirrallo RG., Furmanek D., Lutz M., Shope C., Giles B., et al. Paramedic-Initiated CMS Sepsis Core Measure Bundle Prior to Hospital Arrival: A Stepwise Approach. Prehosp Emerg Care 2016; 05:1-10. Medline
III Neutral (Yellow) Mortality Patient ED-MD Puskarich MA., Trzeciak S., Shapiro NI., et al. Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Crit Care Med 2011; 39(9):2066-71. Medline
X Not Yet Graded (White) - Schinkel M, Paranjape K, Kundert J, Nannan Panday RS, Alam N, Nanayakkara PWB. Towards Understanding the Effective Use of Antibiotics for Sepsis. Chest 2021. Medline

Prenotification
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) EMS identification of sepsis Process PH-Paramedic Guerra WF., Mayfield TR., Meyers MS., Clouatre AE., Riccio JC. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med 2013; 44(6):1116-25. Medline
II Supportive (Green) Time to treatment Process PH-Paramedic & MD Hunter CL, Silvestri S, Stone A, Shaughnessy A, Miller S, Rodriguez A, et al. Prehospital sepsis alert notification decreases time to initiation of CMS sepsis core measures. Am J Emerg Med 2019; 37(1):114-7. Medline
II Supportive (Green) Mortality Patient ED-MD MacRedmond R., Hollohan K., Stenstrom R., Nebre R., Jaswal D., Dodek P. Introduction of a comprehensive management protocol for severe sepsis is associated with sustained improvements in timeliness of care and survival. Qual Saf Health Care 2010; 19(5):e46. Medline
II Supportive (Green) Time to Antibiotics Process ED-MD Rosenqvist M., Fagerstrand E., Lanbeck P., Melander O., Akesson P. Sepsis Alert - a triage model that reduces time to antibiotics and length of hospital stay. Infect Dis (Lond) 2017; 49(7):507-13. Medline
II Neutral (Yellow) 28 day Mortality Patient ED-MD Shapiro NI., Howell MD., Talmor D., et al. Implementation and outcomes of the multiple urgent sepsis therapies (MUST) protocol. Crit Care Med 2006; 34(4):1025-1032. Medline
X Not Yet Graded (White) - Mixon M, Dietrich S, Floren M, Rogoszewski R, Kane L, Nudell N, et al. Time to antibiotic administration: Sepsis alerts called in emergency department versus in the field via emergency medical services. Am J Emerg Med 2021; 44:291–5. Medline

Temperature Monitoring
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Prediction of in-hospital mortality Process ED-MD Gouldthorpe OT., Pilcher DV., Bellomo R., Udy AA. Prevalence of low-normal body temperatures and use of active warming in emergency department patients presenting with severe infection. Critical care and resuscitation 2019; 21(2):96-101. Medline
II Supportive (Green) Association with In-hospital mortality Patient ED-MD Henning DJ., Carey JR., Oedorf K., Day DE., Redfield CS., Huguenel CJ., et al. The Absence of Fever Is Associated With Higher Mortality and Decreased Antibiotic and IV Fluid Administration in Emergency Department Patients With Suspected Septic Shock. Crit Care Med 2017; 45(6):e575-e582. Medline
II Supportive (Green) Association with treatment delays and mortality Process ED-MD Khodorkovsky B, Youssef E, Adamakos F, Cina T, Falco A, LaMura L, et al. Does Initial Temperature in the Emergency Department Predict Outcomes in Patients Admitted for Sepsis? J Emerg Med 2018; 55(3):372-7. Medline
II Supportive (Green) Prognostic value of temperature on in-hospital mortality Process ED-MD Sunden-Cullberg J., Rylance R., Svefors J., Norrby-Teglund A., Bjork J., Inghammar M. Fever in the Emergency Department Predicts Survival of Patients With Severe Sepsis and Septic Shock Admitted to the ICU. Crit Care Med 2017; 45(4):591-599. Medline
II Neutral (Yellow) Sensitivity and Specificity Process ED-MD Niven DJ., Gaudet JE., Laupland KB., Mrklas KJ., Roberts DJ., Stelfox HT. Accuracy of Peripheral Thermometers for Estimating Temperature: A Systematic Review and Meta-analysis. Ann Intern Med 2015; 163:768-77. Medline
III Supportive (Green) Prediction of sepsis Process PH-Paramedic Wallgren UM., Bohm KEM., Kurland L. Presentations of adult septic patients in the prehospital setting as recorded by emergency medical services: a mixed methods analysis. Scand J Trauma Resusc Emerg Med 2017; 25(1):23. Medline


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