Understanding the Knowledge and Attitude of Prehospital Sepsis Care among Emergency Medical Service Personnel.

BACKGROUND: Sepsis represents a huge burden for the health-care system. Septic patients presented by emergency medical services (EMS) are usually sicker in comparison to patients arriving by other means. Knowledge of sepsis is a key factor in recognizing and providing the appropriate care; it is not the only barrier as EMS providers do not have access to the proper diagnostic investigation. This work highlighted the level of knowledge, awareness, and attitude of EMS providers regarding prehospital care of sepsis in Riyadh, Saudi Arabia.
METHODS: This study was a cross-sectional study that conducted among EMS personnel of Saudi Red Crescent Authority and King Abdulaziz Medical City. One hundred and ninety-seven individuals were sampled (99 were technicians and 98 were paramedics).
RESULTS: Most participants (71%) were aware of the term "sepsis;" however, only 48% of participants correctly defined sepsis (30% between emergency medical technicians [EMTs] vs. 66% paramedics group, P < 0.01). Paramedics were noted to have a better understanding of signs, symptoms, and management of sepsis. Most of the participants thought that sepsis can be identified during prehospital care (55%) and 75% suggested that they should be involved in the management of septic patients. About 80% responded that their intervention would result in a better outcome for patients and would influence the behavior of emergency department medical care. Most of the participants (83%) were willing to be actively engaged in the prehospital care of septic patients.
CONCLUSION: This study showed an insufficient level of knowledge and awareness regarding sepsis care in the EMS field in Saudi Arabia. Paramedics had more knowledge and awareness about sepsis care compared to EMT personnel. Future work should focus on exploring the reasons behind this, as well as implementing plans to improve education about sepsis for EMS personnel.

INTRODUCTION

Sepsis is a life-threatening condition causing organ dysfunction due to a dysregulated host-defense mechanism toward infection.[1] It represents a huge burden for the health-care system ranking as the first most expensive condition treated in the United States, accounting for >$20 billion of total US hospital costs in 2011.[2] The global incidence of sepsis is estimated to be 31.5 million cases, with potentially 5.3 million deaths annually.[3]

One-third of the in-hospital patient mortality in the US is septic, twice as much compared to MI and stroke (19.6%).[45] Emergency medical services (EMS) providers encounter more cases of sepsis in the US compared to myocardial infarction (MI) or stroke and are estimated to transport half of the septic patients to the emergency department (ED).[67] Septic patients presented by EMS are usually sicker in comparison to patients arriving by other means.[8] Early recognition and intervention for sepsis has been implemented by the international guidelines, and studies suggest that early recognition of sepsis by EMS yields improved outcomes and survival.[69] Even though knowledge of sepsis is a key factor in recognizing and providing the appropriate care, it is not the only barrier as EMS providers do not have access to proper diagnostic investigations that are available for physicians in the hospital settings.[4] A couple of studies conducted in Korea and Japan found that the EMS personnel lack the appropriate level of knowledge regarding sepsis.[410] Other paper in the US showed that 24% of EMS providers were unaware of the effect of early recognition and management on morbidity and mortality rates.[11]

The resources regarding EMS knowledge and attitude toward sepsis in Saudi Arabia are scarce; this work highlighted the level of knowledge, awareness, and attitude of EMS providers regarding prehospital care of sepsis in Riyadh, Saudi Arabia.

METHODS

Study design and study population

This study was a cross-sectional study that conducted among EMS personnel of Saudi Red Crescent Authority (SRCA) and King Abdulaziz Medical City (KAMC) from January to August 2018. The aim of the study was to know the level of knowledge, awareness, and attitude of the above-mentioned EMS staff regarding sepsis in the prehospital emergency care. In the field of EMS in Saudi Arabia, there are different levels of certifications for a provider of care. The holder of EMS certification could be emergency medical technician (EMT) or a paramedic. The EMT is the one who completes a coursework from 6 months to 2 years.

Study setting

This study was conducted in Riyadh, the capital city of Saudi Arabia. The participants were working in EMS in the SRCA and KAMC. There are almost 79 SRCA centers in Riyadh region. KAMC is a tertiary care hospital with a bed capacity of 1501 and a Level I trauma center. King Abdullah Specialist Children Hospital is a part of KAMC with a bed capacity of 600 beds. The ED receives plenty of cases with acute injuries. On an average, 50,000–60,000 pediatric visits occur annually to the ED.

Sample size

A minimal sample size of 197 was calculated for this study. This was based on the assumption that 50% of the participants would have some level of knowledge, a margin of error of 5%, and a 95% confidence level. A response rate of 50% was assumed because there are no previous studies that have been done in our region about sepsis care knowledge among EMS staff.

Questionnaire

Ten-item self-administered questionnaire was distributed in-person by the research team members to all the available EMS staff of both sexes who meet these inclusion criteria such as EMT or paramedics in SRCA and KAMC. EMS interns and nurses were excluded from the study. The questionnaire was adapted from a study by Park et al.[5] and revised to reach the goals of this study. The questionnaire included three parts as follows: the first part was about the demographic data, the second part was about the knowledge and awareness of sepsis in the prehospital care, and finally, the third part was about the attitude toward sepsis care among EMS personals. Response options for the second and third part included dichotomized “yes/no” options.

Data management and analysis

The Statistical Package for the Social Sciences (IBM Corp., Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY, USA) was used for data management and analysis. Descriptive analyses were carried out by calculating the frequencies and percentages for the categorical variables. The participants were divided into two groups: EMT group which included the technicians and the other group which included the paramedics. The difference in the knowledge, awareness, and attitude was compared between the two groups by using Chi-square test. Other groups were created by dividing the EMT staff into active and passive groups and compared the same test. The active group was those who positively answered to be actively engaged in the management of sepsis in the prehospital setting. Significance was declared at the value of P < 0.05.

Ethical considerations

This study was approved by the Institutional Review Board, King Abdullah International Medical Research Center, Riyadh. Written informed consent forms were distributed to the participants. Only those who agreed to participate in the study were enrolled. Incomplete questionnaires were not included in the study.

RESULTS

Ninety-nine of the responders (50%) were EMTs. Majority of the participants (62%) aged between 26 and 30 years. Sixty-five percent of the participants had 5 years or less in service (100). Females accounted only for 4% (7). Most of the participants (56%) were working only for 5 years or less. Table 1 shows the baseline characteristics for all the participants and for each group.

Table 1

Baseline characteristics

Variable	Category	Overall (n=198), n (%)	Technicians (n=99), n (%)	Paramedics (n=98), n (%)	P
Age category	25 and less	21 (11)	5 (5)	16 (16)	0.022
	26-30	122 (62)	62 (63)	60 (61)
	>30	54 (27)	32 (32)	22 (22)
Gender	Male	190 (96)	99 (100)	91 (93)	0.007
	Female	7 (4)	0 (	7 (7)
EMS career duration category	5 and less	100 (56)	51 (55)	49 (56)	0.715
	6-10	66 (37)	36 (39)	30 (35)
	>10	14 (8)	6 (7)	8 (9)
Training center	Governmental college/university (bachelor)	72 (37)	2 (2)	70 (71)	<0.01
	Governmental institute (diploma)	22 (11)	19 (19)	3 (3)
	Private college/university (bachelor)	25 (13)	1 (1)	24 (25)
	Private institute (diploma)	78 (40)	77 (78)	1 (1)

EMS: Emergency medical service

Most participants (71%) were aware of the term “sepsis;” however, only 48% of the participants correctly defined sepsis (30% in EMT vs. 66% in paramedics group, P < 0.01). Paramedics group was noted to have a better understanding of signs, symptoms, and management of sepsis. The majority of the participants associated fever as the most frequent symptom with sepsis (86%), followed by tachycardia, altered mental status, and tachypnea, respectively. On the other hand, the least associated signs and symptoms were hypothermia (35%), followed by hypotension. Participants considered antibiotics and fluid resuscitation important in the management of sepsis (81% for both), whereas only 53% considered vasopressors as a part of the management. Around half of the participants have suspected sepsis in patients during transportation (36% of the participants in the first-degree EMT group and 57% in paramedics group). Variables that determine the knowledge and awareness of sepsis among EMS personnel are presented in Table 2.

Table 2

Knowledge and perception of sepsis

Question	Answer	Overall (n=198), n (%)	Technicians (n=99), n (%)	Paramedics (n=98), n (%)	P
Have you ever heard of the term “sepsis”? (yes)		139 (71)	47 (48)	92 (94)	<0.01
Which one do you think is the most appropriate definition of sepsis? (correct answer)		95 (48)	30 (30)	65 (66)	<0.01
Do you think the following symptoms and signs are associated with sepsis?
Fever	No/not sure	28 (14)	20 (20)	8 (8)	0.016
	Yes	169 (86)	79 (80)	90 (92)
Hypothermia	No/not sure	129 (66)	76 (77)	53 (54)	0.001
	Yes	68 (35)	23 (23)	45 (46)
Tachycardia	No/not sure	42 (21)	26 (26)	16 (16)	0.089
	Yes	155 (79)	73 (74)	82 (84)
Tachypnea	No/not sure	64 (33)	44 (44)	20 (20)	<0.01
	Yes	133 (68)	55 (56)	78 (80)
Hypotension	No/not sure	80 (41)	57 (58)	23 (24)	<0.01
	Yes	117 (59)	42 (42)	75 (77)
Altered mental status	No/not sure	52 (26)	39 (39)	13 (13)	<0.01
	Yes	145 (74)	60 (61)	85 (87)
Do you think the following treatments are essential for sepsis management?
Antibiotics	No/not sure	38 (19)	31 (31)	7 (7)	<0.01
	Yes	159 (81)	68 (69)	91 (93)
Fluid resuscitation	No/not sure	38 (19)	30 (30)	8 (8)	<0.01
	Yes	159 (81)	69 (70)	90 (92)
Vasopressors in shock	No/not sure	92 (47)	64 (65)	28 (29)	<0.01
	Yes	105 (53)	35 (35)	70 (71)
Have you ever suspected that a patient was suffering from sepsis during transport to the hospital?	No/not sure	105 (53)	63 (64)	42 (43)	0.003
	Yes	92 (47)	36 (36)	56 (57)

As Table 3 shows, most of the participants thought that sepsis can be identified during prehospital care (55%) and 75% suggested that they should be involved in the management of septic patients. About 80% responded that their intervention would result in a better outcome for patients and would influence the behavior of EDs medical care. Most of the participants (83%) were willing to be actively engaged in the prehospital care of septic patients.

Table 3

Attitudes toward sepsis

Question	Answer	Overall (n=198), n (%)	Technicians (n=99), n (%)	Paramedics (n=98), n (%)	P
Do you think EMTs can diagnose sepsis in the prehospital setting?	No or not sure	88 (45)	43 (43)	45 (46)	0.726
	Yes	109 (55)	56 (57)	53 (54)
Do you think EMTs should be involved in the management of sepsis in the prehospital setting?	No or not sure	50 (25)	29 (29)	21 (21)	0.205
	Yes	147 (75)	70 (71)	77 (79)
Do you think medical intervention by EMTs in the prehospital setting will improve outcomes for sepsis patients?	No or not sure	40 (20)	24 (24)	16 (16)	0.167
	Yes	157 (80)	75 (76)	82 (84)
Do you think medical intervention by EMTs in the prehospital setting will influence the behavior of the medical team in the emergency department?	No or not sure	47 (24)	29 (29)	18 (18)	0.072
	Yes	150 (76)	70 (71)	80 (82)
Are you willing to be actively engaged in the management of sepsis in the prehospital setting?	No or not sure	33 (17)	23 (23)	10 (10)	0.014
	Yes	164 (83)	76 (77)	88 (90)

EMTs: Emergency medical technicians

As the results shown in Table 4, passive group was less knowledgeable in regard to defining sepsis and associating the signs and symptoms to sepsis, with statistical significance difference for all the signs, symptoms, and the means of management except for hypothermia (27% for the passive group vs. 36% for the active group). In addition, the proportion who had ever suspected sepsis in a patient during transport were higher in the active group (30% in the active group vs. 50% in the passive group). Moreover, the active group responded with a more positive attitude regarding prehospital sepsis care as seen in Q6–Q9 compared to the passive group, with statistical significance.

Table 4

Comparison of knowledge and attitudes according to activeness of emergency medical service personnel

Variable	Overall (n=198), n (%)			Technicians (n=99), n (%)
	Passive group (n=33)	Active group (n=164)	P	Passive group (n=23)	Active group (n=76)	P
Which one do you think is the most appropriate definition of sepsis? (correct answer)	14 (42)	81 (49)	0.092	7 (30)	23 (30)	0.634
Fever	23 (70)	146 (89)	0.004	14 (61)	65 (86)	0.01
Hypothermia	9 (27)	59 (36)	0.337	5 (22)	18 (24)	0.847
Tachycardia	21 (64)	134 (82)	0.021	13 (57)	60 (79)	0.032
Tachypnea	14 (42)	119 (73)	0.001	8 (35)	47 (62)	0.022
Hypotension	10 (30)	107 (65)	<0.01	4 (17)	38 (50)	0.006
Altered mental status	15 (46)	130 (79)	<0.01	7 (30)	53 (70)	0.001
Antibiotics	18 (55)	141 (86)	<0.01	10 (44)	58 (76)	0.003
Fluid resuscitation	19 (58)	140 (85)	<0.01	9 (39)	60 (79)	<0.01
Vasopressors in shock	12 (36)	93 (57)	0.033	5 (22)	30 (40)	0.119
Have you ever suspected that a patient was suffering from sepsis during transport to the hospital?	10 (30)	82 (50)	0.039	6 (26)	30 (40)	0.242
Do you think EMTs can diagnose sepsis in the prehospital setting?	9 (27)	100 (61)	<0.01	7 (30)	49 (65)	0.004
Do you think EMTs should be involved in the management of sepsis in the prehospital setting?	12 (36)	135 (82)	<0.01	9 (39)	61 (80)	<0.01
Do you think medical intervention by EMTs in the prehospital setting will improve outcomes for sepsis patients?	17 (52)	140 (85)	<0.01	11 (48)	64 (84)	<0.01
Do you think medical intervention by EMTs in the prehospital setting will influence the behavior of the medical team in the emergency department?	14 (42)	136 (83)	<0.01	7 (30)	63 (83)	<0.01

Data are shown as n (%) answered “yes” to each question except “definition of sepsis”. EMTs: Emergency medical technicians

DISCUSSION

Our results showed that less than half of the participants were aware of the term “sepsis.” However, none of the first-degree providers have had a higher understanding level of sepsis signs and symptoms. Antibiotics and intravenous fluid were considered more useful than vasopressors in respect to managing sepsis. Fortunately, most of the providers thought that they can identify sepsis during prehospital resuscitation. In addition, they stated that their intervention would influence the approach of ED physicians. Passive participants had a lower level of knowledge whereas the active group had a more positive attitude regarding prehospital care.

Less than half of the participants were able to correctly define it, especially EMTs when compared to paramedics. This correlates with the findings in both Seymour et al. and Park et al.,[5] where they found that paramedics had a better knowledge regarding the definition of “sepsis.” Fever was the most consistently associated sign with sepsis in our study (86%), as well as in studies by Seymour et al.[12] and Park et al.[5] Again, EMTs were less likely to associate it to sepsis compared to paramedics across the previously mentioned studies. More than half of the respondents in our study also associated other signs and symptoms, including tachycardia, altered mental status, and tachypnea, which were similarly observed across the other studies. Hypotension, however, was less likely to be associated with sepsis, yet still over half of our respondents did so, and this was differently observed in Park et al.,[5] where hypotension was associated only by less than half of their respondents.[5] The least of all signs and symptoms to be associated with sepsis was hypothermia; this was consistent with Park et al.'s findings.[5] Paramedics were observed to have better knowledge regarding defining sepsis, correlating the signs and symptoms and the willingness to be actively engaged in the management of sepsis in prehospital settings when compared to EMTs; this could be attributed to the differences in education, training, and the expected roles in the field.

Regarding management of sepsis, most of the participants were aware of the importance of the antibiotics (81%), fluid resuscitation (81%), and vasopressors in shock (53%) as essential therapeutic measures in sepsis, which were similar to Suffoletto B et al.'s study.[13] Finally, most respondents agreed that EMTs can identify septic patients in the prehospital setting, with 80% of them agreeing that prehospital recognition and interventions may improve outcomes for sepsis. Likewise, other studies found that the majority of the participant in their study agreed or strongly agreed that paramedics can identify patients at high risk for sepsis.[512]

In our region, Middle East, there is a scarce in studying the sepsis knowledge among those who are working in the medical field. Up to our knowledge, this study is the first study that gives a highlight about the level of knowledge, awareness, and attitude of EMS providers regarding prehospital care of sepsis in Saudi Arabia. However, as with most studies, this study had some limitations. One of the limitations is the voluntary manner in which the nature of this type of studies could contribute to a self-selection bias since we used convenience sampling. Another limitation is that it included only participants from the two institutions in the region of Riyadh. One of the limitations is the low number of female participants, and this could be attributed to the low number of females who are working in the emergency medical field in Saudi Arabia. In conclusion, this study showed an insufficient level of knowledge and awareness regarding sepsis care in the EMS field in Saudi Arabia. There were a good number of EMS personnel who are willing to be involved in sepsis care before the hospital arrived. Future work should focus on exploring the reasons behind this level of knowledge and awareness about sepsis care that was found in our study, as well as implementing plans to improve education about sepsis for EMS personnel.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.