主页 International Emergency Nursing Descriptions and presentations of sepsis – A qualitative content analysis of emergency calls
International Emergency Nursing 23 (2015) 294–298 Contents lists available at ScienceDirect International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n Descriptions and presentations of sepsis – A qualitative content analysis of emergency calls Katarina Bohm RN, PhD (Lecturer) a,*, Lisa Kurland MD, PhD (Associate Professor, Senior Lecturer) a,b, Soﬁa Bartholdson (Medical Student) a, Maaret Castrèn MD (Professor) a,b a b Karolinska Institutet, Institution of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden Section of Emergency Medicine, Södersjukhuset, Stockholm, Sweden A R T I C L E I N F O Article history: Received 2 December 2014 Received in revised form 13 April 2015 Accepted 15 April 2015 Keywords: Sepsis Communication Emergency medical services Dispatching A B S T R A C T Background: Sepsis is a serious condition which requires early treatment. We often fail to recognize sepsis patients in the chain of prehospital care. Knowledge of how sepsis is expressed in calls to the emergency medical communication centre (EMCC) is limited. An increased understanding could lead to earlier identiﬁcation of patients with sepsis. Objective: The aim of this study was to describe the descriptions of sepsis used during communication between the caller and the emergency medical dispatcher (EMD). Methods: To achieve the aim of the study, an inductive approach of qualitative content analysis was used. In total, 29 consecutive patients, who arrived at the emergency department by ambulance and received a diagnosis of sepsis according to the International Classiﬁcation of Diseases (ICD)-10, were included in the study. For each case, the corresponding emergency call recording from the EMCC was transcribed verbatim. Main categories and subcategories from the text were abstracted. Results: From ﬁfteen subcategories, three main categories were abstracted: “Deterioration”, “Physical signs and symptoms” and “Diﬃculties establishing satisfactory cont; act with the patient.” The way laymen and professionals expressed themselves seemed to differ. Conclusions: Sepsis was described in terms of the physical symptoms, changes of condition and communication abilities of the patient. This knowledge could lead to the identiﬁcation of keywords which could be incorporated in the decision tool used by the EMD to increase sepsis identiﬁcation, but further research is required. © 2015 Elsevier Ltd. All rights reserved. 1. Introduction Sepsis is a serious condition with a mortality rate of approximately 20% (Wenzel, 2002). For septic shock the mortality rate can be as high as 45% (Wenzel, 2002). The incidence of sepsis in the United States of America (USA) is approximately 240/100 000 citizens (Martin et al., 2003). The incidence is increasing and possible explanations for the increase are the population growth, the ageing of the population, more patients being treated with invasive procedures, a greater use of immunosuppressant drugs and an increase in HIV and antibiotic-resistant infections (Rangel-Frausto, 1999). Time is critical for the outcome of septic patients. A delay in antibiotic administration has been shown to increase mortality (Kumar et al., 2006). Half of all emergency department (ED) patients with severe sepsis, and one-third of patients treated for an infection, are * Corresponding author. Karolinska Institutet, Institution of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden. Tel.: +46736403013; fax: +4686162933. E-mail address: email@example.com (K. Bohm). http://dx.doi.org/10.1016/j.ienj.2015.04.003 1755-599X/© 2015 Elsevier Ltd. All rights reserved. transported by the emergency medical services (EMS) (Wang et al., 2007, 2010). Patients with severe sepsis arriving with the EMS receive antibiotics more quickly in the ED. A documented sepsis impression by the EMS provider decreases the time interval even more (Studnek et al., 2012). Additionally, protocolized sepsis identiﬁcation in the ambulance appears to be feasible (Wallgren et al., 2014). Thus, identiﬁcation of sepsis in the prehospital setting is both possible and important for patient care, but due to the often nonspeciﬁc presentations of sepsis, remains challenging. The emergency medical dispatcher (EMD) plays an important role in the continuum of emergency care. Early identiﬁcation of serious conditions by the EMD has been shown to shorten the ambulance arrival time on scene and reduce mortality in cardiac arrest (Berdowski et al., 2009), while no such studies exist for the septic patient. There is no speciﬁc mention of sepsis in the protocol used by Swedish EMDs today (SOS Alarm AB, 2001) and to our knowledge, no previous publication concerning how sepsis might be described during the emergency call or how the EMD can identify the septic patient (Herlitz et al., 2012). The aim of this study is to describe the presentations of sepsis during the communication between the caller and the EMD. K. Bohm et al./International Emergency Nursing 23 (2015) 294–298 2. Methods 295 Consecutively included by ICD-codes for sepsis 2.1. Design and analysis N=65 A qualitative descriptive approach was chosen because of the lack of previous knowledge regarding sepsis presentation when contacting the EMCC (Fevang et al., 2011; Herlitz et al., 2012). To start with an open mind helped widen the picture and made it possible to ﬁnd descriptions that might otherwise have been overlooked (Graneheim and Lundman, 2004). Authentic emergency call recordings were collected and transcribed verbatim for every included patient. Data were analyzed using content analysis (Graneheim and Lundman, 2004). Multiple authors were involved in the data analysis to decrease the chance of individual biases inﬂuencing the research ﬁndings. Authors reviewed each transcript, used open coding to code the key messages in each passage, organized the codes into common groupings, and began to identify the categories. The thematic development is exempliﬁed in Table 1. The study was conducted with the approval of the ethics committee in Stockholm, dnr: 2011/2013-31/5. Excluded Did not arrive at the ED by ambulance N=24 Excluded Did not have sepsis in the ED N=7 Excluded No recording found Not adequate Swedish Called ambulance for other reasons Presented with undistinguishable co-disease 2.2. Data collection and setting All patients were treated at the ED of Södersjukhuset, Stockholm, Sweden which is one of the busiest EDs in northern Europe, with more than 115 000 patients per year. N=5 Included in analysis N=29 2.2.1. Inclusion and exclusion criteria All patients with an ICD-10 code compatible with sepsis at discharge from hospital were included consecutively between November 30th 2011 and February 12th 2012. Since the aim of the study was to evaluate sepsis presentations to the emergency medical call centre, it was important to include patients who had signs of sepsis, during their ED visit (as described below), which was a proxy for having signs and symptoms during their call to the medical call centre. Therefore, a patient was assumed to have ongoing sepsis in the ED if the term “sepsis” was used in the ED medical record or if broad spectrum antimicrobial agents used to treat sepsis had been administered. The patient was also assumed to have sepsis in the ED if the patient had vital signs fulﬁlling the sepsis criteria (Bone et al., 2009). A patient was excluded if he or she arrived at the hospital by other means than by ambulance, or if the patient did not have a presentation compatible with sepsis during the ED visit, as deﬁned above. If the recorded call was not found or the caller did not speak Swedish (i.e. the qualitative analysis), it was also excluded. Finally, 29 patients were included (Fig. 1). Fig. 1. Flowchart of included and excluded patients in the study. 2.3. Patient population 2.3.1. The patients The age span of the included patients was between 50 and 95 years. Median and mean age were both 80 years. The patient was a female in 55% (n = 16) of the calls. 2.3.2. The callers Most commonly, the caller was either a nurse (n = 15) from a nursing home, geriatric care centre, or sheltered housing, or a relative (n = 10). Other people calling were the police (n = 1), geriatrician (n = 1), home care service (n = 1) and the Swedish medical care hotline (n = 1). In none of the cases, did the patient call by him or herself. Table 1 Examples of condensation and abstraction of the analysis unit in this study, using qualitative content analysis. Meaning unit Condensed meaning unit Code Sub-category Main category This is apparently, according to the staffs who knows her, a quite lively old retiree who is normally ambulant and the one who. . . She is the most vivid there in the department. . . Yes, like that and. . . up and walking around and helping and yes, you know. And now she has just been lying down. EMD: I understand. So you notice a signiﬁcant difference, there? Caller: Yes, absolutely. Since yesterday, there is deﬁnitely a change and I feel that. . . he probably needs a bit more advanced care. She is the most vivid in the department, but now she has just been lying down. Just lying down Weakness Deterioration Since yesterday, there is deﬁnitely a change. New change for the worse Sudden deterioration EMD = Emergency medical dispatcher. 296 K. Bohm et al./International Emergency Nursing 23 (2015) 294–298 3. Results The symptoms and descriptions for sepsis generated three main categories. These were Deterioration, Physical signs and symptoms, and Diﬃculties in establishing contact with the patient. 3.1. Deterioration A common description by the caller was the description of changed condition of the patient, which often seemed to reﬂect a concern of the patient’s condition or asthenia. The sub-categories abstracted were Concern for serious condition, Weakness, Sudden deterioration and Falling and collapsing. Descriptions did not differ substantially between laymen and health professionals (HP). In particular the descriptions in the subcategories Falling and Collapsing and Sudden deterioration were often connected with anxiety of the caller, and this anxiety had made the caller contact the EMCC. 3.1.1. Concern for serious condition The caller described that the patient felt bad, not only general worsened condition but something more. The caller put it often as: Caller (relative): He’s really sick. Caller (nurse): She is really bad here. 3.1.2. Weakness There was a broad spectrum of descriptions of patients who seemed to have lost their normal energy. Most commonly, the caller described the patient as being feeble or passive: Caller (nurse): This is apparently, according to the staff who know her, a quite lively old retiree who is normally ambulant and one who. . . She is the most lively there in the department. . . Yes, like that and. . . up and walking around and helping and yes, you know. And now she has just been lying down. 3.1.3. Falling and collapsing This subcategory contains all kinds of descriptions of falling, including collapsing and fainting. Most often, these symptoms were used by relatives in out-of-hospital settings. Many callers did not distinguish between descriptions such as falling and fainting. Caller (relative): Well it. . . uhm she passed out yesterday and she has been in bad shape for quite some time now. Passes out and falls and so I called the ambulance . . . 3.1.4. Sudden deterioration Sudden deterioration describes a disease evolving over time, usually in the last hour or hours: Caller (relative): He feels worse during the last . . . then only the last hour. Caller (nurse): He was healthy this morning . . . 3.2. Physical signs and symptoms Breathing diﬃculties were commonly described, and the other subcategories were Nausea and Vomiting, Pain, Pallor and Measurable signs of illness. Pallor was mentioned only in a few cases, where the EMD speciﬁcally asked about the appearance of the patient. Laymen and professionals both used these descriptions, but differed in descriptions of pain. 3.2.1. Pain Professionals sometimes told the EMD about pain on palpation when they examined the patient. Caller (nurse): “And she has so much pain when I come and visit her so I try to palpate the stomach and then, well. . . yes. She feels. . . pain. . .” Laymen usually talked about pain expressed by the patient: Caller (relative): “Yes, she has had a huge headache, but now she is taking pain killers, so she says that . . .” 3.2.2. Breathing diﬃculties The caller mentioned heavy or strained breathing or wheezing in more than half of the cases. Laymen often mentioned strained breathing or just answered “No” to the EMD asking if the patient was breathing normally. Professionals usually described the breathing very early in the conversation (often with a measured respiratory rate) and without the need for attendant questions: Caller (nurse): “We have a patient here, and the breathing is very strained right now” 3.2.3. Measurable signs of illness Fever was the most prominent description in this subcategory. Both laymen and professionals measured body temperature. However, only the latter reported the blood pressure level. Measureable signs of illness showed the most distinct disparity between the different types of callers, since professionals explained the speciﬁc values of vital signs to the EMD in every single case and often early in the conversation. The measurements of the vital signs were often the ﬁrst information given by the professionals: Caller (nurse): “His temperature has risen fast and is 38.8. His breathing is a bit fast, the blood pressure is 180/85, the pulse 88. There is no indication of pulmonary oedema or anything now but . . .” In comparison, laymen seldom told the EMD about fever unless they were asked: EMD: “Okay. What is her temperature?” Caller (relative): “Yes, well. . . going to check here. . . [silence] 39.3.” 3.3. Diﬃculties establishing satisfactory contact with the patient In almost half of the recordings, the caller mentioned problems talking to the patient, sometimes explained as the patient being feeble or drowsy, but more often only vague descriptions were used. Subcategories were confusion, drowsiness and simply not answering. Professionals sometimes used more medical language, with terms such as “decreased level of alertness.” Confusion was the smallest sub-category, appearing in only a few calls. It differed substantially from the other subcategories by conveying that the patient did answer, but not appropriately. Most often, the descriptions of contact diﬃculties arose when the EMD asked if the patient was unconscious. 3.3.1. Drowsiness Many callers said sleepiness was the problem. Some said they were able to wake up the patient but that the patient soon went back to sleep and could not keep up a conversation. Caller (relative): She can speak and. . .. So on, then she awakens when I say that. . . she is barely able to contact, but it. . . it is not much more than that. K. Bohm et al./International Emergency Nursing 23 (2015) 294–298 3.3.2. Not answering In several calls there was no explanation at all. Some callers seemed unable to suggest any reason for the problem with the nonspeaking patient. The EMD often did not ask any subsequent questions that could help the caller explain why the patient could not speak. EMD: Does she not respond? Caller (relative): No . . . EMD: Do you mean she is unconscious? Caller: No but. . . she cannot say anything. 4. Discussion In the current qualitative study we found that sepsis was described in terms of deterioration, physical symptoms, and communication abilities of the patient. There was a wide spectrum of descriptions used by the callers. The main category ‘Diﬃculties in establishing contact with the patient’ included vague descriptions of worsened general condition, while diﬃculties breathing, and diﬃculties establishing contact with the patient were the most commonly mentioned symptoms. This may reﬂect the fact that the EMD always asks about breathing and unconsciousness, since these are covered in the criteriabased protocol in the Swedish EMCC. An implication of the current study is that the results can be added to a decision tool/protocol but also to the EMD-education. Prior studies have shown that identiﬁcation of sepsis in the EMS leads to less delay before antibiotic treatment and protocol-driven treatment in the ED (Studnek et al., 2012; Wang et al., 2010). Also, identiﬁcation of the septic patient by the EMD opens the possibility of initiating treatment in the ambulance, i.e. moving the treatment outside the hospital. 4.1. Different callers, different descriptions Our results indicate an interesting difference between laymen and professionals. The latter used more speciﬁc medical terminology when talking to the EMD than laymen. However, this did not inﬂuence the analysis and coding process. In the current study it was more common that the caller was a professional than a relative. Interestingly it was never the patient who called. It is shown to be more diﬃcult for the EMD to identify the symptoms when there is a third party calling the EMCC (Karlsten and Elowsson, 2004). Most of the patients presenting with sepsis in this study lived in geriatric or nursing homes, and this explains the high rate of nurses calling the EMCC. The work as an EMD differs substantially from the work of other health care professionals, since the phone call provides only the caller’s interpreted version of the situation. 297 trigger follow-up questions to work out if the condition is acute, and should also lead to suspicion of severe infection, but more research is needed to conﬁrm this. 4.3. Physical signs and symptoms Typical symptoms of sepsis (Levy et al., 2003; Martin et al., 2003) were described in a clear way (e.g. fever was called fever), which implies that callers were used to these descriptions. Pallor was only mentioned in a few calls, despite being a common symptom of sepsis (Martin et al., 2003). The EMD often asked about fever, but not always. Since there is no speciﬁc EMD protocol for infection in the Swedish EMCC – only for “fever” or “unknown problem” – not asking about fever may slow down the identiﬁcation process of sepsis. All EMDs asked about breathing, but not whether the patient was breathing faster than normal or not. More commonly they only asked if the patient “was breathing normally”. Since laymen are probably not familiar with the concept of increased respiratory rate as a symptom of sepsis the EMD should ask speciﬁc questions regarding this. Hypotension was never directly asked about by the EMD and never mentioned by laymen. A patient’s fall could be caused by hypotension, but could also have other reasons. Low blood pressure might not be known to laymen as a disease indicator (Bone et al., 2009). 4.4. Diﬃculties establishing satisfactory contact with the patient Diﬃculties establishing satisfactory contact with the patient, most often used by laymen, described how the caller was unable to communicate with the patient as he or she normally did, and often came in response to the EMD’s question about consciousness. The exact term “lowered level of consciousness” was seldom used by laymen. These descriptions differed substantially from the other categories because the diﬃculties establishing contact with the patient seemed to be more subjective. Sometimes it was possible to hear the patient talking in the background, even though the caller answered “yes” when the EMD asked if the patient was unconscious. The EMD should listen to the patient through the telephone or even better, ask if it is possible to talk with the patient, to get a better understanding of the situation. A description of unsatisfactory contact should be taken seriously. The results of the current study could be used as the basis for future quantitative studies. Central keywords could be incorporated into the decision tool, i.e. the protocol used by the EMD, once identiﬁcation of these keywords has been done. 5. Conclusions 4.2. Deterioration Professionals used medical terminology when expressing symptoms, but when expressing presentations categorized as deterioration they used descriptions that were as vague as those of the laymen. An explanation for this could be that neither laymen nor professionals know of any “correct way” of expressing behavioural changes in terms of change of condition. These changes are useful as a part of pattern recognition for the EMD. A previous study suggests that the activity level and body position of a patient might help the EMD to make a correct identiﬁcation (Clawson et al., 2008). Considering the symptoms in the subcategory falling and collapsing, it was uncertain whether these falls were caused by general weakness, hypotension or something else. However, falling was mentioned for patients with sepsis, which indicates that this symptom might be of value for recognizing a septic patient. 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