Early Septicemia Recognition and Intervention Education for the Pre-Hospital Setting

Sepsis is a persistent issue globally and causes nearly 270,000 deaths in the United States each year, placing a significant burden on the US economy and the health care system. Over 40% of patients diagnosed with sepsis arrive at the Emergency Department (ED) via Emergency Medical Services (EMS). Recent studies have identified a relationship between the degree of education, recognition, and understanding of the treatment of sepsis by EMS personnel and patient outcomes, including sepsis mortality rates. Earlier recognition of sepsis in the pre-hospital setting may prevent the advancement of the infectious state and improve patient outcomes. This project was a multistep single-site quality improvement project designed to investigate if an educational intervention impacted the outcomes of sepsis patients transported via EMS. The personnel at an EMS Agency within the Salt Lake City region were identified and selected for this project. EMS personnel (n=465) completed a pre- intervention survey aimed at assessing their current level of awareness and understanding of sepsis. Results of the pre-intervention survey were used to develop an online education module designed to train EMS personnel to recognize sepsis and implement appropriate treatment interventions. Following the learning module, a post-intervention survey was distributed to assess changes in awareness and recognition of sepsis signs and symptoms. In the three-month time frame following project implementation, sepsis mortality data were collected at a Trauma Center ED, which serves the participating EMS agency. A total of 465 EMS providers participated. The majority of participants were male (88%), have a Bachelor's level education (42%), ten years or more of EMS experience (67%), with paramedic certification (54%). All 465 participants completed the pre-survey, 68.6% (n=319) indicated that they feel EMS education on sepsis is inadequate. 86% (n=401) of participants completed the post-survey, which revealed that 90.3% (n=362) felt the education module implemented for this project improved their confidence in their ability to recognize and treat sepsis in the pre-hospital setting. Additionally, 78.7% (n=366) participants completed a follow-up survey three months after project implementation; data demonstrates that 96.7% (n=354) felt that the educational intervention improved their understanding of sepsis. In the three-month time frame following project implementation, sepsis mortality data were collected at the Trauma Center ED and demonstrates a 10.7% (p=0.26) reduction in sepsis mortality rates which does not demonstrate statistical significance. Pre-hospital intervention has the potential to decrease mortality rates in septic patients. This project demonstrated that EMS personnel desire more training in recognition of sepsis and have a high interest in participating in online sepsis training

Emily S. Grange University of Utah College of Nursing Background: Sepsis is a persistent issue globally and causes nearly 270,000 deaths in the United States each year, placing a significant burden on the US economy and the health care system. Over 40% of patients diagnosed with sepsis arrive at the Emergency Department (ED) via Emergency Medical Services (EMS). Recent studies have identified a relationship between the degree of education, recognition, and understanding of the treatment of sepsis by EMS personnel and patient outcomes, including sepsis mortality rates. Earlier recognition of sepsis in the pre-hospital setting may prevent the advancement of the infectious state and improve patient outcomes. Methods: This project was a multistep single-site quality improvement project designed to investigate if an educational intervention impacted the outcomes of sepsis patients transported via EMS. The personnel at an EMS Agency within the Salt Lake City region were identified and selected for this project. EMS personnel (n=465) completed a preintervention survey aimed at assessing their current level of awareness and understanding 1 of sepsis. Results of the pre-intervention survey were used to develop an online education module designed to train EMS personnel to recognize sepsis and implement appropriate treatment interventions. Following the learning module, a post-intervention survey was distributed to assess changes in awareness and recognition of sepsis signs and symptoms. In the three-month time frame following project implementation, sepsis mortality data were collected at a Trauma Center ED, which serves the participating EMS agency. Results: A total of 465 EMS providers participated. The majority of participants were male (88%), have a Bachelor's level education (42%), ten years or more of EMS experience (67%), with paramedic certification (54%). All 465 participants completed the pre-survey, 68.6% (n=319) indicated that they feel EMS education on sepsis is inadequate. 86% (n=401) of participants completed the post-survey, which revealed that 90.3% (n=362) felt the education module implemented for this project improved their confidence in their ability to recognize and treat sepsis in the pre-hospital setting. Additionally, 78.7% (n=366) participants completed a follow-up survey three months after project implementation; data demonstrates that 96.7% (n=354) felt that the educational intervention improved their understanding of sepsis. In the three-month time frame following project implementation, sepsis mortality data were collected at the Trauma Center ED and demonstrates a 10.7% (p=0.26) reduction in sepsis mortality rates which does not demonstrate statistical significance. Conclusions: Pre-hospital intervention has the potential to decrease mortality rates in septic patients. This project demonstrated that EMS personnel desire more training in recognition of sepsis and have a high interest in participating in online sepsis training 2 education. Our results suggest that improving EMS awareness of sepsis and their ability to recognize and treat sepsis in the pre-hospital setting may decrease mortality rates in hospitalized sepsis patients. There is a need further to explore the educational needs of EMS personnel regarding sepsis. Interviews with EMS providers to explore current practices regarding sepsis and suggestions for education might also reveal alternative strategies to not only improve the recognition of sepsis but also how to implement appropriate treatment bundles to provide optimal patient care. Introduction Problem Description Sepsis is an ongoing issue globally, placing a significant burden on the US health care system. Just under two million American adults develop sepsis annually, resulting in nearly 270,000 deaths.;. According to the United States Healthcare Cost and Utilization Project (HCUP), in 2013, the United States spent nearly $24 billion on hospital treatment and management of patients with sepsis making it the costliest medical condition to treat throughout the nation (HCUP, 2016). 3 The challenge we face with sepsis is early recognition and treatment. Failure to intervene in the early stages of organ dysfunction results in increased morbidity and mortality . Research indicates that early recognition and intervention leads to improved outcomes for patients and decreased economic burden on the healthcare system . Emergency Medical Services (EMS) personnel frequently encounter patients with sepsis. Despite a high frequency of exposure to the condition, research continues to demonstrate a significant lack of recognition of sepsis in the pre-hospital setting. This lack of recognition includes a lack of understanding of Systemic Inflammatory Response Syndrome (SIRS) and other early signs and symptoms of sepsis. This gap in care contributes to poor patient outcomes, including prolonged hospital stay and increased morbidity and mortality due to sepsis . Adding to the problem is a lack of progress in the development of a sepsis alert system similar to campaigns used for early recognition of stroke and myocardial infarction . This clinical gap is further assessed in a pilot study by Guerra, Mayfield, Meyers, Cloutre, &Riccio (2013) that demonstrated less than half of the sepsis cases seen by the EMS crews were correctly identified . However, more than 40% of sepsis patients in the ED were transported by EMS . Retrospective data analysis indicates that EMS personnel spend an average of 45 minutes with a patient from their arrival on the scene to their arrival in the ED. Each hour that antibiotics are delayed, sepsis survival drops 7.6%; moreover, separate studies have demonstrated that prehospital fluid or even IV placement alone decreases odds of sepsis-related mortality . Dr. James O'Brien, the Medical Director of Sepsis Alliance, stated in an interview: Early recognition of the symptoms of sepsis combined with prompt 4 administration of fluids and antibiotics can make a huge difference not only in morbidity and mortality but also in length of hospital stays and health care costs. Now more than ever, it is critical that we raise awareness of sepsis, which will reduce healthcare costs and, more importantly, save thousands of lives every year. We must do more . Therefore, early intervention on the part of EMS personnel to recognize sepsis and implement IV placement and fluid administration will likely decrease morbidity by decreasing the delay to antibiotic administration. In order to achieve this, EMS must become skilled in the rapid assessment and recognition of sepsis patients. Available Knowledge Earlier recognition of SIRS in the pre-hospital setting may prevent the advancement of the infectious state and improve outcomes . To identify a patient as having SIRS, they must meet two of the following criteria, a heart rate higher than 90 beats per minute, a respiratory rate greater than 20 breaths per minute, or a temperature less than 36 degrees Celsius or greater than 38.3 degrees Celsius. EMS personnel are educated to recognize the aforementioned vital signs as abnormal or concerning. However, EMS education is currently lacking in regards to training EMS personnel to recognize these vital signs as signs of sepsis as well as appropriate interventions indicated for sepsis care. In response to the wide variety of symptoms associated with sepsis and the apparent difficulty for medical staff to recognize and intervene early on in the sepsis process, the Surviving Sepsis Campaign collaborated with the Institute for Healthcare 5 Improvement to design a sepsis treatment bundle. The product of this collaboration is a checklist that guides medical staff in recognizing signs and symptoms of sepsis. These bundles also guide healthcare providers in implementing timely intervention (i.e., largebore peripheral IV placement, fluid administration at 30mL/kg, collection of blood samples for laboratory analysis including blood cultures, urine collection, and timely administration of antibiotics) for best possible outcomes of sepsis patients. Hospitals across the nation are implementing these treatment bundles, but they are under-utilized during the pre-hospital phase of care. Data reports generated from the records at a Level 1 Trauma Center in the Salt Lake City region reflect that from September 2018 through September 2019, 35% (n= 183) of patients identified with sepsis were transported to the ED by EMS. Of those patients, 20% (n=37) subsequently died due to sepsis . Rationale In May 2017, the World Health Organization (WHO) and the World Health Assembly (WHA) deemed sepsis a global health priority. They urged the members of the United Nations to focus on improving the diagnosis and management of sepsis . In 2001, Rivers et al. performed a randomized control trial (RCT) of 263 patients in an urban emergency department to evaluate the efficacy of early intervention therapy for sepsis; the results of the study were a decrease of in-hospital mortality by 16% . In response to the Rivers study, in 2004, the Surviving Sepsis Campaign, a collaboration of expert clinicians whose primary focus is reducing sepsis-related mortality, released a set of international guidelines for the management of sepsis. These guidelines continue to be 6 updated every four years and have been summarized and condensed in the form of sepsis treatment bundles . A treatment bundle, as defined by the Institute for Healthcare Improvement (IHI), is a set of interventions related to a disease process. When implemented together, these interventions result in improved outcomes for the affiliated disease process. A treatment bundle aims to transition a complex set of guidelines into behavior changes that reduce mortality, improve outcomes, and ensure timely intervention . In the years since the initiation of sepsis treatment bundles, studies have demonstrated improvements in the length of hospital stays for patients with sepsis, reduction in the overall cost of sepsis care, and decreased morbidity and mortality ;;. In step with the recommendations put forth by the Surviving Sepsis Campaign, a goal of this project was to tailor a sepsis treatment bundle based on the assessed educational needs of pre-hospital providers. An online educational module complete with pre- and post-survey and an EMS specific sepsis treatment bundle was developed and distributed to all emergency medical technicians (EMT's) and paramedics (PM's) within a Fire Department located in Salt Lake City. The treatment bundle was a modified version of the treatment bundle utilized in the Emergency Department at an urban/suburban Level 1 Trauma Center and teaching hospital in the Salt Lake City, Utah area (see Figure 2 and Figure 3). This quality improvement process was developed around the Normalization Process Theory (NPT). NPT assists researchers in identifying promoting and inhibiting factors that affect the implementation of complex interventions into health practices. NPT 7 also aims to explain how interventions become so engrained into practice that it becomes "normal" and is actively practiced without conscious thought . This theory was used to identify which aspects of sepsis recognition EMS struggle with most and to that end, where the most significant lack of education lies for EMS personnel to understanding and recognizing sepsis. The areas identified as lacking were, for this project, considered barriers to intervention implementation. The education module was tailored to teach the identified barriers and introduce the treatment bundle intervention with the goal that the education provided will become a natural, ingrained part of the EMS process. Specific Aims The aim of this project is two-fold: First, to assess the current level of understanding and awareness that EMS providers have of sepsis and evidence-based sepsis treatment; Second, to investigate the effect of educating EMS providers to recognize sepsis and initiate sepsis protocols in the pre-hospital setting. There is a potential lack of existing education on sepsis for the pre-hospital provider, further decreasing their ability to recognize and treat sepsis adequately in the pre-hospital setting and potentially contributing to poorer patient outcomes. The goal of first-responder specific education on sepsis recognition was to improve early recognition of sepsis and increase EMS awareness of sepsis signs and symptoms. The implementation of a prehospital sepsis treatment bundle aims to decrease morbidity and decrease the delay in early intervention and the administration of fluid resuscitation and antibiotic therapy as well as rapid transport to the ED. Methods 8 Context A local Fire and EMS Agency within the Salt Lake City area consisting of 25 individual fire stations was identified and selected for this quality improvement project. All EMTs and paramedics (PM) totaling 465 individuals were shown the educational video with information on sepsis signs and symptoms recognition and sepsis treatment bundle implementation. An Emergency Department at a Level 1 Trauma Center in the Salt Lake City area was chosen to track and identify patients diagnosed with sepsis who were transported to the ED by EMS. Intervention(s) This multistep intervention began with a literature review of pre-hospital awareness of treatment options for sepsis patients. The results of the literature review indicated a need for increased sepsis awareness in the pre-hospital setting and more robust education for EMS providers to recognize the stages of sepsis as well as when and how to initiate sepsis treatment. Studies indicate that EMS awareness of sepsis is lacking, and increased education could potentially improve earlier recognition and treatment, thereby reducing mortality in sepsis patients. The second step was to assess the current level of awareness and understanding of sepsis of EMS providers. This step was achieved through a pre-intervention survey completed in an online format distributed via an online learning system to all EMTs and PMs employed by the EMS agency. The pre-intervention survey included a total of 19 questions that assessed the EMS provider's ability to accurately identify sepsis, their familiarity with sepsis treatment protocols, and their level of comfort in recognizing 9 sepsis in the pre-hospital setting (see Appendix A). Next, data collected from the pre-intervention survey were used to create an online learning module and educational presentation that included up-to-date, researchbased information on sepsis signs, symptoms, and recognition. This module was targeted at appropriately addressing the barriers and deficiencies in the EMS provider's knowledge of sepsis. This educational intervention was distributed to 465 EMS providers at a Fire-EMS agency in Salt Lake City via the online learning management system the agency uses for continued education training for all EMS personnel. Immediately following the completion of this learning module, each individual was prompted to complete a post-intervention survey to assess for changes in their awareness and recognition of EMS signs and symptoms. The post-intervention survey totaled 17 questions (see Appendix B). A pre-hospital checklist was created based on a modified version of an evidence-based treatment bundle checklist currently used by the local Level 1 Trauma Center Emergency Department in Salt Lake City (see Figure 2). This treatment bundle was modified for the pre-hospital setting to support EMS providers to accurately recognize sepsis and prompt EMS personnel to ask valuable questions that further identify patients at risk for the development of sepsis. The bundle also provides appropriate and reasonable interventions that can be easily implemented during transport to the ED (see Figure 3). The development of both the educational learning module and the modified sepsis treatment bundle were created in collaboration with multiple content experts in EMS pre-hospital care, ED nursing, and both nursing education and EMS education. 10 A follow-up survey was distributed to all EMTs and PMs at the same fire agency approximately two months after the completion of the online learning module. The follow-up survey totaled 19 questions and included short answer questions for feedback on how EMS education on sepsis could be improved (see Appendix C). The goal of this follow up survey was to evaluate retention of the educational intervention. For the final step of the project, overall mortality rates of sepsis patients brought into the hospital by the EMS providers were assessed monthly. Figure 1. Demonstrating how each step of the process influenced the next step. Study of the Intervention(s) The study of interventions was completed through the comparison of statistics collected from pre-, post-, and follow-up surveys administered to EMS personnel. The surveys were conducted using Google Forms to collect the initial data. Additionally, reports of overall patients brought to the ED from the pre-hospital providers, including those diagnosed with sepsis and admitted, were collected. Measures The effectiveness of the interventions was determined through careful analysis of pre-, post-, and follow-up surveys. The questions in these surveys were explicitly designed to capture the pre-hospital provider's understanding of sepsis and the ability to recognize sepsis in the pre-hospital setting. Survey questions focused on recognizing and differentiating between 1) The stages of sepsis (SIRS, Sepsis, Severe Sepsis, and Septic Shock); 2) the signs and symptoms of sepsis, i.e., hypo- or hyperthermia, tachycardia, tachypnea, hypotension, AMS, symptoms of an infection; 3) The role and responsibility 11 of the pre-hospital provider in caring for patients with sepsis in the pre-hospital setting; and 4) The recognition of the need for and implementation of The EMS Pre-Hospital Sepsis Treatment Bundle. All surveys were distributed electronically to pre-hospital EMS providers (n= 465). Each of these individuals also completed the online sepsis education module. After the deadline for pre-survey completion had elapsed, the online learning module on sepsis education was widely distributed to the same group of EMS providers. The learning module required approximately 30 minutes to complete and included mixed pedagogical techniques consisting of lecture, case scenarios, and embedded quiz questions. Once the module was complete, the learner was provided an electronic link to complete the postsurvey. Two months after the completion deadline for the learning module, the participating EMS providers were sent a link to complete the follow-up survey. The follow-up survey, in addition to questions similar to the pre- and post-surveys, provided the opportunity for participants to give feedback regarding the education module itself. All data collected from the pre-, post-, and follow-up surveys were captured via google forms. To further assess the implementation of the education and treatment bundle interventions, hospital-based statistics were analyzed. Data was pulled from the hospital to compare pre-intervention rates and post-intervention rates, including the number of patients seen in the ED, the number of sepsis patients brought in by EMS providers, the overall mortality rate of sepsis patients seen in the ED, and the mortality rate for sepsis 12 patients transported by EMS. Analysis This project included calculated statistical analysis to measure the variations between pre-intervention, post-intervention, and follow-up surveys. Demographic statistics were calculated for each category. A two-tailed t-Test was used to analyze hospital data. Open-ended questions from the follow-up survey were discussed with the research team. These questions primarily contain feedback about the educational intervention, how this intervention has impacted the current EMS approach to sepsis recognition and treatment, and what EMS providers feel is necessary moving forward to improve sepsis education and recognition for pre-hospital providers. Ethical Considerations During the early stages of project development, an online questionnaire, provided by the University of Utah Institutional Review Board (IRB), was completed and submitted for review. It was determined that this project is a quality improvement project which does not directly involve human subjects and is exempt from requiring IRB review. The PI (EG) also completed a training course in research ethics through the Collaborative Institutional Training Initiative (CITI) as well as a course in good clinical practice for social and behavioral research from the Society of Behavioral Medicine (SBM). All EMS providers who participated in this project did so voluntarily and were not identifiable by any personal information. Furthermore, no identifiers were collected 13 for the patients who were treated using the treatment bundle intervention, and none were contacted directly. There are no conflicts of interest. Results Demographic results can be found in Table 1. The majority of EMS participants were male (88%), between the ages of 36 and 45 years-old (40.7%), had a Bachelors prepared education (42%), over ten years of experience (67%), with paramedic level certification (54%) (see Table 1). In phase one of this process, 465 EMS providers participated in the pre-survey and online education module regarding sepsis recognition and treatment. Of the 465 participants, all 465 completed the pre-survey (Appendix A), 401 completed the postsurvey (Appendix B), and 366 completed the follow-up survey (Appendix C). Of the EMS providers who participated in the pre-intervention survey, 68.6% (n= 319) indicated that they feel EMS education on sepsis recognition and treatment is inadequate, and 89% (n=416) feel that early recognition and treatment of sepsis in the pre-hospital setting would positively impact outcomes of sepsis patients. Comparatively, post-intervention survey results 98% (n=393) of participants indicated that early recognition and treatment of sepsis in the pre-hospital setting would positively impact patient outcomes; this is a 9% increase in EMS understanding of the impact of prehospital recognition and treatment. Additional post-intervention survey results revealed that 90.3% (n=362) of participants indicated that the education module implemented for this project made them feel more confident in their ability to recognize and treat sepsis in the pre-hospital setting. These results indicate that the online learning module was 14 effective in increasing EMS personnel's understanding of sepsis signs and symptoms and appropriate interventions before arrival in the ED. A total of 366 participants completed the follow-up survey. Of these results, 97.8% (n=358) of participants agree that early recognition is critical in improving the outcomes of sepsis patients. 96.7% (n=354) of participants felt that overall, the education module was beneficial in helping them to understand sepsis, recognize sepsis signs and symptoms, and increased their ability to treat sepsis more confidently in the pre-hospital setting. Again, these results are supportive that the online learning module was effective in increasing the EMS provider's knowledge base on sepsis recognition and treatment in the pre-hospital setting. Phase three, qualitative data analysis was performed on the feedback comments from the follow-up survey. The open-ended question regarding feedback focused on ways in which we can improve this learning module and how overall EMS education on sepsis can be improved if any. There were a total of 113 responses with repetitive themes throughout the comments including, "More often for more exposure," "More frequent refresher courses like this one," "Keep training!", "Ongoing training, like this, is very helpful," and "This should be a yearly requirement." These comments from the follow-up survey are supportive that the education was beneficial and that EMS wants additional and more frequent education on sepsis and sepsis care. In addition to analyzing pre-, post-, and follow-up surveys, a senior value engineer within the Level 1 Trauma Center in Salt Lake City generated descriptive statistics from November 2019 to February 2019. These data included all patients seen in the ED with a 15 sepsis diagnosis during that time frame. In this three-month time frame, a total of 184 patients were seen and treated for a diagnosis of sepsis in the Level 1 Trauma Center ED. Of those 184, 31% (n=57) arrived via EMS. Mortality rates found that of the 57 sepsis patients who arrived via EMS, 12.3% (n=7) died due to sepsis. Additional reports generated from the same data pool but for three months before the intervention implementation from July 2019 through September 2019 found that 39 sepsis patients arrived at the ED via EMS during this time frame and of those patients, 23% (n=9) died due to sepsis. This data demonstrates a 10.7% reduction in mortality rate following the online module distribution (see Table 2). A two-tailed t-Test run on the hospital data resulted a p-value of 0.26 demonstrating that this decrease in sepsis mortality is not statistically significant. Discussion Summary Implementation of this EMS pre-hospital sepsis education with an EMS agency in the Salt Lake City region demonstrated a potentially positive impact on patient outcomes and had a positive reception from the participating EMS personnel. The project demonstrated that EMS provider's knowledge about sepsis signs and symptoms, as well as sepsis treatments increased after completing the online education module and the potential that educational interventions decreased mortality rates in the hospital. Interpretation There may be several factors contributing to the 10.7% decrease in mortality rate. One potential contributor is the change in process by which the ED receives patients who 16 were recognized as septic by EMS providers. Prior to project implementation the process for receiving patients in the ED from EMS involved the EMS provider contacting the ED Charge Nurse with a patient report prior to arrival at the ED. Then, upon arrival at the ED, the EMS team, along with the patient, would be directed to a pre-assigned exam room where they would wait for a Registered Nurse (RN) to arrive. Once the RN was present, EMS would provide a patient report and the RN would assume care of the patient. During the process of this Quality Improvement project, a delay in the continuation of sepsis care from EMS to ED was recognized. The hand-off process was evaluated, discussed, and adjusted to better serve patients who arrive to the ED via EMS who were suspected of having sepsis. The new process consisted of the same pre-arrival report between EMS provider and the ED Charge Nurse. During this project the Charge Nurse made an overhead announcement stating "EMS Code Sepsis" with an estimated time of arrival (ETA) in minutes. The Charge Nurse's responsibility was to place an exam room on hold for the expected patient. Next, to minimize any delay in the continuation of care, an ED Physician, an ED RN, and ED-Tech waited for the patient in the designated room. Although this might contribute to a decrease in mortality rate, it is uncertain if every patient who was deemed septic by EMS was received by the ED staff in this manner. Furthermore, it is uncertain if every patient deemed septic by EMS was indeed septic. However, because of the change in the process by which potential sepsis patients received treatment once identified as septic, it is vital to explore this in the future. One other potential contributor to the decrease in mortality rates is, not all 17 patients diagnosed with sepsis who arrived at the ED were under the care of the participating EMS agency. The participating EMS agency transported 164 patients to the participating ED during the time frame; the number of those who were subsequently diagnosed with sepsis is unknown. This missing data may have further supported the effectiveness of the learning module. The EMS personnel who received the sepsis education demonstrated an improved ability to recognize sepsis signs and symptoms and screen patients. These results are consistent with the findings from previously published studies regarding the importance of sepsis education for EMS personnel as well as the importance of early recognition and intervention to improve outcomes of sepsis patients ; . A systematic review of nine studies concluded that research to address the need for increased EMS sepsis education and the impact of the pre-hospital intervention on the outcomes of sepsis patients is lacking and what evidence is available to support this is low quality. . Another systematic review that further supports the goal of this project demonstrated that recognition of sepsis by EMS providers is poor, and the use of an adapted screening tool similar to the checklist developed for this project may prove to be beneficial in the pre-hospital setting. However, further research and validation of clinical benefit are needed for this topic . Additionally, a cross-sectional study performed in 2019 amongst EMS personnel in Saudi Arabia exhibited a lack of awareness and understanding of sepsis care in the prehospital setting. Of the 197 EMS personnel sampled in this study, only 48% were able to identify sepsis correctly. The recommendation from this study was also to improve sepsis education for EMS providers. It is recommended that further research be done to study 18 and analyze the need and benefit of increased EMS sepsis education. Furthermore, this research should be expanded to include both urban and rural communities where prehospital providers have different training (e.g., volunteer EMTs) or communities where pre-hospital care is provided via telemedicine. Current studies on this topic are limited. The Pre-Intervention survey distributed in this project inquired if participants felt that current EMS sepsis education was adequate, nearly 70% (n=319) indicated that it is not. Additionally, on the Follow-Up survey, 96.6% (n=313) of participants indicated that the education received through this study was overall beneficial and increased understanding and recognition of sepsis in the pre-hospital setting as well as improved confidence in treating and reporting sepsis. The participants in this project represent a diverse population of EMS providers covering a wide range of demographics, thus demonstrating applicability to the general EMS population. This project was implemented over a relatively short time frame of four months and was positively received by participating parties. Because EMS personnel were allowed to complete this education while on shift, this education module, as delivered, had no associated cost aside from the cost of time to complete the education module. The ease in which this intervention can be implemented, coupled with its reasonable time frame and low cost, has the potential to be easily incorporated into training regimens in EMS agencies. The proposed treatments indicated for sepsis, as recommended in this project, also do not require the addition or elimination of any supplies on the EMS vehicle. Limitations 19 The design of this project was a Quality Improvement (QI) format, thereby creating limitations. The use of a control group may have potentially identified if the decrease in sepsis mortality rates are linked to the group that viewed the educational module. We did not track individuals and their responses to the educational module and patients that those individuals treated in the pre-hospital setting. As a result, we can only hypothesize that the educational module had an overall impact. We also did not track survey responses of each EMS provider, and this would have provided a projection of the growth in understanding of each participant. Another limitation of this project is that each sepsis patient admitted was not flagged. Flagging the patients transported by the participating EMS agency would have allowed for a more thorough data collection to demonstrate further the effectiveness of the online learning module and treatment bundle implementation, however. The third identified limitation was the disbursement of education in an online format versus in person. An in-person delivery may have allowed for a real-time question and answer portion for the EMS personnel. However, this type of delivery format would have likely, significantly limited the number of EMS providers available to complete the education training as an online format is much more convenient. Lastly, this project was limited geographically and thereby is limited in its generalizability due to its urban setting. However, the goal of this project was to demonstrate the need for increased EMS sepsis education, and the results support that goal. Conclusions In conclusion, this type of project is only the second of its kind to be implemented 20 in the Salt Lake region. It is feasible to implement this education platform to additional EMS agencies as well as community clinics, and urgent care facilities would benefit from this education model. Having increased education to improve the EMS personnel's ability to recognize sepsis and treat it appropriately in the pre-hospital setting decreased sepsis mortality rates at a Level 1 Trauma Center ED in Salt Lake City. There is much room for additional EMS education on the topic of sepsis and many EMS agencies who would benefit from this education. The next step is for additional research and analysis of EMS sepsis mortality rates, length of hospital stays, the overall cost of sepsis care, and the need for increased EMS education on sepsis. Acknowledgments I would like to acknowledge my project chair, Katherine Doyon MS, Ph.D., an adjunct professor at the University of Utah College of Nursing. I would like to thank her for her assistance and guidance through this project. I would also like to acknowledge Matthew Sanford, Senior Value Engineer at the University of Utah Hospital, for his assistance with data collection and analysis. I would like to thank Chris Middlemiss, PM, Medical Education Specialist at Unified Fire Authority, for his assistance with the distribution of education module, surveys, and data collection. Funding This project did not receive any funding contributing to the completion of this project. 21 22 23 24 Figure 2. Emergency Department Sepsis Treatment Bundle. This figure shows the sepsis treatment bundle utilized in the participating Level 1 Trauma Center ED. (Pulse, 2019). 25 26 Figure 3. EMS Pre-Hospital Sepsis Checklist. This figure shows the Pre-Hospital Sepsis Checklist developed for this project. (Grange, 2019). Table 1 27 Table 2 Data regarding sepsis mortality rates at the Level 1 Trauma Center in Salt Lake City, Utah. Month and Year Number of Sepsis Patients Seen in ED Number of Sepsis Patients Transported by EMS July - September 2019 99 39 9 November 2019 - February 2020 184 57 7 Two-tailed t-test p = 0.26 28 Number of EMS Sepsis Deaths Appendix A Pre-Intervention Survey EMS Pre-Hospital Sepsis Care Education Pre-Survey: Demographics: ⦁ ⦁ Age ⦁ 18-25 ⦁ 26-35 ⦁ 36-45 ⦁ >45 Gender ⦁ Female ⦁ Male ⦁ Prefer not to say 29 ⦁ ⦁ ⦁ ⦁ Non-Binary ⦁ Transgender ⦁ Other… Education Level ⦁ High School Diploma/GED ⦁ Associates Degree ⦁ Bachelor's Degree ⦁ Graduate Degree or Higher Years of EMS experience ⦁ <1 year ⦁ 2-5 years ⦁ 6-10 years ⦁ >10 years Level of EMS Training Certification ⦁ Basic EMT ⦁ Advanced EMT ⦁ Paramedic ⦁ Other… Questions: ⦁ ⦁ Are you familiar with the term 'Sepsis'? ⦁ Yes ⦁ No Which definition do you think BEST defines sepsis? ⦁ Another name for an allergic reaction ⦁ Simple infection treated with oral antibiotics 30 ⦁ ⦁ ⦁ ⦁ Life-threatening systemic infection ⦁ a genetic condition How confident do you feel recognizing sepsis during patient care? ⦁ Not at all Confident ⦁ Somewhat Confident ⦁ Mostly Confident ⦁ Very Confident Have you ever cared for a patient during transport to the hospital whom you suspected of having sepsis? ⦁ Yes ⦁ No Do you think the following signs and symptoms are associated with sepsis? ⦁ ⦁ ⦁ ⦁ ⦁ Fever ⦁ Yes ⦁ No ⦁ Not sure Hypothermia ⦁ Yes ⦁ No ⦁ Not Sure Tachycardia ⦁ Yes ⦁ No ⦁ Not Sure Tachypnea 31 ⦁ ⦁ ⦁ Yes ⦁ No ⦁ Not Sure Hypotension ⦁ Yes ⦁ No ⦁ Not Sure Altered Mental Status ⦁ Yes ⦁ No ⦁ Not Sure ⦁ ⦁ ⦁ As an EMS provider, do you feel that current EMS education of sepsis is adequate? ⦁ Yes ⦁ No How Confident are you in your understanding of sepsis treatment? ⦁ ⦁ ⦁ Not at all Confident Confident 1 2 3 4 5 Very Do you think that earlier recognition and treatment of sepsis in the pre-hospital setting would improve outcomes? ⦁ Yes ⦁ No Are you willing to actively participate in the management of sepsis in the prehospital setting? ⦁ Yes ⦁ No 32 ⦁ Maybe Appendix B Post-Intervention Survey EMS Pre-Hospital Sepsis Care Education Post-Survey: Demographics: ⦁ ⦁ ⦁ Age ⦁ 18-25 ⦁ 26-35 ⦁ 36-45 ⦁ >45 Gender ⦁ Female ⦁ Male ⦁ Prefer not to say ⦁ Non-Binary ⦁ Transgender ⦁ Other… Education Level ⦁ High School Diploma/GED 33 ⦁ ⦁ ⦁ Associates Degree ⦁ Bachelors Degree ⦁ Graduate Degree or Higher Years of EMS experience ⦁ <1 year ⦁ 2-5 years ⦁ 6-10 years ⦁ >10 years Level of EMS Training Certification ⦁ Basic EMT ⦁ Advanced EMT ⦁ Paramedic ⦁ Other Questions: ⦁ ⦁ ⦁ Before this education, were you familiar with the term 'Sepsis'? ⦁ Yes ⦁ No Which definition do you think BEST defines sepsis? ⦁ Another name for an allergic reaction ⦁ Simple infection treated with oral antibiotics ⦁ Life-threatening systemic infection ⦁ a genetic condition How confident do you feel recognizing sepsis during patient care now that you have had this education? ⦁ Less Confident 34 ⦁ ⦁ The same - it did not help ⦁ More Confident Do you think the following signs and symptoms are associated with sepsis? ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ Fever ⦁ Yes ⦁ No ⦁ Not sure Hypothermia ⦁ Yes ⦁ No ⦁ Not Sure Tachycardia ⦁ Yes ⦁ No ⦁ Not Sure Tachypnea ⦁ Yes ⦁ No ⦁ Not Sure Hypotension ⦁ Yes ⦁ No ⦁ Not Sure Altered Mental Status 35 ⦁ Yes ⦁ No ⦁ Not Sure ⦁ ⦁ How Confident are you in your understanding of sepsis treatment having had this education? ⦁ ⦁ ⦁ Not at all Confident Confident 1 2 3 4 5 Very Do you think that earlier recognition and treatment of sepsis in the pre-hospital setting would improve patient outcomes? ⦁ Yes ⦁ No ⦁ Maybe Are you willing to actively participate in the management of sepsis in the prehospital setting? ⦁ Yes ⦁ No ⦁ Maybe 36 Appendix C Follow-Up Survey EMS Pre-Hospital Sepsis Care Education Follow-Up Survey: Demographics: ⦁ ⦁ ⦁ ⦁ Age ⦁ 18-25 ⦁ 26-35 ⦁ 36-45 ⦁ >45 Gender ⦁ Female ⦁ Male ⦁ Prefer not to say ⦁ Non-Binary ⦁ Transgender ⦁ Other… Education Level ⦁ High School Diploma/GED ⦁ Associates Degree ⦁ Bachelors Degree ⦁ Graduate Degree or Higher Years of EMS experience ⦁ <1 year ⦁ 2-5 years 37 ⦁ ⦁ 6-10 years ⦁ >10 years Level of EMS Training Certification ⦁ Basic EMT ⦁ Advanced EMT ⦁ Paramedic ⦁ Other Questions: ⦁ ⦁ ⦁ ⦁ Before this education, were you familiar with the term 'Sepsis'? ⦁ Yes ⦁ No Which definition do you think BEST defines sepsis? ⦁ Another name for an allergic reaction ⦁ Simple infection treated with oral antibiotics ⦁ Life-threatening systemic infection ⦁ a genetic condition How confident do you feel recognizing sepsis during patient care now that you have had this education? ⦁ Less Confident ⦁ The same - it did not help ⦁ More Confident Do you think the following signs and symptoms are associated with sepsis? ⦁ ⦁ Fever ⦁ Yes 38 ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ No ⦁ Not sure Hypothermia ⦁ Yes ⦁ No ⦁ Not Sure Tachycardia ⦁ Yes ⦁ No ⦁ Not Sure Tachypnea ⦁ Yes ⦁ No ⦁ Not Sure Hypotension ⦁ Yes ⦁ No ⦁ Not Sure Altered Mental Status ⦁ Yes ⦁ No ⦁ Not Sure ⦁ ⦁ How Confident are you in your understanding of sepsis treatment having had this education? ⦁ Not at all Confident 1 2 39 3 4 5 Very Confident ⦁ ⦁ ⦁ Do you think that earlier recognition and treatment of sepsis in the pre-hospital setting would improve patient outcomes? ⦁ Yes ⦁ No ⦁ Maybe Do you feel that the Sepsis education you completed in November 2019 was overall beneficial in helping you to understand sepsis, recognize sepsis, and treat sepsis more confidently? ⦁ Yes ⦁ No If you answered no to the previous question, why? ⦁ ⦁ Short answer question How can EMS sepsis education be improved to better prepare EMS personnel to recognize and treat sepsis? ⦁ Short answer question 40