Our study shows that PENs experience difficulties in identifying sepsis in the prehospital environment. We identified factors that facilitated PENs’ management of patients with suspected sepsis. These were clinical experience, education about sepsis and explicit medical guidelines on sepsis.
PENs reported that sepsis was considered difficult to identify and therefore it was also difficult to manage the flow and initiate correct treatment. Other research points in the same direction. Multiple and vague symptoms as well as the lack of specific biomarkers are factors that give rise to difficulties in identifying these patients(1). There are conflicting views on the actual definition of sepsis as well as conflicting opinions on diagnostic tools and criteria(19, 20). These disagreements underline that difficulties in diagnosing sepsis can also give rise to complications in the EMS as well as in the Emergency Department and in-hospital facilities. Studies suggest that only 10–50% of patients with sepsis are coded correctly according to the International Classification of Disease (ICD) system(7, 21) following hospitalization. This further emphasizes the difficulty that sepsis presents for healthcare professionals.
Our study showed that pre-septic patients were considered particularly challenging. The early phase of sepsis develops its own pathogenic mechanisms and physiological responses, different from patients with fulminant sepsis(22), explaining why pre-septic patients are particularly challenging. Generally, the pre-septic patient does not show clinically distinct symptoms(22), making diagnosis difficult for PENs.
Elderly patients and/or patients who had comorbidities were considered especially difficult to identify. PENs reported that elderly patients differed in the symptoms they showed compared with younger patients. This can be explained by the altered physiological responses shown in elderly patients(23). Also, those with multiple comorbidities were reported as being especially challenging.
PENs agreed that clinical experience correlated with a sense of providing high-quality care. They described having met septic patients earlier in their clinical career as aiding their assessment and their ability to think early on in terms of sepsis. Studies show that in order to understand and see their patients holistically, PENs need previous clinical experience(24). The prehospital environment presents complex and unpredictable situations, and to cope with them, experience of multiple situations is needed(24, 25).
PENs concluded that medical guidelines promote optimal care. However, they found medical guidelines inadequate for sepsis compared with other diagnoses. Research shows that guidelines can improve patient outcome as well as preventing ineffective or harmful interventions. Following guidelines generally improves care consistency, so that patients with similar conditions are treated similarly regardless of where or from whom they receive care(26). This study indicates that PENs usually feel supported when adhering to guidelines, although this is less true for sepsis since the guidelines ar deficient. This leaves an area for improvement in the future.
There have been improvements in handling these patients within the last 10 years, according to PENs. More specifically, continuous education, actualization of the topic and case report discussions with colleagues have improved sepsis management. Learning from their own or their colleagues’ previous mistakes was also reported to aid judgements. Knowledge and experience gained from colleagues’ feedback facilitates decision-making in complex situations, just as sharing patient cases with colleagues offers a positive learning environment(27, 28).
4.1 Limitations
One limitation of this study may be the small number of PENs interviewed. Thirteen interviews were carried out. Interviews were conducted until saturation occurred. In spite of the small number of informants, interviews were rich in content which is considered to give a credible result(29). The trustworthiness of the study was reinforced by the fact that authors [LR, VV, MB, EHRA, RRW] reflected upon the results as a team.
PENs had varying degrees of experience (2–22 years) resulting from their different years of graduation, which meant that educational content varied over time. This may have affected their interviews and descriptions. (Är detta en limitation eller en styrka, menar du?)
The informants included were Stockholm County Council employees, meaning that most of the PENs interviewed had work experience from urban areas. However, PENs working in Region Jönköpings län were also interviewed, working 40–50 km from the nearest hospital. Furthermore, some PENs were working in suburbs where the nearest hospital was relatively far away. The study therefore represented both urban and rural areas. This constitutes a strength.