Archives of Academic Emergency Medicine. 2023; 11(1): e48 OR I G I N A L RE S E A RC H Pre-hospital Prognostic Factors of 30-Day Survival in Sep- sis Patients; a Retrospective Cohort Study Thongpitak Huabbangyang1, Rossakorn Klaiangthong1∗, Fahsai Jaibergban1, Chanathip Wanphen2, Thanakorn Faikhao2, Passakorn Banjongkit2, Ratchaporn Kuchapan2 1. Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand. 2. Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand. Received: May 2023; Accepted: June 2023; Published online: 13 July 2023 Abstract: Introduction: According to excising findings, if the emergency management system (EMS) operation will be developed, the survival outcome of sepsis patients might improve. This study aimed to evaluate the pre-hospital associated factors of survival in sepsis patients. Methods: This retrospective cohort study was conducted on patients diagnosed with sepsis, coded with the Thailand emergency medical triage protocol and criteria-based dispatch symptom group 17. Information on the 30-day survival rate of patients was obtained from the electronic medical records. Pre-hospital factors associated with 30-day survival were analyzed using univariate and multivariate logistic regression analyses and were reported using odds ratio (OR) with 95% confidence interval (CI). Results: 300 patients diagnosed with sepsis were enrolled. Among them, 232 (77.3%) survived within 30 days. Non-survived cases had significantly older age (p = 0.019), lower oxygen saturations (92.5% vs. 95.0%; p = 0.003), higher heart rate (p = 0.001), higher respiratory rate (p < 0.001), lower level of consciousness (p < 0.001), higher disease severity based on qSOFA score (p = 0.001), and higher need for invasive airway management (p = 0.001) and supplementary oxygen (p = 0.001). The survival rate improved by 3.5% with every 1% increase in pre-hospital oxygen saturation (adjusted OR = 1.035, 95% CI: 1.005–1.066, p = 0.020) and the survival probabilities of patients who responded to voice (adjusted OR = 0.170, 95% CI: 0.050–0.579, p = 0.005), those who responded to pain (adjusted OR = 0.130, 95% CI: 0.036–0.475, p = 0.002), and those who were unresponsive (adjusted OR = 0.086, 95% CI: 0.026–0.278, p-value < 0.001) were lower than patients who were alert. Conclusion: The 30-day survival rate of patients with sepsis managed by the EMS team was 77.3%. Pre-hospital oxygen saturation and level of consciousness were associated with the survival of patients with sepsis who were managed in the pre-hospital setting. Keywords: Emergency medical services; emergency treatment; sepsis; survival Cite this article as: Huabbangyang T, Klaiangthong R, Jaibergban F, Wanphen C, Faikhao T, Banjongkit P, Kuchapan R. Pre-hospital Prognostic Factors of 30-Day Survival in Sepsis Patients; a Retrospective Cohort Study. Arch Acad Emerg Med. 2023; 11(1): e48. https://doi.org/10.22037/aaem.v11i1.2029. 1. Introduction Sepsis is a leading cause of death worldwide. Its inci- dence rate is approximately 48.9%, which is lower than that of accident-related mortality. Based on previous studies worldwide, variations in the reported incidence of sepsis are caused by differences in disease definitions, study periods, types of data collected, patient groups, and public health sys- tems in each area (1). A study in the United States of Amer- ∗Corresponding Author: Rossakorn Klaiangthong; Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technol- ogy, Navamindradhiraj University, Bangkok 10400, Thailand. Tel: +66 2- 244-3000, Email: rossakorn@nmu.ac.th, ORCID: https://orcid.org/0000-0002- 5846-5754. ica revealed that the mortality rate of sepsis decreased from 28.6%–45.0% in 2001 to 12.3% in 2019, due to improvement in medicine and public health within 20 years (2, 3). In ad- dition, a study with long-term follow-up found that the mor- tality rate of patients with severe sepsis or those with delayed evaluation and treatment is higher (3). A previous meta- analysis on studies from seven countries revealed that the mortality rate of sepsis was 17.0% and the mortality rate of severe sepsis was higher, at 26.0% (4). Research on Southeast Asian countries, including Thailand, Malaysia, and Vietnam, reported that the 28-day mortality rates of sepsis were 7.0% in patients without signs of organ dysfunction and 47.0% in those with at least four signs (5). According to the index statistics on the rate of mortality due to sepsis in the ministry This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index E. Rahmani et al. 2 of public health hospitals of Thailand, more than 452,480 patients presented with sepsis, and there were over 153,324 deaths recorded from 2018 to 2022 (6). Based on the Surviving Sepsis Campaign in 2016 guidelines, sepsis is an actual medical emergency condition (7). It com- monly requires emergency medical service (EMS) in the pre- hospital setting (8). Therefore, patients with sepsis should be managed during the pre-hospital period, and the window for the hour-1 sepsis bundle must be reduced. Sepsis can be screened and diagnosed in the pre-hospital setting. Thus, pa- tients can receive treatment more quickly, which can conse- quently increase the survival rate (9, 10). If the EMS team can immediately initiate a provisional diagnosis of sepsis, per- form appropriate evaluation, provide treatment, and mon- itor vital signs continuously at the scene and during trans- portation, the survival rate can increase (11). A study in Brazil showed that oxygen depletion and Sequential Organ Failure Assessment (SOFA) score of ≥3 was associated with a lower survival rate in sepsis patients (12). A study that aimed to evaluate the epidemiology of sepsis in the pre-hospital con- text found that an abnormal respiratory rate and decreased level of consciousness are significantly associated with a high mortality rate (13). Based on the above-mentioned points, this study aimed to assess the 30-day survival rate and its pre-hospital associ- ated factors in patients with sepsis whose managements were started by EMS in the pre-hospital setting in Thailand. 2. Methods 2.1. Study design and settings This retrospective cohort study was conducted at the Vajira- EMS (V-EMS) unit, Faculty of Medicine Vajira Hospital, Nava- mindradhiraj University, Bangkok, Thailand to evaluate the pre-hospital associated factors of survival in sepsis patients whose managements were started by EMS, from January 1, 2019 to October 31, 2022. The V-EMS unit is the leading EMS center among nine zone areas in Bangkok, dispatched from Erawan Center, Bangkok, networking with both public and private hospitals, with six hospitals in the responsible area, which was 50 square kilometers and a population of 500,000 (14, 15). The EMS team of the V-EMS unit comprises at least three staff, which include paramedics or emergency nurse practitioners (ENPs), which act as the operation team leader, and emergency medical technicians. During each operation, the paramedics or ENPs can operate under off- and on-line medical protocols based on the orders of emergency physi- cians. In the study area, the sepsis management guidelines include the use of the quick Sepsis-Related Organ Failure As- sessment (qSOFA) score in the pre-hospital setting. Patients should have a score of at least 2 for the following parameters: respiratory rate (at least 22 cycles/min), systolic blood pres- sure (approximately 90 mmHg), and Glasgow Coma Scale (GCS) score (13) or decreased level of consciousness, and sepsis diagnosis. A diagnosis of sepsis is made based on the presence of at least two items of systemic inflammatory re- sponse syndrome (SIRS) criteria (16). According to the off- line protocol for patients with sepsis, paramedics or ENPs should start oxygen supplementation with a cannula or mask with a reservoir bag and endotracheal intubation accord- ing to pre-hospital guidelines. Oxygen saturation should be maintained at ≥94%. Venous catheterization must be per- formed to administer at least 30 mL/kg of crystalloid solu- tions (e.g., lactated Ringer’s solution [LRS] and acetar) if there are no contraindications such as crepitation in both lungs and edema in both legs (systolic blood pressure maintained at ≥90 mmHg). Moreover, reassessment is performed after every administration of 300–500 mL of fluid. 2.2. Participants Adult patients with final diagnosis of sepsis, symptom group 17red1 – 17red9, dispatched to V-EMS, aged more than 18 years, coded with Thailand emergency medical triage pro- tocol and CBD symptom group 17, which is sepsis or septic shock and transported to emergency department, were en- rolled in the study. Patients who refused treatment or trans- portation to the hospital, those with incomplete or missing data, and those receiving end-of-life or palliative care were excluded from the analysis. 2.3. Data collection The data of patients finally diagnosed with sepsis or septic shock were collected from the EMS patient care report, which is a record of advanced EMS operation. This form com- prised data on EMS operation units, patients, and all treat- ments provided by the EMS teams. All data were recorded by dispatchers and paramedics or ENPs at the scene. Further, these data were a part of remuneration for the EMS opera- tion units. Data on 30-day survival were extracted from the electronic medical records of Vajira Hospital. We collected information including demographic and clinical characteris- tics of the participants (such as gender; age; underlying dis- ease; location; sepsis category; pre-hospital systolic and di- astolic blood pressures, heart and respiratory rates, oxygen saturation, body temperature, level of consciousness [alert, responds to pain, responds to voice, and unresponsive], air- way management, oxygen supplementation with a cannula, mask with a reservoir bag, and bag valve mask, fluid supple- mentation, and blood glucose level; qSOFA score; response time; on-scene time; distance from the base station to the scene; and distance from the scene to the hospital, and data on 30-day survival outcome), which were reviewed by the pri- mary investigator from the electronic medical records. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index 3 Archives of Academic Emergency Medicine. 2023; 11(1): e48 2.4. Outcome measures The primary outcome was 30-day survival. 2.5. Definition of terms - Sepsis is a life-threatening condition caused by the host’s abnormal response to infection. Septic shock is defined as a systolic blood pressure of <90 mmHg and arrhythmia with a heart rate of >100 beats/min (17). In our study area, paramedics or ENPs suspect infec- tion in patients with fever or a history of fever and those with symptoms indicative of infection or organ dysfunction. Fur- ther, they assess qSOFA score. If the score is at least 2, a diag- nosis of sepsis is made, and the management guidelines for patients with sepsis or septic shock can be applied immedi- ately at the scene. - The Thailand emergency medical triage protocol and CBD severity code was used at the scene. It utilizes data obtained by evaluating the situation and symptoms of patients at the scene. Further, it uses 26 symptom groups. Symptom group 17 is defined as a diagnosis of sepsis or septic shock using 17 code red 1–9. - Response time (min) was defined as the duration from emergency call to ambulance arrival at the scene. - On-scene time (min) was defined as the duration from am- bulance arrival at the scene to departure from the scene. - Thirty-day survival was defined as the survival of patients with sepsis or septic shock (RC code 17 red) who were man- aged by EMS in the pre-hospital setting and evaluated within 30 days (from day 1 [service day] to day 30). 2.6. Sample size The sample size was estimated using the formula for infinite population proportion. A normal curve was defined as a p- value of 0.05 and an error rate of 4%. The proportion of pa- tients was based on a previous study. The 30-day survival rate of patients with sepsis managed by EMS at the pre-hospital setting was 89.3% (10). The sample size was at least 230. Thereafter, 288 patients were added based on the following formula: nnew = 230/(1 0.20). Hence, the final sample size was 300. Simple random sampling was performed to obtain a sample including patients diagnosed with sepsis in the pre- hospital setting and dispatched to the V-EMS unit. 2.7. Statistical analysis A descriptive analysis was performed to examine variable distribution. Continuous variables were expressed as mean ± standard deviation or median and inter-quartile range (IQR) and categorical variables as frequencies and percentages. Between-group differences were evaluated using the inde- pendent t-test or the Mann–Whitney U test for numeric vari- ables and the chi-square test or the Fisher’s exact test for cat- egorical variables. The 30-day survival rate of patients with sepsis whose man- agement was started at the pre-hospital setting was ex- pressed as frequency distribution and percentage. To eval- uate factors associated with the 30-day survival of patients with sepsis managed in the pre-hospital setting, crude anal- ysis was performed using the chi-square test or the Fisher’s exact test based on data appropriateness and multivariate lo- gistic regression analysis, the result were reported as odds ra- tio (OR) and 95% confidence interval (CI). The Statistical Package for the Social Sciences software for Windows, version 28.0 (IBM SPSS Statistics for Windows, ver- sion 26.0; IBM Corp., Armonk, NY, the USA) was used. A p- value of <0.05 was considered statistically significant. 2.8. Ethical statement This study was conducted in accordance with the 1975 Dec- laration of Helsinki and its 2000 revised version. It was ap- proved by the Institutional Review Board of the Faculty of Medicine Vajira Hospital, Navamindradhiraj University (COA no. 220/2565). The need for informed consent was waived due to the retrospective nature of the study and anonymity of all patient data. 3. Results 3.1. Baseline characteristics of the participants 300 patients diagnosed with sepsis were enrolled. Among them, 232 (77.3%) survived within the 30 days of follow-up. The mean age of patients was 73.40 ± 16.00 years (53.7% male). Table 1 compares the baseline characteristics of stud- ied cases between survived and non-survived cases. The mean ages of the survivors and non-survivors were 72.34 ± 16.51 and 77.01 ± 13.63 years, respectively (p = 0.019). The two groups had similar conditions regarding gender distri- bution (p = 0.488), underlying diseases (p = 0.331), location of residence (p = 1.000), disease category (p = 0.167), pre- hospital systolic blood pressure (p = 0.111), diastolic blood pressure (p = 0.389), body temperature (p = 0.389), blood glu- cose (p = 0.359), the median response time (p = 0.688), the median on-scene times (p = 0.925), the median distance from the base station to the scene (p = 0.973), the median distance from the scene to the hospital (p = 0.442), and volume of hy- dration therapy in pre-hospital setting (p = 0.098). Non-survived cases had significantly lower oxygen satura- tions (92.5% vs. 95.0%; p = 0.003), higher heart rate (p = 0.001), higher respiratory rate (p < 0.001), lower level of consciousness (p < 0.001), higher disease severity based on qSOFA score (p = 0.001), and higher need for invasive air- way management (p = 0.001) and supplementary oxygen (p = 0.001). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index E. Rahmani et al. 4 Table 1: Comparing the baseline characteristics of the participants between survivors and non-survivors Factors Survivors (n = 232) Non-survivors (n = 68) p-value Age (years) Mean ± SD 72.34 ± 16.51 77.01 ± 13.63 0.019t Gender Male 122 (52.6) 39 (57.4) 0.488c Female 110 (47.4) 29 (42.6) Underlying disease No 83 (35.8) 20 (29.4) 0.331c Yes 149 (64.2) 48 (70.6) Location Home 225 (97.0) 66 (97.1) 1.000f Public 7 (3.0) 2 (2.9) Disease category Sepsis 203 (87.5) 55 (80.9) 0.167c Septic shock 29 (12.5) 13 (19.1) Pre-hospital Vital signs SBP (mmHg) 129.95 ± 31.80 122.79 ± 34.82 0.111t DBP (mmHg) 73.29 ± 19.69 73.90 ± 27.12 0.839t Heart rate (/min) 102.22 ± 21.9 112.66 ± 25.71 0.001t Respiratory rate (/min) 25.30 ± 6.67 28.82 ± 8.06 <0.001t Oxygen saturation (%) 95 (92–98) 92.5 (81–97) 0.003m Body temperature (°C) 37.79 ± 1.05 37.85 ± 0.99 0.671t Blood glucose level (mg/dL) 144 (115–181) 145 (119.5–190.5) 0.359m Pre-hospital level of consciousness Alert 97 (41.8) 6 (8.8) <0.001c Respond to pain 49 (21.1) 32 (47.1) Respond to voice 56 (24.1) 13 (19.1) Unresponsive 30 (12.9) 17 (25.0) qSOFA score < 2 118 (50.9) 19 (27.9) 0.001c ≥ 2 114 (49.1) 49 (72.1) EMS management Response time (min) 12 (7–16) 12 (8.5–16.5) 0.688m On-scene time (min) 16 (12–24) 17 (13–23) 0.925m Base station to the scene (km) 3 (2–5) 4 (2–5) 0.973m Scene to the hospital (km) 3 (2–5) 4 (2–6) 0.442m Pre-hospital airway management No 220 (94.8) 55 (80.9) 0.001f Endotracheal tube 10 (4.3) 7 (10.3) Oropharyngeal airway 2 (0.9) 5 (7.4) Nasopharyngeal airway 0 (0.0) 1 (1.5) Pre-hospital oxygen supplementation No 115 (49.6) 16 (23.5) 0.001c Cannula 62 (26.7) 21 (30.9) Mask with a reservoir bag 47 (20.3) 25 (36.8) Bag valve mask 8 (3.4) 6 (8.8) Pre-hospital fluid supplementation No 83 (35.8) 14 (20.6) 0.098f Normal saline 71 (30.6) 26 (38.2) Ringer lactate 73 (31.5) 27 (39.7) 10% DN/2 5 (2.2) 1 (1.5) Data are presented as mean ± standard deviation (SD), number (%), or median (interquartile range). SBP: systolic blood pressure; DBP: diastolic blood pressure EMS: emergency medical services; qSOFA: quick Sepsis-Related Organ Failure Assessment. P-value corresponds to the tindependent samples t-test, mMann–Whitney U test, cchi-square test, or fFisher’s exact test. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index 5 Archives of Academic Emergency Medicine. 2023; 11(1): e48 Table 2: Multivariate logistic regression analysis of associated factors of survival in sepsis patients Factors ORadj1 95% CI p-value Age (years) 0.980 (0.959–1.002) 0.080 Prehospital vital sign Heart rate (beats/min) 0.988 (0.973–1.004) 0.143 Respiration rate (cycles/min) 0.976 (0.926–1.029) 0.372 Oxygen saturation (%) 1.035 (1.005–1.066) 0.020 Prehospital level of consciousness Alert 1.000 Reference Responds to voice 0.170 (0.050–0.579) 0.005 Responds to pain 0.130 (0.036–0.475) 0.002 Unresponsive 0.086 (0.026–0.278) <0.001 qSOFA Score <2 0.531 (0.228–1.238) 0.143 ≥2 1.000 Reference Prehospital airway management No 1.000 Reference 0.383 Yes 0.621 (0.213–1.812) Prehospital oxygen supplementation No 1.000 Reference 0.362 Yes 0.697 (0.321–1.513) Prehospital fluid supplementation No 1.000 Reference 0.660 Yes 0.843 (0.395–1.8) Abbreviations: OR, odds ratio; ORadj, adjusted odds ratio; CI, confidence interval; NA, not applicable; qSOFA: quick Sepsis-Related Organ Failure Assessment. Variable with a p-value of <0.050 in the univariate analysis were included in the multivariate analysis. 1Adjusted odds ratio estimated using the multiple logistic regression model. 3.2. Multivariate analysis of factors associated with 30-day survival Age, qSOFA score, and pre-hospital heart and respiratory rate, oxygen saturation, level of consciousness, airway man- agement, and oxygen supplementation were significantly as- sociated with 30-day survival of sepsis patients based on the univariate analysis. Table 2 shows the findings of multivariate logistic regression analysis of factors associated with 30-day survival. Based on this analysis pre-hospital oxygen saturation level and level of consciousness were found to be the independent predictors of 30-day survival in sepsis patients. With every 1% increase in pre-hospital oxygen saturation, the survival rate improved by 3.5% (adjusted OR = 1.035, 95% CI: 1.005–1.066, p = 0.020). The survival probabilities of patients who responded to voice in the pre-hospital settings, those who responded to pain, and those who were unresponsive were 0.170 (adjusted OR = 0.170, 95% CI: 0.050–0.579, p = 0.005), 0.130 (Adjusted OR = 0.130, 95%CI: 0.036–0.475, p = 0.002), and 0.086 (Adjusted OR = 0.086, 95%CI: 0.026–0.278, p < 0.001) times lower than patients who were alert. 4. Discussion The 30-day survival rate of patients diagnosed with sepsis or septic shock was 77.3%. This finding is consistent with that of a previous study in the Netherlands. That is, the survival rate of patients with sepsis who received EMS care was 79.0%, and the mean hospitalization period was 13.5 days (18). An- other study revealed that the overall 30-day survival of pa- tients with sepsis and septic shock in the emergency depart- ment of Mexico was 83.07%. Although the survival rate de- creased in the septic shock group (19), the 28-day survival rate of patients with sepsis was 53.0% in Southeast Asian countries, such as Malaysia (5). According to previous re- search, if the EMS operation is performed, the survival out- come of patients with sepsis might improve. Further, assis- tance can be provided in various processes, which include the development of appropriate and convenient pre-hospital sepsis screening tools, fluid replacement, and antibiotic ini- tiation, which might improve patient survival (20). Never- theless, a previous study showed that the mortality rate and length of hospital stay are different in survived cases (21). The current study showed that pre-hospital oxygen satura- tion and level of consciousness were associated with 30-day survival in patients with sepsis managed by EMS. This find- ing is consistent with that of a previous study on the EMS of a tertiary care institution in North-Western India. Results showed that oxygen saturation was a predictive factor of sur- vival outcome in patients with sepsis and septic shock. More- over, patients with hypoxia had a higher mortality rate (aver- age: 26.92%) than those with normoxia (22). A study con- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index E. Rahmani et al. 6 ducted in the intensive care unit showed that patients who were treated at the intensive care unit and survived sepsis had a higher oxygen saturation level than those who did not survive. Moreover, patients with sepsis should receive appro- priate oxygen therapy to improve survival outcome (23). With every 1% increase in pre-hospital oxygen saturation, the sur- vival rate improved by 3.5%. Therefore, appropriate and adequate pre-hospital oxygen supplementation was recommended. Further, indirect non- invasive oxygen delivery, which can be easily performed by the emergency medical staff, must be considered. That is, capillary refill time and cyanosis assessment is required to improve the quality of management in patients with sepsis who were managed in the pre-hospital setting. This finding was consistent with the latest standard guidelines for manag- ing patients with sepsis or septic shock. That is, patients with septic shock must undergo regular capillary refill time as- sessment (24). Patients with sepsis who had low pre-hospital level of consciousness might have a significantly lower sur- vival rate. This finding was similar to that of a previous ob- servational study using GCS as a predictive tool for survival rate, which showed that patients with decreased level of con- sciousness had a significantly higher mortality rate (25). Moreover, it is comparable to two studies in the emergency departments. The first study reported a high 30-day mortal- ity rate after sepsis diagnosis at the emergency department among patients with a low level of consciousness. Unrespon- sive patients could have a higher mortality rate than respon- sive patients (26). The second study found that an altered mental state could classify the mortality rate in septic pa- tients in the emergency department at 28 days and could be a predictor of survival (27). Based on the standard guide- lines for managing patients with sepsis in the pre-hospital setting, the EMS staff should emphasize and focus on assess- ing the level of consciousness using either the GCS or the AVPU (Alert, Voice, Pain, Unresponsive) scale, whichever is appropriate in each area. Proper neurological assessment and maintenance of level of consciousness at the scene and during hospital transport were important in improving survival outcomes in patients with sepsis. Regarding suggestions for future research, since the present study only focused on pre-hospital factors affecting septic patients’ survival at 30 days, the future research should study factors affecting the patients’ survival in pre-hospital and hospital, as well as definitive care contexts, such as emer- gency department or intensive care unit. For health man- agers and policymakers, the present study presented factors important for pre-hospital management by EMS team, which affected 30-day survival of septic patients and sepsis. This type of study is substantially necessary for policy making in pre-hospital management system for specific diseases that are time-sensitive and have pretty high mortality rates, such as sepsis. 5. Study limitations The current study had several limitations. First, it was retro- spective in nature and was conducted at a single center with two data sources. Although neutrality was tried to be main- tained in every way, there might still be a risk for potential se- lection bias, such as biases from population selection of pa- tients with sepsis and septic shock, selection of qSOFA score in pre-hospital diagnosis of sepsis, which were believed that these potential biases did not have a significant impact on re- sults important for septic patients’ survival. Second, some confounding factors associated with outcomes of interest might not have been evaluated. Only data on pre-hospital management were analyzed. Nonetheless, data from the emergency department or intensive care unit in the hospital should also be considered and analyzed be- cause they might affect survival. Third, only patients diag- nosed with sepsis or septic shock who were transported to the emergency department of Vajira Hospital were analyzed. However, patients brought to the emergency departments of other hospitals should also be considered because the capa- bility of a hospital’s emergency department can affect sur- vival outcome. Fourth, the study was conducted in a sin- gle EMS unit, which was an academic center. The present study results might not be generalizable. Further studies are needed to test the external validity of the present study re- sults. Finally, in the study area, only qSOFA was used as a screening tool. Nevertheless, bias was tried to be reduced from the screening tool by using final diagnosis at ED as in- clusion criteria, which is in accordance with the Surviving Sepsis Campaign: International Guidelines for the Manage- ment of Sepsis and Septic Shock 2021. The application of qSOFA was not recommended for screening patients with sepsis and septic shock. However, in the study area, only qSOFA was used, and an accurate provisional diagnosis by paramedics or ENPs at the scene could substantially affect decision-making. 6. Conclusion The 30-day survival rate of patients with sepsis managed by the EMS team was substantially high (77.3%). Pre-hospital oxygen saturation and level of consciousness were associated with the survival of patients with sepsis who were managed in the pre-hospital setting. Hence, guidelines on the pre- hospital management of sepsis, which emphasize the need to evaluate oxygen saturation and level of consciousness during hospital transport, should be developed. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index 7 Archives of Academic Emergency Medicine. 2023; 11(1): e48 7. Declarations 7.1. Acknowledgments The authors are grateful to the Navamindradhiraj University Research Fund for Publication. We would like to thank the paramedics at V-EMS, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, for facilitating data collection and access in the present study, Gawin Tiyawat, MD., chief of Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, and Chunlanee Sangketchon, MD., deputy dean of Faculty of Science and Health Technology, Navamindrad- hiraj University, for support and suggestions in the research development and Aniwat Berpan, MD. for suggestions on En- glish for the present study. 7.2. Conflict of interest The authors have no conflicting interests to declare. 7.3. Funding and support This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 7.4. Authors’ contribution Conceptualization: Thongpitak Huabbangyang, Chanathip Wanphen, Thanakorn Faikhao, Passakorn Banjongkit and Ratchaporn Kuchapan; Methodology: Thongpitak Huab- bangyang, Rossakorn Klaiangthong and Fahsai Jaibergban; Software: Thongpitak Huabbangyang; Validation: Thong- pitak Huabbangyang; Formal analysis: Thongpitak Huab- bangyang; Investigation: Thongpitak Huabbangyang; Re- sources: Thongpitak Huabbangyang, Chanathip Wanphen, Thanakorn Faikhao, Passakorn Banjongkit and Ratchaporn Kuchapan; Data Curation: Thongpitak Huabbangyang; Writ- ing – Original Draft: Thongpitak Huabbangyang; Writing - Review & Editing: Thongpitak Huabbangyang; Visualization: Thongpitak Huabbangyang, Rossakorn Klaiangthong and Fahsai Jaibergban; Supervision: Thongpitak Huabbangyang; Project administration: Thongpitak Huabbangyang; Fund- ing acquisition: Thongpitak Huabbangyang. All authors read and approved the final version of manuscript. 7.5. Data Availability The datasets generated and analyzed during the current study are available from the corresponding author on reason- able request. 7.6. Using artificial intelligence chatbots None. References 1. Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, et al. Global, regional, and national sepsis in- cidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study. Lancet. 2020;395(10219):200- 11. 2. Stoller J, Halpin L, Weis M, Aplin B, Qu W, Georgescu C, et al. Epidemiology of severe sepsis: 2008-2012. J Crit Care. 2016;31(1):58-62. 3. Alberti C, Brun-Buisson C, Goodman SV, Guidici D, Granton J, Moreno R, et al. Influence of systemic inflam- matory response syndrome and sepsis on outcome of critically ill infected patients. Am J Respir Crit Care Med. 2003;168(1):77-84. 4. Fleischmann C, Scherag A, Adhikari NK, Hartog CS, Tsaganos T, Schlattmann P, et al. Assessment of global in- cidence and mortality of hospital-treated sepsis. 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Predicting mortality in pa- tients with suspected sepsis at the Emergency Depart- ment; A retrospective cohort study comparing qSOFA, SIRS and National Early Warning Score. PloS One. 2019;14(1):e0211133. 27. Nupaw J, Surasit K, Samuthtai W. Evaluation of a Nako- rnping Early Warning Scores (NEWS) at Emergency De- partment to predict 24 hours mortality of sepsis patients. J Nakornping Hosp. 2020;11(1):28-44. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index Introduction Methods Results Discussion Study limitations Conclusion Declarations References