Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Online Letters to the Editor Physicians’ Variation in Care: The Practical Balance of Warranted Versus Unwarranted Variation To the Editor: P oor quality and wide variation in sepsis care are pre- ventable causes of death and avoidable costs (1). Recent evidence-based guidelines, notably the Surviving Sepsis Campaign, provide practical directions for optimal care paths for these patients (2). The investigation by Peltan et al (3), in a recent issue of Critical Care Medicine, into the variability of ini- tiating antimicrobial therapy is noteworthy for finding exten- sive provider to provider variability in such a widely accepted practice standard (2) and the clear association between care variation and poor outcomes. Warranted versus unwarranted care variation is a hotly debated topic (4). In our work, many physicians and advance practice professionals suggest that care variation is appropri- ate for accommodating local practice patterns, accounting for institutional capabilities and adapting evidence to individual patients. While not without merit in some situations, this argument is often a defensive posture, by us the providers, that Could the Outcome of Septic Patients Be Improved by a Prehospital Emergency Medical Service With Physician on Scene? To the Editor: I n a recent issue of Critical Care Medicine, Peltan et al (1) reported that among severe sepsis or septic shock patients, door-to-antimicrobial times varied five-fold among treat- ing physicians in an emergency department. They also under- lined an association between antimicrobial delay and mortality and suggested that interventions which aimed to reduce phy- sician variation in antimicrobial initiation are indicated. In human cares, evidence for the efficacy of the checklist and crew resource management training is well established and useful to reduce physician variation. For the management of severe sepsis and septic shock, one major prognostic factor is early initiation of appro- priate treatments (2, 3). As underlined by Peltan et al (1), diagnosis of severe sepsis and septic shock is not easy, espe- cially in patients without low blood pressure and/or obvi- ous infectious origin of sepsis. This may contribute to a part of explanation for differences between studies on the benefit bundle of care to improve outcome of patients with severe sepsis and/or septic shock (2, 3). The first step in the bundle of cares is early recognition of sepsis and severity evaluation. In the Third International Consensus Defini- tions for Sepsis and Septic Shock, it has been specified that early identification and triage of patients are therefore key points. They are the two prerequisite steps before initiation of any bundle of cares. In France, calling the national access phone number 15 con- nects the public to the prehospital emergency medical service (PHEMS), known as the “service d’aide médicale urgente.” Efficiency of this organization has been observed in life-threat- ening emergencies, such as cardiac arrest and severe trauma patients (4). To improve outcomes of septic patients, early identification of sepsis since the first call to PHEMS could be useful, enabling immediate intervention of a mobile ICU with an emergency physician who could initiate antibiotherapy on scene. The potential benefits of such strategy are currently investigated in the multicentric study “Samu Save Sepsis” (5). The purpose of this study is to determine whether an aggressive strategy initi- ated since prehospital care for patients presenting with severe sepsis and/or septic shock, including early antibiotics admin- istration, hemodynamic optimization, and opotherapy when indicated, could reduce mortality. Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000002682 Dr. Jouffroy received a National Grant from the French Health Ministry for the study “Samu Save Sepsis”: Early Goal Directed Therapy in Pre Hospital Care of Patients With Severe Sepsis and/or Septic Shock, ClinicalTrials.gov Identi- fier: NCT02473263. The remaining authors have disclosed that they do not have any potential conflicts of interest. Romain Jouffroy, MD, Pierre Carli, MD, Benoît Vivien, MD, PhD, SAMU de Paris, Service d’Anesthésie Réanimation, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, and Université Paris Descartes - Paris 5, Paris, France REFERENCES 1. Peltan ID, Mitchell KH, Rudd KE, et al: Physician Variation in Time to Antimicrobial Treatment for Septic Patients Presenting to the Emergency Department. Crit Care Med 2017; 45:1011–1018 2. Leisman DE, Doerfler ME, Ward MF, et al: Survival benefit and cost savings from compliance with a simplified 3-hour sepsis bundle in a series of prospective, multisite, observational cohorts. Crit Care Med 2017; 45:395–406 3. Seymour CW, Gesten F, Prescott HC, et al: Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med 2017; 376:2235–2244 4. Adnet F, Lapostolle F: International EMS systems: France. Resuscitation 2004; 63:7–9 5. Samu Save Sepsis: Early Goal Directed Therapy in Pre Hospital Care of Patients With Severe Sepsis and/or Septic Shock (SSS). ClinicalTrials.gov Identifier: NCT02473263. Available at: https://clini- caltrials.gov/ct2/show/NCT02473263. Accessed August 21, 2017 Critical Care Medicine www.ccmjournal.org e1297