When septic patients first arrive at emergency departments (EDs), they do not always appear to be that sick. Some are discharged home, and plaintiff attorneys later allege the patient was misdiagnosed.
The plaintiff in one such case was a young man who presented to an ED with a swollen right leg, with a mild temperature and elevated heart rate at triage. An ultrasound was negative for deep vein thrombosis. The patient returned to the ED waiting room, and waited four more hours. No additional vitals were obtained, despite an ED protocol requiring reassessment every two hours.
“The security guard took pity on him when he saw the patient laying on the floor because he was too uncomfortable to sit, and got him a pillow,” says David Sumner, JD, a Tucson, AZ, medical negligence specialist with a multistate trial practice.
The hospital’s security cameras recorded all this. Eventually, the patient left without ever undergoing evaluation. “He was emergently admitted at another ED hours later for cellulitis and sepsis, and died of complications,” Sumner reports.
Plaintiff attorneys alleged the triage nurse at the first ED failed to recognize the implications of the swollen leg, failed to reassess the patient, and failed to recognize the ultrasound confirmed major cellulitis (indicating a higher acuity designation).
“The case settled before a lawsuit was even filed, shortly after the notice of claim was received,” Sumner says. These issues arise repeatedly in missed sepsis ED claims:
• Problems with systemic inflammatory response syndrome (SIRS) alert protocols. “Some institutions exempt patients in the ED waiting room from SIRS alarms,” Sumner explains. In the malpractice case described earlier, vital signs obtained at triage met criteria for a SIRS alert. However, the patient was missed because the protocol excluded patients who remain in the ED waiting room. Therefore, no alert appeared in the system.
The problem is there can be long delays between the patient’s arrival and when the patient is brought back to a room. “I have seen five- and six-hour delays due to high ED patient volumes and understaffing,” Sumner recalls.
• Some SIRS alert protocols have too long of a lockout period for new alerts. Once a SIRS alert is taken off for a particular patient, some systems have a 12-hour lockout on new SIRS alerts for that patient. This time frame is dangerous.
“There are too many urgent conditions that can evolve from stable to critical within a 12-hour SIRS lock out period,” Sumner warns.
One patient with acute pancreatitis worsened because of inadequate fluid management. “It went undetected due to a 12-hour lockout for new SIRS alerts,” Sumner explains.
• In some EDs, the threshold for a finding to be considered a “critical” lab value is too high. In some systems, it is a white blood cell count of at least 30,000. “There are too many patients who can be septic or have advancing SIRS without ever having a count as high as 30,000,” Sumner notes. The critical level values should not be set so high that the window of therapeutic benefit has passed.
“I see too many protocols where critical value thresholds are so high that the patient is near extremis before a critical lab is ever alerted,” Sumner says.
Some septic patients experienced fatal complications. But despite high white blood cell counts, these patients never recorded a count of 30,000 or higher.
“If you look at the policy for critical level values and you say, ‘Wow, if this value is that high, I am not sure we can successfully turn this around,’ then the value is too high for an effective critical level communication policy,” Sumner says.