Failure to diagnose sepsis cases becoming more common
Malpractice cases involving sepsis have been "on the upswing" for several years, says Kathleen M. Roman, MS, a Greenfield, IN-based risk management consultant. This increase is primarily because of the increased severity and variety of infectious agents and the diminished number of effective treatments available, she says.
"It is especially important to identify the septic patient as quickly as possible," says Roman. "Some of them may also pose risk for members of the healthcare team."
Failure to diagnose sepsis cases are likely to become more common due to growing evidence about the need for early recognition and intervention, says Bradley A. Sharpe, MD, professor of clinical medicine at the University of California, San Francisco.
To avoid suits, Sharpe says the key is for physicians to "recognize, recognize, recognize!" systemic inflammatory response syndrome [SIRS]; and that seemingly minor vital sign changes, such as new tachypnea, might mean impending sepsis. Also, providers need to realize that patients can have severe sepsis and septic shock without a fever or hypothermia, he adds.
Physicians also should work with nursing staff on recognition of sepsis, as nurses are on the front lines, Sharpe advises. "At our hospital, we have a standard screening tool the nurses use," he says. If it is positive, they call a "code sepsis" which helps to make sure the patient gets what he or she needs quickly. [The sepsis screening tool is included with the online version of this month’s Physician Risk Management. For assistance, contact customer service at email@example.com or (800) 688-2421.]
Plaintiff attorneys are unlikely to pursue a missed sepsis claim if there is clear documentation that sepsis was considered and that appropriate interventions were not done for specific reasons, says Sharpe. For example, a physician might document that "a fluid bolus was deferred with concerns for volume overload," or "hold on antibiotics for now, as suspicion for sepsis is lownew tachycardia is likely related to ongoing severe pain."
If a missed sepsis case goes to trial, plaintiff attorneys are likely to show graphs of mortality related to time of antibiotics. In one study, each hour delay increased mortality by 7.6%, and mortality was 21.1% if antibiotics were given in the first hour compared with 58% if delayed by more than six hours.1 "Mortality goes up quite a bit for each hour that is delayed," Sharpe explains. "A graph that shows this [increase], and then shows that antibiotics were delayed for many hours, could be very powerful for a jury."
Missed sepsis claims typically allege failure to diagnosis sepsis, failure to treat sepsis, and/or delay of diagnosis and/or treatment of sepsis, says Roman. She suggests these practices to reduce risk of missed sepsis claims:
• Use a protocol for assessing patients.
"There should be a requirement that specific assessments are implemented and that all staff follow the same protocols," says Roman.
• Act on the results of these assessments and tests.
• Because time is of the essence for this type of patient, written ED protocols also should include anticipated timeframes for test results and communication among members of the healthcare team who must take necessary steps to ensure that it is promptly implemented, says Roman.
"Documentation is critical to ensuring progress in the patient’s care and in protecting the doctor, staff, and hospital from allegations of negligence," she says.
Poor communication, as well as poorly implemented processes for sepsis, can increase patient risk and provider liability, warns Roman. For example, someone needs to act as a "quarterback," especially when the patient needs to be transferred from the ED to the hospital, and track lost/delayed lab results, pharmacy delays, and shortages of intensive care unit beds.
"Resources should be available to ensure that staff actually can abide by the plan," she says. "Lack of equipment or supplies, staffing shortages, and poorly trained staff also contribute to delayed or disorganized care in our stressed-out healthcare system."
Roman says the consequences are higher in the ED, where doctors are treating patients they don’t know and who often are very ill. "In addition, the doctor may have little or no access to previous medical records," she says. "Together, these elements comprise a perfect recipe for catastrophe."
1. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34:15891596. F