Missed Sepsis: ED Nurses Are "First Line of Defense"
Nurses share in culpability
The ED nurse is the "first line of defense" against a malpractice lawsuit alleging missed or delayed diagnosis of sepsis, according to Paula Mayer, RN, LNC, a partner at Mayer Legal Nurse Consulting in Saskatchewan, Canada.
"It is widely recognized that sepsis is a leading cause of preventable death in patients," she warns. Mayer says the ED nurse is most likely to be sued for breach of fiduciary duty in a failure to recognize, assess, monitor, communicate, advocate, and/or document adequately.
"The ED nurse must recognize that infections can place patients at risk of sepsis, and fully assess and monitor their status," she says. "They must have clear and ongoing communication with the physician regarding their assessment findings, changes in status, and deteriorating condition."
ED nurses must advocate for their patient to receive treatment prior to the patient entering a shock state, which can develop very quickly, she adds.
"The physician may be sued for a failure to recognize and a failure to treat sepsis," says Mayer. "But all the information necessary to recognize this condition can come from a full nursing assessment. Nurses share in the culpability when this diagnosis is missed."
In the ED, nurses should expect the patient will be started on intravenous (IV) crystalloid fluids, oxygen, and be started on their first dose of IV antibiotics, says Mayer.
"If the patient is entering a shock state, the fluid challenges will become more aggressive, the oxygen administration at higher flow rates," she says. "If the blood pressure drops, they may be started on vasopressors or be considering colloid preparations."
Sepsis diagnosed and treated within the first six hours drastically improves outcomes, underscores Mayer.
"Failure to recognize and adequately intervene in a case of sepsis in the ED can mean a septic patient can be discharged home to further decompensate," she says. "By the time they return to the ED for treatment, if they do, their status can be critical, and even lead to death."
Mayer recommends that ED nurses document all of the information below in the patient record if sepsis is suspected. "If it is not documented, it is not done if the case goes to court," she says.
Document frequent checks of the patient's vital signs including temperature, respiratory rate, pulse, blood pressure and oxygen saturation, and level of consciousness.
Document frequent assessments of the patient's status.
It is important to put a patient suspected of sepsis on a cardiac monitor and an oxygen saturation monitor, says Mayer. "As they decompensate, the shock state will cause an increase in heart rate," she explains. "This increases myocardial oxygen demand and consumption and necessitates the use of oxygen to maintain adequate oxygen saturation levels."
Note monitoring of level of consciousness at regular intervals, as disorientation, confusion, agitation, and dizziness are all signs the patient may be deteriorating into septic shock.
Document a full physical assessment to determine skin color and temperature, lung sounds, assess for diaphoresis, rash or purpura, any wounds (including size, type, appearance and drainage), and any other evidence of infection.
Note the patient's intake and output.
If the patient is admitted, ED nursing reports to the floor nurses must include all assessment findings, relevant test results, treatments and interventions, responses to treatment, and what the patient is being admitted for.
"If all that is included in the report, the floor nurses should know what to watch for," says Mayer.
To reduce risks, Mayer says that EDs can implement "team huddles" to ensure adequate communication among team members to better recognize sepsis.
"One group of hospitals is introducing 'time-outs' during the discharge phase of treatment," she reports. "This allows the team to catch anything that may have been overlooked, such as sepsis."
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