Failure to recognize sepsis

By Gracie Awalt, Marketing Associate, and Anthony Passalacqua, Risk Management Representative
 

Presentation

On November 3, a 30-year-old woman came to a hospital emergency department (ED) in labor. She was admitted and estimated to be 36 weeks pregnant.

She had been scheduled for a cesarean delivery on November 19, but that date was changed due to low amniotic fluids on a recent sonogram. This was the patient’s second pregnancy. Her first child was also delivered by cesarean.

Physician action

Ob-gyn A performed a low transverse cesarean delivery, noted as uneventful. On November 6, the patient had a temperature of 99 degrees and an elevated pulse rate. The patient was kept overnight.

In the early morning on November 7, she vomited undigested food and was seen by Ob-Gyn B. He noted that the patient was feeling better later that morning. By lunch time, she had retained her lunch, moved with ease, and showed no signs of distress. The patient and her newborn were discharged at 5 p.m.

On November 8 at 7:48 p.m., the patient came to the ED of a different hospital with nausea and vomiting for three days. She reported having a small bowel movement, but no diarrhea or constipation. The patient’s blood pressure was 128/79 mm Hg; pulse was 124; respiratory rate was 20; and temperature was 99 degrees. She rated her pain at 6 out of 10.

Emergency Medicine Physician A noted the patient’s abdomen was soft, with normal bowel sounds and no distention or tenderness. The physician’s differential diagnoses included anemia, infection, dehydration, and electrolyte imbalance. EM Physician A testified that she believed the patient’s symptoms were consistent with viral gastroenteritis.

The patient’s white blood cell count was normal with a bandemia of 65%. A CBC showed mild anemia with hemoglobin of 10.4. The patient’s complete metabolic panel showed “sodium 136, chloride 96, bicarbonate 19, BUN 51, creatinine 1.37, normal glucose, and normal LFTs and lipase.”

The patient was given two liters of normal saline, and EM Physician A re-examined the patient at 11:57 p.m. After consuming a rehydration drink, the patient reported no further vomiting.

On November 9, the patient was discharged at 1:12 a.m. with a prescription for hydrocodone and ondansetron. She was instructed to continue drinking fluids and to follow up with Ob-gyn A. The patient’s vital signs at discharge showed her blood pressure at 102/58 mm Hg; her pulse at 78; respirations at 18; and a 98% oxygen saturation.

The patient continued to report nausea and chest pain to family members. On November 11, the patient experienced stomach swelling. According to the patient’s father, she did not want to call her doctor or go to the ED. She wanted time for her medications to work.

On November 12, the patient’s family called for an ambulance twice. When the first ambulance arrived, the EMT told the patient that she would be fine, and that a trip to the hospital was not necessary. The first ambulance was sent away without examining the patient. However, a second ambulance was called, because the patient’s temperature exceeded 100 degrees, and she looked very pale. This ambulance transported her to the hospital on November 13 with significant abdominal pain.

Upon arrival in the ED, the patient’s blood pressure was 66/38 mm Hg, with a 130-pulse rate and respirations of 30. Her oxygen saturations were 90% on oxygen. She received fluid resuscitations. Examination revealed abdominal tenderness with rebound, guarding, and distention. It was believed the patient was bleeding intra-abdominally.

An ultrasound showed free air in her abdomen, and a massive blood transfusion protocol was initiated. After developing acute respiratory failure, the patient was intubated and taken to the operating room for an exploratory laparotomy.

The patient was ‘’found to have a perforation primarily of the right colon and cecum, but marked peritonitis with diffuse enteric contents throughout the peritoneal cavity, which resulted in an additional perforation of the small bowel.” Her small and large bowel were also gangrenous. Excised areas of the bowel were sent to pathology.

After surgery, the patient was transferred to the ICU. She arrested on November 14, but returned to spontaneous circulation. She required pressor drips to support her vital signs and dialysis due to renal failure. She developed disseminated intravascular coagulation (DIC), and she went into severe metabolic acidosis on November 16. The results of a brain stem exam revealed no cerebral activity.

The patient’s family withdrew medical care that day, and the patient died at 6 p.m. Her death certificate listed the cause of death as “intestinal perforation with onset of 4-5 days, peritonitis, septic shock and brain death.” No autopsy was performed.

Allegations

A lawsuit was filed against EM Physician A and the hospital. It was alleged that she failed to recognize symptoms of sepsis, and that she should have admitted the patient on November 8. The allegations included gross negligence.

Legal implications

EM Physician A testified that when she saw the patient on November 8, her symptoms were consistent with viral gastroenteritis, not an infection. EM Physician A attributed the patient’s elevated BUN and creatinine levels to dehydration, and the patient’s bandemia to physical stress from the recent cesarean delivery and repetitive vomiting. EM Physician A did not believe the patient’s lab results and symptoms indicated sepsis.

Defense consultants offered mixed opinions about this case. One consultant stated that EM Physician A ordered appropriate labs, while another consultant believed a CT scan should have been ordered, and that a bedside ultrasound would have shown fluid in the patient’s abdomen. Both consultants thought that the patient was septic.

Both the pathologist and surgeon who treated the patient thought that she developed Ogilvie’s syndrome, causing the perforation in her small intestine. However, the pathologist did not believe Ogilvie’s syndrome could be diagnosed based on her one episode of vomiting and nausea. The surgeon stated that the patient’s symptoms and vital signs did not warrant further testing. But if  imaging had been performed, it would have likely shown Ogilvie’s or an ileus. The surgeon thought that EM Physician A was prudent in recommending that the patient see her ob-gyn in 24 hours if symptoms continued.

The plaintiff’s expert criticized EM Physician A for not addressing the patient’s “very abnormal” electrolytes and complete blood count results, as well as the “grossly abnormal” white blood cell count. This expert also criticized the defendant for not ordering further testing to identify the bacterial infection and for not admitting the patient to the hospital for observation.

An expert for the defense stated that EM Physician A correctly diagnosed the patient given her  symptoms. This expert believed that the clinical presentation of the patient was the most important mechanism for determining sepsis. This expert also believed that the documentation did not support the patient having a bowel perforation.  

Disposition

This case was settled on behalf of EM Physician A and the hospital.

Risk management considerations

Communication and documentation issues are frequently a focus of medical malpractice suits. In this case, the hospital staff failed to communicate to the physician that the patient had nausea with vomiting. Omissions in documentation can lead to adverse outcomes; the physician may have changed his diagnosis if he had been aware of the patient’s vomiting. 

Another communication breakdown occurred between the patient and hospital staff during discharge. The patient and her father did not inform the hospital staff that she was still experiencing nausea and chest pain at discharge. It was crucial for the patient to report these ongoing issues, which may have prevented her discharge from the hospital.         

Following up with a patient after a major event such as an ED visit or surgery is crucial not only for patient safety, but also patient satisfaction. The Patient Safety Network of the federal Agency for Healthcare Research and Quality recommends following up with patients within the first 72 hours after discharge. Having clinically trained staff with a pre-determined triage check list can help you identify complications before they become serious. Instructing a patient to follow up with their general practitioner may delay care, especially if there is a public health crisis such as a pandemic or natural disaster. Staff should be trained to ask the physician about appropriate timing of a patient’s follow-up appointment, and if the scheduled appointments may delay treatment. If so, it is important to suggest alternatives to the patient, such as returning to the ED if necessary. (1)

Source

1. Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. Patient Safety Network.  Agency for Healthcare Research and Quality. March 1, 2012. Available at https://psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call. Accessed October 13, 2021.