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MPL Association Data Sharing Project: Sepsis-related claims

Author Olga Maystruk

The Medical Professional Liability Association (MPL Association) is a trade association of liability insurance companies that compiles medical malpractice claim data to help identify areas of practice most vulnerable to medical liability claims.

Since 1985, the MPL Association has collected this information through its Data Sharing Project (DSP), the largest independent collaborative database of medical professional liability claims. The DSP provides participating member companies with the necessary statistical information needed to enhance risk management in medicine and to track claim costs.

TMLT is a participant of the DSP. All data provided to DSP is codified, and the names of physicians are not reported.

This year, the MPL Association published a report on sepsis cases based on DSP findings. Before the COVID-19 crisis, there had been a significant focus on the number of sepsis cases leading to severely compromised health. Sepsis is a serious medical condition, a leading cause of death in hospitals, and a primary reason for readmissions.

The following is not an in-depth analysis of sepsis-related claims, but a short review of data on national risk trends associated with sepsis and potential connections between sepsis and COVID-19.

 

DSP claim data

Overall, there were 64,384 closed claims reported to the DSP between 2009 and 2018. The average cost to defend these claims was $50,491. Approximately 26 percent (16,490) of the closed claims paid an average indemnity payment of $376,938.1

In the DSP, sepsis can be reported as either a presenting medical condition or an outcome condition. Table 1 below summarizes claim data where sepsis was reported either as a presenting medical condition or an outcome condition. For the purpose of this study, the DSP focused on sepsis as the outcome condition (1,087 closed claims).

The top three primary allegations for sepsis claims were diagnostic (36 percent), procedural (35 percent), and administrative (14 percent) (See Table 2). The remaining 15 percent of allegations included hospital acquired conditions, patient accidents, and medication/IV fluids.

Among the three primary allegations, procedural accounted for the highest average allocated loss adjustment expenses (ALAE) ($56,141), total number of paid claims (109), and average indemnity paid ($336,586).1 Approximately 58 percent of closed claims (222) cited death as the severity of injury and 23 percent (86) cited major temporary injury. For the claims that cited death, the average ALAE was $51,493 and more than 25 percent of these claims resulted in an average indemnity payment of $246,544.

Nearly three quarters (73 percent) of the closed claims involving a diagnostic allegation reported death as the severity of injury and cost an average of $51,100 to defend. Of these death claims, 63 paid an average indemnity of $320,521.

Lastly, 78 percent (124) of closed claims named administrative allegations with death as the severity of injury and 14 percent (20) with major temporary injury. Among the administrative allegation claims involving death, the average ALAE was $54,872 and 19 percent (30) of the closed claims paid an average indemnity of $146,550.

 

New guidelines and risk management considerations

Part of the complexity of addressing sepsis is the lack of consensus between states, as guides vary in different jurisdictions. In January 2013, New York became the first state to issue state-wide regulations for sepsis. These protocols, known as “Rory’s Regulations,” require all New York state hospitals to:

  • employ protocols that address the screening and recognition of sepsis, severe sepsis, and septic shock;
  • identify and document appropriate treatment for septic patients; and
  • use guidelines for treatment, including early antibiotics.2

 

In addition, hospitals in New York are required to report adherence and clinical outcomes to the state government. The effectiveness of these new regulations was measured using a retrospective cohort study of adult patients in a hospital with sepsis in the state and four other “control” states. After adjusting for patient and hospital characteristics, post-implementation mortality for New York decreased significantly relative to control states.2

 

Recommendations for managing sepsis

In risk management efforts, a high emphasis is placed on the importance of early recognition of sepsis. The American College of Emergency Physicians (ACEP) provides a DART (Detect, Act, Reassess, Titrate) guide for sepsis detection and management on its website: https://www.acep.org/DART/.

Additionally, other considerations include the following.

  • Considering sepsis in the differential diagnosis of patients with infections and abnormal vital signs especially those vulnerable to infections, such as post-surgical patients.
  • Providing patients with appropriate follow-up and clear instructions, including symptoms and signs that should alert them to seek immediate medical attention.
  • Re-evaluating the diagnostic assumptions and revisiting the diagnosis if a patient is readmitted for the same or worsening symptoms.

 

Emerging: COVID-19 pandemic

As of November 18, 2020, there have been 55,064,128 confirmed cases of COVID-19 globally with a reported global mortality of 1,328,015.3

The pathophysiology of this novel virus is still being unraveled, but it is currently believed to be a respiratory virus that enters the body through the nose, mouth, or eyes that replicates and spreads throughout the body. The infected cells cause inflammation in the airways—making breathing difficult—and causing fluid to leak into a patient’s lung tissue, making oxygen transfer to the blood difficult.4 Secondary infections, such as pneumonia, may also occur. In addition, literature has found some links to sepsis as a complication.

According to recent studies, the progression of COVID-19 may lead to sepsis based on clinical findings within populations in Wuhan, China. According to authors in JAMA on February 24, 2020, 5 percent (more than 2,000 patients) of their 44,672 confirmed COVID-19 cases were critical enough to require intensive care and use of ventilation.5 These critical patients had respiratory failure, septic shock, and/or multiple organ dysfunction or failure. In a subsequent article published in JAMA on March 11, 2020, a review of critical care COVID-19 patients noted a significant number of patients developing septic shock and organ dysfunction, such as kidney failure.6 These patients were at highest risk of dying from the virus.

The Lancet published a study on March 11, 2020 that found patients with the poorest outcomes from COVID-19 were older in age and showed signs of sepsis, and/or had blood clotting disorders.7 In the study, more than half of the patients developed sepsis. The authors of the study stated, “Sepsis was a common complication, which might be directly caused by SARS-CoV-2 infection, but further research is needed to investigate the pathogenesis of sepsis in COVID-19 illness.” 7

In a study published by StatPearls on March 20, 2020, the basics of COVID-19 infection and the SARS-CoV-2 virus were reviewed. Authors mentioned the connection between COVID-19 and sepsis and septic shock, stating, “The COVID-19 may present with mild, moderate, or severe illness. Among the severe clinical manifestations, there are severe pneumonia, ARDS, sepsis, and septic shock. The clinical course of the disease seems to predict a favorable trend in most patients. As a reference, the criteria of the severity of respiratory insufficiency and the diagnostic criteria of sepsis and septic shock can be used.” 4 The study further defines the sepsis definition it used as the International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).

At this time, the World Health Organization, Centers for Disease Control and Prevention, and the Surviving Sepsis Campaign have all released comprehensive guidelines for the inpatient management of patients with COVID-19, including those who are critically ill. In addition, on April 1, 2020, a new COVID-19 ICD-10 code was included for further tracking in health databases. Review of this complex condition and its impact on MPL will be part of the broader discussion for years to come.

 

Sources

  1. MPL DSP Data 2009-2018, MPL Association. Copyright, 2020.

  2. Fleming, M. New York State Sepsis Regulations Cut Mortality Rates. Contagion Live. July 16, 2019. Available at https://www.contagionlive.com/news/new-york-state-sepsis-regulations-cut-mortality-rates. Accessed November 18, 2020.

  3. WHO Coronavirus Disease (COVID-19) Dashboard. World Health Organization. Last updated November 18, 2020. Available at https://covid19.who.int/. Accessed November 18, 2020.

  4. Cascella M. Rajnik M. Cuomo A. et. al. Features, Evaluation, and Treatment of Coronavirus. StatPearls [Internet]. Updated October 4, 2020. Available at https://www.ncbi.nlm.nih.gov/books/NBK554776/. Accessed November 23, 2020.

  5. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. February 24, 2020. Available at https://jamanetwork.com/journals/jama/fullarticle/2762130. Accessed November 18, 2020.

  6. Murthy S, Gomersall CD, Fowler RA. Care for Critically Ill Patients With COVID-19. JAMA. March 11, 2020. Available at https://jamanetwork.com/journals/jama/fullarticle/2762996. Accessed November 18, 2020.

  7. Zhou F. Yu T. Du R. et al. Clinical Course and Risk Factors for Mortality of Adult Inpatients with COVID-19 in Wuhan, China: a Retrospective Cohort Study. The Lancet. Volume 395, Issue 10229. March 11, 2020. Available at https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext. Accessed November 18, 2020.

 

Reprinted with permission from the MPL Association. Research Notes - Focus on Sepsis. May 2020