Confusing Presentation Could Result in Successful Missed Sepsis Claims
Despite recent emphasis on early sepsis intervention, little is known on exactly what symptoms these patients experience when presenting to EDs — and how frequently.
“This knowledge is important for educating the public about what symptoms may portend a diagnosis of sepsis, as well as educating our clinicians about what symptom profiles they should be aware of when it comes to diagnosing sepsis,” says Vincent Liu, MD, MS, a research scientist at the Kaiser Permanente Northern California division of research and critical care specialist with The Permanente Medical Group.
Without understanding what a “typical” sepsis patient looks like, it is hard for EDs to know what to watch for. Liu and colleagues analyzed 408,377 patients admitted through the ED from 2012 to 2017 with stroke, heart failure, suspected infection, or sepsis. They found there really is not a clear “typical” sepsis patient.1 “We found that the symptoms of sepsis and infection were diffuse and heterogeneous,” Liu reports.
The way septic patients presented varied widely. Dyspnea, weakness, altered mental status, pain, cough, edema, nausea, hypertension, fever, and chest pain all are common signs and symptoms. Only a few patients presented with clear symptoms of infection (fevers or chills). Many presented with symptoms that overlapped with other conditions, such as pain, vomiting, or confusion. “This differed from the presentation of heart failure or stroke, which had well-defined profiles that fit with the condition,” Liu explains.
Sepsis patients with typical or clear symptoms received antibiotics earlier. For those cases, the diagnosis of sepsis is clear, and the clinical workup and treatment are standardized. “However, our data confirm the challenges in clearly identifying sepsis,” Liu explains.
So many symptoms with which septic patients present mimic symptoms of other conditions. The entire picture of infection is not immediately apparent. “Even without a ‘typical’ sepsis presentation, patients can still suffer the systemic effects of a severe infection,” Liu notes.
Even young and otherwise healthy patients have succumbed to sepsis as a direct result of immune modulators, says Andrew P. Garlisi, MD, MPH, MBA, VAQSF, medical director of Geauga County (OH) EMS and University Hospitals EMS Institute Paramedic Training Program. Adalimumab, etanercept, golimumab, and infliximab (and many others in this class of medications) are used for a variety of conditions (e.g., rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, Crohn’s disease, ulcerative colitis, and psoriasis). “Often, these medications are not listed, or are not recognized by the emergency physician as serious risk factors for sepsis and septic shock,” Garlisi says.
Garlisi is aware of two patients younger than age 50 years who were on adalimumab and died from unrecognized sepsis. “It is the obligation of the emergency staff to ensure the accuracy and completeness of the medication list,” Garlisi stresses.
Unfortunately, this often is difficult or impossible. Patients cannot or will not provide the information. “It would behoove the emergency physician to consult the EMR for any information regarding patient medications, and document this effort,” Garlisi suggests.
Failure to timely recognize sepsis in its early stages is a recurring issue in malpractice claims reviewed by Heather A. Tereshko, JD, a principal in the professional liability practice at Post & Schell in Philadelphia. “Frequently, sepsis does not present with features that are commonly associated with overwhelming infection,” Tereshko says.
Underlying symptoms of infection might be masked by presenting symptoms that point to a cardiovascular issue. In a recent case, a 64-year-old man presented to the ED with a chief complaint of shortness of breath and change in mental status, accompanied by hypotension and tachycardia. He was afebrile, but appeared cachectic. He had no significant medical history, and his family could not provide any additional history or details of the patient’s condition preceding his ED presentation.
His preliminary ECG was abnormal. The differential diagnosis included pulmonary embolism and myocardial infarction. The patient was seriously dehydrated, requiring multiple “sticks” to draw blood for lab work. The patient required IV fluid resuscitation before a vein could be accessed. This delayed lab results, through no fault of providers.
Labs showed a significantly elevated white blood cell count, BUN/creatinine, and lactate. “Fluid resuscitation was initiated, however, with concern for fluid overload because of the patient’s abnormal ECG,” Garlisi reports.
The patient was admitted and transferred to the hospital’s ICU for further aggressive IV fluid resuscitation and treatment in accordance with the hospital’s sepsis protocols. “Unfortunately, he was in organ failure, and required vasopressors, which led to limb ischemia, resulting in gangrene and subsequent amputations,” Garlisi says. The case was settled for an undisclosed amount.
In other missed sepsis claims, patients presented with low blood pressure, shortness of breath, and tachycardia, and the focus was to rule out pulmonary embolism. Likewise, if a patient presents with shortness of breath, chest pain, and an abnormal ECG, and labs are positive for an elevated troponin level, the thought logically turns to a cardiac-related illness. “Diagnosing, or suspecting sepsis timely, is as important as diagnosing or suspecting stroke or cardiac event in a timely manner,” Tereshko says.
Patients with sepsis often do not report initial symptoms severe enough to go to the ED. By the time they feel so ill they decide to seek treatment, timely diagnosis becomes even more critical. “Once the patient demonstrates two or more criteria for sepsis, the clock starts,” Tereshko notes.
All treatment that follows is subject to scrutiny in terms of acting timely and within the hospital’s sepsis protocol. “Timestamp notations in the EHR can make or break a malpractice case,” Tereshko observes.
Tereshko says that plaintiff attorneys usually focus on delays in obtaining or resulting a patient’s labs from the time of triage, failure to initiate aggressive IV resuscitation timely and in accordance with the clinical pathway outlined in the hospital’s sepsis protocol, and failure to follow the hospital’s sepsis protocol/clinical pathway. “It is incumbent upon every physician and nurse providing care in an ED setting to be acutely aware of their hospital’s sepsis protocol and order sets, and to ensure that it is followed whenever sepsis is suspected,” Tereshko stresses.
Ensuring adequate perfusion, and making every attempt to avoid the development of ischemic injury, which becomes more difficult when vasopressors are needed to support the patient’s failing organs, also is critical to the defense. Obtaining a history from the patient regarding the severity and length of time symptoms were experienced before presenting for treatment may provide some cushion for defending the case. “The fact that the patient had to be emergently transported for treatment could be important for the defense,” Tereshko offers.
Obtaining testimony from the patient and family, and analyzing the history provided to emergency responders, may be helpful in setting up a contributory negligence defense. “In sepsis cases, when the patient seeks medical treatment so late that he or she is already experiencing organ failure, the physician can only do so much to reverse that which has gone untreated,” Tereshko says.
There always will be experts on both sides who disagree as to the timeliness of diagnosing and initiating the appropriate treatment in an ED. Annie E. Howard, JD, an attorney with Hancock, Daniel & Johnson, sees a common fact pattern in missed sepsis cases: Some indicators of sepsis are there (e.g., fever, chills, or nausea) and are initially appreciated by the nursing staff or physician. Yet the patient is discharged without appropriate treatment.
The patient returns to the ED when symptoms worsen, after which time the infection may have progressed past a point of recovery. “There is a less common fact pattern, but one that emergency departments must plan for,” Howard notes.
This involves notifying patients if a blood culture returns positive after discharge. In those cases, the patient may not have presented with symptoms acute enough to warrant admission or IV antibiotics for potential sepsis. However, a blood culture indicates treatment is imminently necessary. “Well-documented procedures, and documentation those were carried out, and a formalized approach is critical,” Howard stresses.
A simple phone call often is not enough to reach the patient. “If the patient’s phone number is out or if a voicemail box is full, there must be an alternative method to contact the patient and document it was completed,” Howard says.
REFERENCE
- Liu VX, Bhimarao M, Greene JD, et al. The presentation, pace, and profile of infection and sepsis patients hospitalized through the emergency department: An exploratory analysis. Crit Care Explor 2021;3:e0344.