Another tragic but educational sepsis case

Feldman, James MD James.Feldman at BMC.ORG
Tue Jul 8 18:20:24 UTC 2014


Re: In our ER, blood pressure is taken carefully and frequently and lactic acid is determined in every patient with infection so that severe sepsis can be identified early.

One comment about the below suggests the problems with trying to legislate quality of care even around sepsis without evidence base or research

-          One can have severe sepsis without elevated lactate and ROC for lactate cut point GT 4. The Surviving Sepsis Campaign (IC rec) suggests screening = "We recommend routine screening of potentially infected seriously ill patients for severe sepsis to increase the early identification of sepsis and allow implementation of early sepsis therapy (grade 1C).

-          Applying mandated trigger protocols can affect costs without demonstrated benefit- most patients in ED with viral syndrome or strep throat will have 2/4 SIRS triggering mandatory sepsis bundle including lactate to meet the quality measure. An alternatively extreme example arguing with an admitting resident about a patient needing admission to ICU for suspected and confirmed sepsis who "Didn't meet SIRS criteria"

-          An example of knowledge translating to practice  of this was a med resident rotating in ED saw pt with clear cut viral illness fever tachy who ordered BC x 2, sepsis bundle and vanc/cefipime b.o that was the inpatient education to approach sepsis and rapidly give abx

-          We have noted a consistent small proportion of patients admitted to the ICU who have confirmed sepsis who do not have antibiotics in the ED- usually b/o may have many presenting symptoms and not be recognized, not because providers do not understand sepsis, could not cite the data from PROCESS or Rivers initial paper

-          There will be some collateral injuries from the war on sepsis- stat routine broad  spectrum antibiotics to quickly cover the bases - examples patient in ED with clear cut UTI, boarding, called back for + gm neg BC that was appropriately treated given vancomycin b/o "sepsis" developed life threatening thrombocytopenia.



I believe that we should have some evidence that the New York state approach to the tragic case that triggered the legislation should be guided by evidence, and that we have already seen unintended consequences of efforts to direct and improve care such as pneumonia guidelines leading to increase costs (false + BC, rx vancomycin, prolonged hospital stay, increased administration of antibiotics to meet the metrics etc



Efforts to reduce diagnostic errors should be subject to the same standard of EBM and data



jim

From: Jain, Bimal P.,M.D. [mailto:BJAIN at PARTNERS.ORG]
Sent: Tuesday, July 08, 2014 1:14 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Another tragic but educational sepsis case

Hi Jason,

Thank you for bringing this unfortunate patient to our attention. He is similar in many ways  to a 13 or 14 year old boy who died from severe sepsis in similar circumstances in New York city about 2 or 3 years back. The most striking thing about him, as in your patient, was how his proper care was neglected till it was too late. The main reason for these two deaths and several others we know of is knowledge deficit among physicians in general about severe sepsis and its lethal nature if it is not recognized and treated in a timely manner. Indeed, this disorder should be placed in the same category as acute myocardial infarction and stroke as a time sensitive disease. After the tremendous publicity due to NY patient's death, the Commissioner of Health in Née City made it mandatory for all physicians in the city to take a course about severe sepsis.
Briefly, the important facts about severe sepsis are as follows:

1.It is a major cause of death, killing about 240,000 patients, as many as acute myocardial infarction, each year in United States.
2.It is a complication of infection, characterized by generalized micro vascular inflammation.
3.It is a progressive disorder characterized by worsening hypotension, tissue hypo perfusion with time and ending in multiorgan failure and death if not recognised and treated early.
4.Unfortunately, early clinical features of severe sepsis are subtle or absent and therefore it is not often suspected in its early stage. But altered mental status in a patient with infections a very important sign and should always make us suspect severe sepsis.
5.The important early features of severe sepsis are (a) low or borderline blood pressure in a patient with infection and/or (b) elevated lactic acid indicating tissue hypo perfusion in a patient with infection.
6. In our ER, blood pressure is taken carefully and frequently and lactic acid is determined in every patient with infection so that severe sepsis can be identified early.
7. The treatment of severe sepsis, once it is recognised is simple and consists of:
(a) Rapid, large volume fluid infusion
(b)Prompt administration of appropriate antibiotics
(c) Careful monitoring usually in ICU.

I believe education and increased awareness  about lethal nature of severe sepsis may be the key to early recognition and treatment of this deadly disease.

All the best

Bimal


Bimal Jain MD
Pulmonary-CriticalCare
NorthShore Medical Center
Lynn, MA 01904





From: Vic Nicholls [mailto:nichollsvi2 at GMAIL.COM]
Sent: Monday, July 07, 2014 2:05 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Another tragic but educational sepsis case

One item to this: even if you come with medical research, and you are confident in your opinions, doctors frequently don't accept it. Its not just me but several others also.

Victoria
On 7/7/2014 1:10 PM, Jason Maude wrote:
The Health Service Ombudsman in the UK recently published a report on the tragic case of Sam Morrish, a 3 year old boy who died from sepsis. He had had flu but the various clinicians he saw failed to recognise the secondary infection until it was too late. Sam Morrish came in contact with several clinicians from his primary care practice, NHS Direct (telephone triage service) and emergency clinicians at his local hospital.

These reports are a fantastic educational resource as they are incredibly detailed containing in depth accounts from all the parties concerned and applicable to many diseases. You can access the report from this link:
http://www.ombudsman.org.uk/__data/assets/pdf_file/0003/25896/An-avoidable-death-of-a-three-year-old.pdf

On reading the report, I was struck by how the mother's sentiments were very accurate but she relied on her local GPs and the national phone triage service to tell her what to do rather than directly going to the Emergency Department which may have acted more appropriately.

I wondered whether a patient triage tool attached to a symptom checker could help patients in this situation have more confidence in their own convictions rather than wait to be told what to do. If anybody does have any feedback on our new triage tool (listserv message of June 27th), I would really appreciate it.

Many thanks
Jason


Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886
Tel: +1 703 879 1890
www.isabelhealthcare.com<http://www.isabelhealthcare.com/>

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