Claims Case Study: Sepsis

Lack of recognition of sepsis criteria by Emergency Department (ED) physicians is one of the most common causes of ED claims activity. Sepsis is caused when an infection triggers a dangerous body-wide response that typically includes fever, weakness, rapid heart rate, rapid breathing rate, and an increased number of white blood cells. The response also affects many internal organs, such as the kidneys, heart, and lungs, which all may begin to fail. Sepsis that causes dangerously low blood pressure is called septic shock. This is a life-threatening condition which causes internal organs to receive too little blood, resulting in their malfunction. In this study, we evaluate two patient cases that resulted in death, and offer some guidance as to how physicians can prevent this outcome.

Case #1: 20-Year-Old Female

A 20-year-old female presented to the ED following delivery of a child two days prior. She complained of pain all over her body and sweating. The initial exam revealed no vaginal discharge and her vital signs were normal, with the exception of slight tachycardia. Per the insured emergency physician, there were no classic signs of post-partum infection, such as abdominal tenderness, fever and elevated white blood cell count. The patient improved during her stay in the ED with pain medications and Tylenol. She was discharged with instructions to follow-up with her OB/GYN, which she did two days later.

Upon presentation to her OB/GYN, her physical exam was unremarkable. No labs, ultrasound or CT were ordered, and she was continued on pain medications and sent home.

The patient was found deceased 3 days later. The cause of death was septic shock with disseminated intravascular coagulation due to acute endometritis.

Case #2: 5-Week-Old Infant

The parents of an otherwise healthy 5-week-old infant male presented to the ED for evaluation of the child’s fever of up to 103 degrees and “crankiness”. The mother did report that the baby was feeding well and that there was no change in his amount of wet diapers.

Our insured emergency physician examined the baby and described him as awake, alert, and appropriately fussy with placement of an IV. Other than a fever of 100.8, his vital signs were normal. The physician proceeded with a bacteremia workup.

Chest x-ray, CBC, blood cultures, urine culture, and RSV tests were performed. His UA and RSV screen were negative, and his chest x-ray was unremarkable. The infant had developed some stridorous respirations but did not show signs of respiratory distress. A dose of Decadron improved the infant’s respirations.

Our insured physician spoke with the parents about keeping the infant in the hospital overnight for observation and proceeding with a lumbar puncture. The parents stated that they felt comfortable taking their child home and would follow-up with the pediatrician “first thing in the morning”. The parents agreed that if the baby worsened in any way, they would return to the ED.

After the decision to discharge the baby had been made, his vitals were taken again, and he had a fever of 102.5. Our insured again offered to keep the infant overnight but the parents declined. The infant was discharged from the ED with a diagnosis of fever of unknown origin.

The preliminary blood culture results came back later that morning and were significant for gram-positive organism. A nurse from the ED called the mother and instructed her to bring the infant back to the ED. The mother advised they had an appointment with the pediatrician later that day and the child’s fever was better, but that he was still experiencing some “noisy” breathing. The hospital ED nurse called the child’s pediatrician and notified the staff of the culture results.

Later that morning, the infant was brought by the parents to the ED. Upon arrival, his skin was pale and mottled and he was experiencing grunting respirations. While being evaluated, the child became bradycardic and his oxygen saturation levels decreased. The child was intubated and required resuscitation. He was admitted to the pediatric ICU, where he was diagnosed with sepsis, respiratory failure, meningitis, and hypothermia. Despite aggressive measures, the child died one week later as a result of overwhelming sepsis.

What Went Wrong

In the first case of the 20-year-old mother, our experts indicated that complaints of pelvic pain and fever two days postpartum should have led to a more aggressive workup, including labs and diagnostic testing by our insured emergency physician. However, our experts also indicated that this failure by our insured did not result in the patient’s death. As instructed, the patient presented to her OB/GYN, who also failed to appreciate the seriousness of the patient’s condition. It was this specialist’s lack of a more aggressive workup that ultimately led to the patient’s death. Due to our insured’s failure to initiate an appropriate workup at the ED, it was determined that he would also be held accountable for the patient’s death; therefore, a reasonable contribution was negotiated, and the claim was settled outside of court.

In the second case of the five-week-old infant, the age of this infant placed him on the “border-line” category as to the recommendations regarding when to obtain a lumbar puncture, specific admission criteria, and when to administer antibiotics. The most difficult aspect to defend was our insured’s decision to discharge the infant who was experiencing stridor and a spike in his temperature at the time of discharge that was outside of typical discharge criteria. Our experts believed a lay jury would conclude that given the potential consequences, it would have been better to err on the side of caution and, at a minimum, admit the child for observation. For this reason, a settlement was reached outside of court.

Risk Management Takeaways:

• Physicians should complete routine screening in the ED to identify signs of sepsis as early as possible, thereby improving patient outcomes.
• Sepsis should be suspected in all cases involving fever, leukocytosis and hypotension. Outside of classic presentations, physicians should suspect sepsis for unexplained altered mental status, tachypnea with a clear chest and normal oxygenation, or if clinical instinct suggests something is “not right” in a patient with a seemingly routine infection or suspected infection.
• Discharge instructions should be provided and discussed in detail with the patient. Physicians should make sure to specifically mention symptoms requiring their immediate return to the ED.
• ED staff should conduct follow up calls to patients after discharge for the purpose of evaluating their current condition as well as recommending return to the ED should there be ongoing or worsening symptoms.

For more information on this topic, click here to view an evidence-driven tool designed to guide the early recognition and treatment of sepsis and septic shock, and click here to read about the relationship between bacteremia, sepsis, and septic shock.

For further guidance on this issue, Curi members are encouraged to reach out to our Claims and Risk Management Departments at 800.662.7917.