One of the greatest barriers to successfully treating a sepsis patient is simply identifying the condition in the first place. Sepsis can escalate so rapidly, and its consequences be so severe that prevention, early diagnosis, and immediate treatment are the greatest weapons physicians possess against bad outcomes and potential liability. Patients often appear in the emergency department with the general complaint that “I don’t feel good.”1 Symptoms may include either high or low temperature, general signs of infection, mental decline/confusion, feeling extremely ill, and severe pain and/or shortness of breath (SOB). “If we had a single test that identified sepsis it would make it much easier,” says Mitchell Levy, MD, Professor of Medicine at The Warren Alpert Medical School of Brown University, and a founding member of the Surviving Sepsis Campaign (SSC).1
Liability may result when patients or their families believe that early signs of sepsis go unheeded, and patients do not receive appropriate treatment in time to prevent severe injury or death. This article summarizes the most recent guidelines published by entities dedicated to the reduction of sepsis and offers risk reduction strategies geared toward early detection and prevention.
In the fall of 2021, the SSC released its most current guidelines. SSC believes use of a performance improvement program for sepsis with rapid screening can reduce mortality. A full discussion of the new SSC guidelines is beyond the scope if this article. Nevertheless, it is important to be aware that they highlight “recommendations for recognition and early care, source diagnosis and treatment of infection, hemodynamic care, ventilation, and additional therapeutic treatment recommendations.”2
The CDC published a comprehensive program addressing sepsis in 2023 called the “Hospital Sepsis Program Core Elements: 2023.” The resource provides an overview of Core Elements in hospital sepsis programs and attempts to identify and summarize the critical attributes of the best programs.1 The elements of the program are Hospital Leadership Commitment, Accountability, Multi-Professional Expertise, Action, Tracking, Reporting, and Education.3
The patient, a 28-year-old female with a 38-week gestational pregnancy, presented to the hospital emergency department at 1:45 p.m. on June 6, 2019. She reported leaking clear vaginal fluid since 11:00 a.m. and the onset of irregular contractions. The insured hospitalist (MD1) suspected premature rupture of membranes (PROM) and consulted with the patient’s obstetrician prior to admission. Upon admission, oxytocin followed by an epidural were administered. A viable male infant was born by vaginal delivery at 6:47 p.m. that same day, with no complications noted.
On July 1st the on-call OB/GYN (MD2) examined the patient at 5:24 a.m. and found her doing well with no complaints. Vital signs revealed tachycardia but were otherwise within normal limits. Labs indicated a white blood cell (WBC) count of 15.9 with 61% bands. MD2’s plan stated 1) stable, advance postpartum care, and 2) discharge next day.
On July 2nd at 7:53 a.m. MD2 prepared to discharge the patient noting her as stable in the summary with vitals T 99, HR 104, RR 18, BP 105/59 and SpO2 at 97%. MD2 instructed her to return to the clinic in six weeks for examination.
At 12:30 p.m. the patient complained of abdominal pain and shortness of breath. The nurse assessed her vital signs which were recorded as T 99, RR 24, HR 128, and BP 125/75. Labs revealed WBC of 7.7 with 84% bands, prompting the nurse to alert MD1. MD1 ordered an EKG and repeat CBC. At 1:30 p.m. the patient complained of even worse abdominal pain and asked for pain medications.
MD2 evaluated the patient at 3:18 p.m. The patient exhibited slight distension but reported passing gas and three stools, with no nausea or vomiting. She experienced uterine contractions and was taking Percocet and naproxen around the clock. Despite these meds the patient indicated the intensity of the pain made her feel she was “going in and out.” MD2 was concerned that more narcotics may exacerbate the patient’s respiratory distress and ordered Ativan for anxiety. She also encouraged the patient to walk the halls to ease the abdominal distention and placed the discharge on hold for continued closer monitoring.
MD1 examined the patient at 4:20 a.m. noting that she had continued severe abdominal pain, loss of appetite, diarrhea, shortness of breath, and pain with deep inspiration, but no excess vaginal bleeding. The patient was reluctant to move but did roll from her side to her back when requested. On exam, her abdomen was distended, firm, and diffusely tender to palpation, but the exam was limited due to the patient’s body habitus. Vitals were T 99.3, HR 137, RR 22, BP 97/51 and SpO2 of 93 percent. Labs revealed creatinine of 2.29, BUN 26 and bilirubin 3.9, prompting a stat abdominal CT scan.
A sepsis alert order was placed at 5:41 a.m. The CT results came in at 5:55 a.m. and revealed minimal opacity in the lower right lung lobe indicating possible early pneumonia, and esophageal distention. At 6:20 a.m. labs showed Hgb of 14.5, WBC of 4.3, bands of 45% and platelets of 74. No antibiotics were administered.
At 7:05 a.m. the patient was unresponsive at a vital sign check. Despite intense efforts to revive the patient, she was pronounced at 8:31 a.m.
The lab reported on July 5th that group A streptococcus grew from the blood culture collected on July 3rd.
The patient’s family brought claims against both MD1 and MD2. The allegations pointed out the decline in the patient’s health over the approximately twelve hours between when MD2 saw her on July 2nd and MD1 saw her on July 3rd. Plaintiffs argued that prophylactic antibiotics should have been administered but were not. Experts also believed that the patient’s condition change on July 1st and July 2nd was a red flag that should have been addressed by MD2. Plaintiffs alleged that the patient demonstrated clear signs of infection on July 2nd. By the time MD1 saw the patient again on July 3rd the experts speculated it may have been too late to save her. While generally supportive of her care, defense experts conceded that MD1 appeared to have sepsis in her differential as early as the time she ordered additional labs and exams, yet she failed to order antibiotics. Note that even a sepsis alarm did not result in the patient receiving antibiotics. This made the claim more difficult to defend, and ultimately the case settled prior to trial.
Create and employ a standardized method for sepsis screening that evaluates patients from intake through discharge and considers the specific patient population (adults, pediatrics, obstetrics, etc.).
Sepsis is a critical illness that can affect anyone and arise from the most seemingly mundane of ailments. Alarmingly, the time from the patient’s first symptoms to severe illness or death can be mere hours. Early recognition of sepsis and timely, aggressive treatment are necessary to give patients the best chance of survival. Institutions like the CDC and SSC continue to update recommendations for best practices in diagnosing and treating sepsis and septic shock. To protect patients and eliminate or reduce potential liability, providers in every setting must strive to maintain their awareness and knowledge about sepsis to ensure the earliest diagnosis and response.