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That said, it is critical for organizations to recognize that the medical evidence is solid, implement treatment algorithms consistent with the evidence, and build a system solution to recognize sepsis early, resulting in early intervention. Creating the algorithm is relatively easy; the hard part is getting practitioners and systems in place to reliably recognize the indicators of sepsis and act upon them.
Sepsis is clearly in the spotlight. Since the evidence around management is so strong, when there is a delay or a failure to recognize in cases with adverse outcomes, patients suffer and litigation may follow.
According to the legal Complaint and Trial Brief, Nicole Bermingham gave birth to her first child on August 20, 2013. Labor lasted over 24 hours, and Mrs. Bermingham had severe vaginal and rectal tearing. Three days later, she began experiencing chills, nausea, worsening vaginal pain and fever. She measured her temperature; she had two elevated readings of 101.8°F (38.7°C) and 101.9°F (38.8°C). As an interesting aside, Mrs. Bermingham and her husband were both physician assistants.
There are additional facts forthcoming, but there is already enough data for discussion. According to the currently accepted literature, fever plus tachycardia equals systemic immune response syndrome (SIRS). Together with her abdominal pain complaint and a recent complicated delivery, the practitioner was obligated to consider the possibility of sepsis and begin working down an evidence-based algorithm. That would include ordering certain labs, including a serum lactate.
The NP did not consider sepsis and did not initiate a sepsis algorithm. And here is the key to this case: Why not? Think through this presentation. Sepsis had to be in the differential at this point, but the trial documents indicate that it was not. The NP diagnosed a urinary tract infection and discharged Mrs. Bermingham on Amoxicillin. Understanding the spotlight on recognition of early sepsis and the high priority placed upon recognition and intervention, why didn’t the NP consider sepsis?
Let’s assume for the sake of discussion that this NP is as qualified as any other and is a veteran emergency practitioner. Why does she miss possible sepsis? Humans exhibit bias, particularly in a busy, high-anxiety environment. It feels good and right to get the diagnosis and move to the next patient. In the twenty years TSG has been evaluating emergency medicine litigation, we have seen countless cases where highly qualified veteran physicians and advanced practice clinicians have fallen prey to the impact of deep bias affecting the human thought process.
And once bias has struck — once the practitioner has anchored — extraordinary things happen. In this case, the white blood cell count returned demonstrating an elevated white blood cell count with a left shift, or bandemia. The CBC also demonstrated that Mrs. Bermingham had a platelet count of 50,000, well below the normal range of 150,000 to 450,000. These facts are like hitting someone in the head with a baseball bat and screaming “Sepsis,” “Sepsis.”
Perhaps UTI should have been in the differential diagnosis, but sepsis should have been at the top of the differential and the NP should have initiated an evaluation according to the hospital’s sepsis algorithm.
Mrs. Bermingham was discharged to home on antibiotics. That same afternoon, she lost consciousness and collapsed and was taken back to the same emergency department. Upon arrival, the emergency physician promptly diagnosed sepsis and admitted Mrs. Bermingham to the hospital. Her condition deteriorated; the next day she underwent a total abdominal hysterectomy. However, her condition worsened; she went into multiple organ failure and septic shock, and died the next day. The source of her sepsis was endometritis.
We have already discussed the likely cause of this failure to diagnose, that being the human condition! Knowing that is the case and armed with the knowledge that every single medical practitioner is prone to make the same type of error, what can we do to make an early diagnosis on patients like Mrs. Bermingham and perhaps save a life?
The following are a series of steps that organizations, hospitals and emergency departments can take to avoid these cognitive pitfalls. Rest assured, the answer is not pointing the finger at this NP. The key is creating systems that do not allow this type of error to occur — EVER! We need total clinical alignment around early recognition of sepsis. If that’s true, we must bring information technology together with the human mind to create system solutions that impact clinical decision-making in real time, during the patient visit.
It is unimaginable that medicine has not incorporated such life-saving decision support inside of health records, but that is the status quo with the large EHR systems in the U.S.
This is a tragic case. TSG utilizes this type of outcome in order to generate meaningful systemic change in the practice of medicine that could have saved Mrs. Bermingham and should save many, many lives in the future.