Delays in Sepsis Identification and Treatment Lessons Learned from the CHPSO Database
Delays in identification and treatment can have catastrophic
consequences for patients with sepsis. At the least, patients may
experience longer than necessary hospital stays from delays in
care. In extreme cases, septic patients may die or may suffer
severe harm, such as amputations, from delays in care.
Information gleaned from safety events submitted to the CHPSO
database can help determine which factors are associated with
delays in sepsis care. Organizations can work with their team to
address the factors contributing to unnecessary delays in sepsis
identification and treatment.
CHPSO recently completed an analysis of over 1,300 safety events
related to delays in sepsis identification and treatment with a
specific focus on identifying reports of amputations related to
sepsis and delays in care. The query for this analysis included
any cases in the CHPSO database containing “sepsis”
and “amputation” or “delay.”
The analysis of these data revealed the following themes and
Delays associated with rapid response calls
Delayed medication administration
Bed availability, and
Ordering, communication, and hand-off
In many cases, an examination of an individual safety report
revealed that there were multiple factors related to the delay in
care and, ultimately, to the untoward outcome. Consider the
following examples of safety reports related to sepsis, delays in
care, and severe morbidity or mortality.
Case 1 from the CHPSO database: Septic
patient in emergency department had orders for linezolid and
meropenem signed and held by primary physician at 0515, timed to
start as scheduled (0600 for meropenem, 0900 for linezolid).
Released by day nurse at 0728. Pharmacist paged primary physician
to request Infectious Disease (ID) specialist approval at 0730.
Physician later reported not receiving page, noticed antibiotics
not administered at 0830, called nurse and pharmacist and was
notified of ID approval requirement. ID approval obtained and
antibiotics verified at 0845.
Orders released for pharmacist verification after 0700
require ID approval; in this case, this led to an additional hour
delay. Delays may have been avoided if orders were not placed on
hold, if they had been ordered as “start now,” or if instructions
to release were carried out sooner. Pharmacy discussing whether
breaking ID approval requirement for first dose may have been
acceptable in this case.
Case 2 from the CHPSO database: Patient was
s/p amputation and went to her primary care clinic with c/o
redness on her amputation stump. An urgent wound care referral
was ordered. The patient had not been seen by wound care after
two weeks. Primary care office attempted to advocate for patient
and was told that, due to insurance restrictions and provider
availability, the patient could not be seen for another two
weeks. One week later the patient was admitted to the local
hospital with stump cellulitis and C. diff. Patient developed
severe sepsis and died two days later.
Safety reports involving delays in sepsis related care resulting
in amputations were also evident in the database. Like the cases
above, these cases also reveal that multiple contributing factors
including communication breakdowns, insufficient bed
availability, and issues with care coordination across treatment
settings were all factors related to potentially preventable
Case 3 from the CHPSO database: S/P
amputation of toe. Patient returned to ED with signs of
infection. Radiology results not communicated to provider
(destructive osteomyelitis). Due to the delay in treatment, the
patient developed sepsis leading to amputation of leg.
Case 4 from the CHPSO database: High risk
patient called clinic with complaints of “flu like” symptoms
including fever, runny nose and cough. Instructed to call back if
symptoms worsened, no treatment/evaluation needed. Patient did
not improve and went to the local ED the following day. Patient
was diagnosed with pneumonia. Local facility attempted to
transfer patient to a tertiary care center due to the severity of
illness and past medical history, but no beds were available.
Transferred the following day and developed severe sepsis leading
to amputation of all four limbs.
The analysis of these data can provide organizations with insight
into areas for consideration regarding potential opportunities
for improvement in sepsis identification and treatment. Below is
a list of sepsis related references and resources.