Lessons Learned

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 issues:

  • Lab delays
  • 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 amputations.

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.

References and Resources

FREE Sepsis Resources available on the HQI Website: http://www.hqinstitute.org/post/sepsis-resources

  • Sepsis in California Monograph
  • Sepsis Roundtables
  • Sepsis Performance in California
  • HSAG HIIN Sepsis tools
  • kNOw Sepsis: From Detection to Recovery, presentation from the HQI Conference