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Lapse in Antibiotics Leads to Sepsis
Administered antibiotics in the emergency department and rushed to the operating room for emergent cesarean delivery, a pregnant woman was found to have an infection of the amniotic sac. After delivery, she was transferred to the hospital floor without a continuation order for antibiotics. Within 24 hours, the inpatient team realized she had developed septic shock. In the accompanying commentary, Mitchell Levy, MD, of Brown University, discusses the potential for lapses in care during handoffs and the importance of prompt identification and treatment for patients with sepsis.

Cases & Commentaries
Published October 2016

Lapse in Antibiotics Leads to Sepsis

Commentary by Mitchell Levy, MD

The Case

A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal pain, fevers, and shortness of breath. Upon further evaluation, she was noted to have a rapid heart rate and low blood pressure. Laboratory studies, including blood cultures, were drawn. Given that the fetus was in distress, intravenous (IV) antibiotics were administered and the patient was rushed to the operating room for an emergent cesarean delivery. The amniotic fluid was foul smelling and chorioamnionitis—an infection of the amniotic sac that can cause severe infection in both the mother and the baby—was diagnosed.

After delivery, the patient was transferred to the hospital floor and admitted to the postpartum service. Antibiotics should have been continued to treat the infection, but the initial order was placed as a one-time dose by the ED providers, and the inpatient team did not realize that it had been discontinued. Several hours later, the patient was noted to be lethargic with a low blood pressure. IV fluids were administered. While the inpatient care team discussed possible causes for her low blood pressure, the microbiology lab called to notify the team that the patient's blood cultures had grown gram-negative rod bacteria. At that point, the team realized that the patient was in septic shock. A review of the inpatient orders revealed that IV antibiotics had not been continued since the initial dose administered almost 24 hours earlier in the ED.

Although antibiotics were administered immediately, the patient's clinical status deteriorated further, and she was transferred to the intensive care unit for management of septic shock. She required intubation and hemodynamic support but eventually made a full recovery. The delay in appropriate treatment of sepsis with continued antibiotic therapy on admission resulted in a longer and more complex hospital stay for the patient.

The Commentary

by Mitchell Levy, MD

The case described above presents the opportunity to discuss screening for early identification and management of sepsis, the risk of error during handoffs and transitions, and the benefits and risks associated with utilizing the electronic health record (EHR) for sepsis screening.

Sepsis, severe sepsis, and septic shock—defined as progressive multi-organ system dysfunction in the setting of infection—are top causes of morbidity and mortality in the inpatient setting. It is estimated that more than 700,000 patients in the United States are admitted to the hospital with severe sepsis, with costs exceeding $24.3 billion.(1) Over the past decade, third-party payers, government agencies, and the public have become increasingly aware of the danger posed by hospital-acquired sepsis, given the significant risk of long-term complications or death.(2) Delay in sepsis recognition and treatment has been associated with worse outcomes, and early aggressive treatment has been linked to improved survival.(3,4) Severe sepsis in patients on general medical–surgical units (hospital floors) often goes unrecognized until their condition worsens, necessitating urgent intervention as occurred in the case of the patient described above. Such delay may account for the increased mortality.(5)

Early identification and appropriate management of sepsis has been consistently demonstrated in published studies to be associated with improved outcomes. Prompt intervention with fluids and antibiotics is the mainstay of treatment for sepsis; several studies have demonstrated that any delay in antibiotic administration is associated with significant increased risk of death.(6) The primary challenge to rapid identification of sepsis is the lack of precise markers or diagnostic tools. As we know, the sensitivity of SIRS (systemic inflammatory response syndrome) criteria is such that a large percentage of patients in the hospital at any point in time may meet these criteria (7), and therefore many patients will be incorrectly identified as having possible sepsis. For a long time, it was hoped that biomarkers would provide an accurate and specific tool for early identification of patients with sepsis. Unfortunately, no single biomarker or set of biomarkers has been proven to successfully facilitate early identification of patients with sepsis.

In theory, the EHR should be the perfect tool to facilitate early identification of patients with sepsis by electronically screening for sepsis and alerting providers to patients who may have sepsis and who are in danger of developing organ dysfunction. A great deal of attention has been directed toward the possibility of developing EHR-generated alerts. Unfortunately, these alerts have not yet lived up to expectations. Several studies have been published on these electronic "sniffers" demonstrating limited results.(8,9) The primary problem with these electronic alerts is that they fire too frequently, leading to "habituation" by clinicians, who simply begin to ignore these alerts. With the advent of mandated public reporting of sepsis performance measures by the Centers for Medicare & Medicaid Services (CMS), many hospitals and EHR vendors are actively working to develop electronic alerts that will facilitate early identification while avoiding alert fatigue.

More pertinent to the current case, use of the EHR to manage care transitions and prevent errors in transferring from one area of the hospital to another has not been completely unsuccessful. A recent systematic study suggested that bedside handoffs during nursing shift transition is a potential solution to the communication errors associated with shift-to-shift handoffs.(10)

Problems arising during handoffs are not limited to the postoperative environment. One study recently demonstrated improved frequency of intraoperative information transfer with a checklist.(11) In a survey conducted by the Agency for Healthcare Research and Quality in 2009 of hospital staff from more than 500 hospitals in the United States, more than 80% of respondents identified transition from unit to unit as a source of error.(12) In a recently published survey of ED physicians, 29% reported adverse events during the transition from the ED to the hospital wards, and 78% reported that these events negatively impacted patient care.(13) Investigators at the University of Pennsylvania recently demonstrated decreased number of omissions per handoff between the operating room and intensive care unit with the use of a simple checklist.(14) In another recent survey, physicians identified early communication, team member participation, and collaborative relationships as the key factors facilitating a reduction of errors associated with transition between the operating room and the intensive care unit.(15) The accidental discontinuation of antibiotics in the current case may well have been prevented by the implementation of checklists and protocols developed in these studies. The common theme in most published studies is the benefits of using tools to focus communication and attention to details during these interunit transitions. Given the chaotic nature of hospital environments and the multitasking required of clinicians practicing within these environments, it should come as no surprise that errors of omission are frequent and—more importantly—that checklists, protocols, and prompts have been shown to reduce these errors.

Although anecdotally many clinicians talk about these types of errors as common, no published studies report the frequency of accidental lapses in antibiotic coverage. In reviewing data from our own institution over 12 months (April 2014–March 2015), when automated stop dates for antibiotics were in place, we found only 3 instances in which the expiration of an antibiotic therapy order resulted in a missed dose. This low incidence rate may reflect the multiple redundancies in hospitals that prevent these types of errors during care transitions. Nursing staff, physicians in the receiving units, and pharmacy staff all report reminding physicians caring for these patients about lapses. This redundancy is probably the best safeguard against serious harm from these lapses. Having said that, given the frequency of handoffs and care transitions, it is clear that a formal mechanism or protocol to prevent such errors is needed.(11,15,16)

Errors of omission, like from this current case, can be as serious as errors of commission and can lead to serious adverse events for patients. Providers must remain vigilant to guard against inadvertent lapses in our pursuit of excellence in patient care.

Take-Home Points

Early identification and treatment improves outcomes in patients with sepsis.
Thus far, attempts to develop alerts for early sepsis drawn from electronic health record data (electronic "sniffers") have shown disappointing results due to issues with false positives and alert fatigue.
Transitions in care across institutions and within hospitals may lead to errors and put patient safety at risk.
Protocols and checklists have been shown in published studies to reduce risks associated with transitions of care.

Mitchell Levy, MD
Chief, Division of Critical Care, Pulmonary, and Sleep Medicine
Professor of Medicine
Department of Medicine
Warren Alpert Medical School
Brown University
Providence, RI

References

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2. Magill SS, Edwards JR, Bamberg W, et al; Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. Multistate point-prevalence survey of health care–associated infections. N Engl J Med. 2014;370:1198-1208.[go to PubMed]

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4. Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377. [go to PubMed]

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14. McElroy LM, Macapagal KR, Collins KM, et al. Clinician perceptions of operating room to intensive care unit handoffs and implications for patient safety: a qualitative study. Am J Surg. 2015;210:629-635. [go to PubMed]

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