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Delayed antibiotics for patient with sepsis (13HDC00343)
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(13HDC00343, 29 June
District health board ~ Public hospital ~ Emergency
department ~ Sepsis ~ High INR ~ Effective communication across
teams ~ Right 4(1)
A man aged in his early 60s experienced sudden severe back pain
several weeks after having back and shoulder surgery. He was taken
to the emergency care department of a public hospital (the ED)
where he was assessed and diagnosed with musculoskeletal back pain.
The emergency senior medical officer (SMO) who assessed the man
said that the man was stable on physical examination with
satisfactory vital signs, normal sensation in his legs, and an
improvement over six hours of observation. No blood tests or X-rays
were performed. The man was given analgesia and discharged.
Four days later, the man experienced back pain and dizziness,
and was again taken to the ED by ambulance. He was assessed and
found to have low blood pressure and an elevated heart rate. Blood
samples were taken and X-rays were performed. At 11am, an emergency
care medical officer special scale (MOSS) reviewed the man and the
results of initial investigations, and queried sepsis. His plan
included giving the man antibiotics. However, the MOSS discussed
the man's presentation with the orthopaedic team, and they asked to
review the man before antibiotics were given.
Following this, the man was reviewed by an Intensive Care SMO,
to determine whether the man was eligible for a trial of patients
with sepsis that was being undertaken. The SMO noted that the man's
high INR discounted him from the trial. The SMO felt that the man
did not need intensive care unit (ICU) care, and noted that his
blood pressure had improved.
The man was reviewed by an orthopaedic registrar between 1.15pm
and 2.15pm, but no antibiotics were given at that time. The man was
reviewed by the medical team at 2.15pm and noted to be hypoxic and
in acute renal failure. At approximately 4.30pm, the man had an MRI
of his lumbar spine, which showed a large inflammatory mass and
discitis. At 7.15pm, the man received intravenous antibiotics.
At 11.03pm, the man was transferred to the orthopaedic ward, but
shortly afterward was transferred to the high dependency unit
(HDU), as he was in respiratory distress. The man's INR was still
high despite the administration of Vitamin K on three occasions.
His INR was finally corrected at 3.50am following the
administration of Prothrombinex. At 4.30am the man was
transferred to ICU. However, he continued to deteriorate and
developed multiple organ failure. The man died that evening.
It was held that on his second presentation, the man was
promptly identified as having sepsis. However, he should have
received antibiotics shortly after his admission, and the decision
to withhold them was inappropriate. The lack of clear understanding
in emergency care regarding when it is appropriate to withhold
antibiotics contributed to this delay. In addition, given the man's
presentation and concerning blood test results, including an INR
over 10, he should have been transferred to ICU. The lack of
effective communication among teams and across teams compromised
the man's care. The DHB was responsible for the multiple failures
of its staff, and breached Right 4(1).
Adverse comment was made about the DHB regarding the management
of the man's pain, and for the delay in managing his concerning INR
result. The DHB's record-keeping and documentation management was
Adverse comment was made about the emergency SMO in relation to
the man's first presentation.