Sepsis and Rory: Ten Thoughts

A recent NYT article described a tragic tale of a child who died due to a bloodstream infection (here, with supplemental reactions here. Here’s ten quick thoughts:

1. Reading this article gives just enough information to condemn, but not enough to actually understand. I’m sure a lot of folks will be brought to a boiling rage (and maybe they should be), but the true story of how this case happened is likely both much more interesting and much more ominous.

2. We have a tremendous problem with continuity of care in the emergency department. It should be obvious that a department designed to manage high acuity cases and triage lower acuity cases is not designed to follow up with patients. After a patient is discharged from the emergency department, and their last note is written, no one will look back at their chart or follow up their labs. Especially not labs which take hours.

3. As one of the commenters noted, bandemia is usually a “critical” value, meaning that it must be verbally communicated to a person on the patient’s care team by the laboratory. At some institutions, that person must be a “licensed independent practitioner” which usually means NP, PA, MD, DO, or any other flavor. At other institutions, a clerk or other person can take the message, and then they are in charge of contacting the relevant “LIP”. It is not clear how this would work in the emergency department after a patient is discharged.

4. Much is missing from this account, including the patient’s initial labwork (as opposed to the labs obtained after discharge) and vital signs. As a piece of medical (as opposed to popular) communication, the article falls short in crucial areas.

5. We need a better tool to diagnose bacteremia than blood cultures which take >12h to grow and often require >48h before identification of a species and antibiotic susceptibilities are complete. Especially in the emergency department setting (or primary care setting) where patient triage occurs. I’m thinking a rapid molecular technique, perhaps involving biomarkers.

6. Are there pediatric ED observation units? Could such a thing have been helpful in these cases?

7. The biggest challenge in emergency medicine is the lack of longitudinal followup of a patient. One would hope that a thorough EMR would eventually allow patients’ inpatient and outpatient providers to communicate. Alternatively, a quick hack would have been for the parents to bring a copy of the office note and vital signs to the ED with them. Depending on the thoroughness and reliability of the office note (often limited, especially in private practice), this might have added a longitudinal dimension.

8. We need a better forum for discussing quality improvement and morbidity and mortality within the hospital. On the surgical services, the morbidity and mortality conferences serve this role. There are no, or only limited, equivalents on other services. This is bad.

9. We need a better forum for discussing quality improvement and morbidity and mortality BETWEEN different health care silos. I humbly submit that this piece of journalism is not the best way to effect change since it does not have all the facts, encourages reactionary feeling and defensiveness, and publicly “names, shames and blames” instead of causing actual improvement. Yes, I know that the muckraking style has this process of “name shame blame” at its core. However, we have seen how far that gets you in medicine – and the answer is: not very far.

10. My condolences go out to the Staunton family. No words can measure or traverse their grief. Although there are many thousands of young people whose life’s work to ensure that this tragedy is not repeated,  their loss is a tragic reminder that we are not nearly “good enough,” whatever that means.

Onwards.

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