The Importance of Early Identification of Sepsis
Infections are a common medical ailment. Infections can be a complication of a healing wound, a surgical site, or secondary to an invasive procedure. Infections may also develop from common illnesses such as a urinary tract infections or community acquired pneumonia. When someone develops an infection that is localized, this is often managed with minimal care or treatment. It may need a wound to be cleaned regularly or need a course of antibiotics. When a beginning infection is misdiagnosed, not treated properly or not identified promptly, the outcome can be fatal.
Untreated infections that become systemic, affecting the whole body, and causing an extreme response, is known as sepsis. Sepsis has an incredibly high mortality rate compared to other infections. When reviewing a case that involves any infection, a consideration for sepsis must be considered. A sepsis case is often a very complicated due to the vast affect the illness process has on the entire body and all organ systems. Though a medical record of a patient with a diagnosis of sepsis quickly becomes riddled with complicated medical terms, such as procalcitonin and disseminated intravascular coagulation, knowing key things to look for can help make these cases easier to comprehend.
Early identification of sepsis is crucial to preventing organ dysfunction and death. Early detection often occurs at a skilled nursing facility or in the emergency room when a patient presents for care, though 87% of sepsis starts outside the hospital setting (CDC, 2021). Sometimes, when a person presents to the emergency room, their complaints are vague, such as confusion or increased work of breathing. Early signs of infection include mild cough, low grade fever, redness or swelling at a wound site, nausea, diarrhea, or painful urination. Early signs that this infection may be becoming septic include fever and chills, confusion, disorientation, pain, rapid heart rate, and low blood pressure (CDC, 2021). Those most at risk for sepsis are the very old, the very young, the immunocompromised, those with chronic illnesses that weaken the immune system or effect end organs, and those who have been recently hospitalized.
If early signs are missed or the patient arrival to a medical facility is delayed, a patient might present with late signs of sepsis. The signs include a high fever, severe pain, difficulty breathing, severe confusion, unconsciousness, significantly rapid heartrate, and a dramatic drop in blood pressure. Late sepsis often results in septic shock, which causes “highly abnormal problems with how the cells work and produce energy” (Mayo Clinic, 2021). This leads to multiple organ failure, problems with blood clotting or bleeding, difficulty maintaining blood pressure, increased lactic acid levels, and often death. It is difficult to interrupt the cascade of organ failure and septic shock once it has begun.
Because sepsis effects the entire body, these cases can quickly become complex with multiple system specialists being involved in the patient care. When evaluating a legal case involving sepsis, it is important to evaluate the primary care provider notes, such as a hospitalist or an intensivist as they are the initial foundation and coordinator between specialists. This can help provide a clear path of treatment management. To begin, it is imperative to notate when the patient arrived in the medical care system with symptoms of infection. It is important to note what type of infection they are presenting for and what symptoms they have at the time of arrival. Many newer electronic health records systems have an embedded sepsis screening tool that grades risk factors such as temperature, which is important to notate if present. Additionally, abnormal white blood cells, lactate levels, radiology reports that might identify pneumonia or abdominal infections, urine leukocytes or fever may be annotated in the first visit. After there is an initial recognition of infection, normal treatment and management would include ordering antibiotics, intravenous fluids, management of metabolic acidosis, medications to help maintain blood pressure if needed, and fever management (UpToDate, 2021). In some cases, oxygen supplementation is needed, occasionally in the form of intubating the patient to protect the airway if they are unable to maintain this naturally. An order for blood cultures indicates that the provider considered sepsis, even if an initial diagnosis of sepsis was not made. Blood cultures are important in sepsis management as they allow the antibiotic regimen to be tailored to the specific bacteria causing the infection.
As a patient enters into septic shock and organ failure, numerous complications can arise. Depending on the organ being affected, any complication that might arise would be specific to that particular body process. For example, a septic urinary tract infection may lead to kidney failure requiring dialysis treatments. Specialist consults are incredibly important to review when looking at specific complications during sepsis. When a specific complication is identified, looking up the generally accepted standard of care for that diagnosis is important for a legal nurse. Ensure when evaluating these issues, to utilize reliable and authoritative literature resources to help understand the care that was provided.
Implications of a missed diagnosis on a legal case can be catastrophic. A missed diagnosis or a delayed diagnosis can result in lifelong organ failure complications. In many cases, it can lead to brain damage or death. When evaluating any case that involves an infection, ensure that sepsis has been considered as a potential complication. Notate what has been done to prevent or manage this critical diagnosis.
Centers Disease Control and Prevention. (2021). What is Sepsis? Retrieved from https://www.cdc.gov/sepsis/what-is-sepsis.html
Mayo Clinic. (2021). Sepsis. Retrieved from https://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc-20351214
UpToDate. (2021). Evaluation and Management of Suspected Sepsis and Septic Shock in Adults. Retrieved from https://www.uptodate.com/contents/evaluation-and-management-of-suspected-sepsis-and-septic-shock-in-adults?search=sepsis&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2