Were ED antibiotics delayed? You're liable
A nursing home patient comes to an ED at 1 p.m. with clear signs and symptoms of sepsis. Antibiotics are ordered immediately, but they aren't given for eight hours. Here's what went wrong:
The ED nurse starts an intravenous line and faxes the antibiotic order to the pharmacy while the patient is being admitted to the medical/surgical floor. At 3 p.m., the ED nurse takes verbal orders for admission which include antibiotics, and realizes that the ED physician's antibiotic order still hasn't been given. She calls the pharmacy and is told that the antibiotics are on their way.
"The nurse then attends to her other patients, and forgets that she still has antibiotics to administer," says Elisabeth Ridgely, RN, LNCC, a Telford, PA-based emergency nurse and legal nurse consultant. "She transfers the patient and never starts the antibiotics."
It is now 6 p.m., and the floor nurse wrongly assumes that all orders are completed. "Upon admission to the medical floor, the patient's vital signs worsen. It is not until 9 p.m. that antibiotics are finally administered," says Ridgely. "The patient succumbs to sepsis and dies the following day."
Both the ED nurse and the floor nurse were named in the ensuing lawsuit, for failing to implement a physician's order and administer antibiotics in a timely manner. "An infectious disease physician testified that had the antibiotics been administered earlier, the patient would not have succumbed to sepsis and would have recovered," says Ridgely.
The entire health care team, including the ED nurse, is responsible for making sure a potentially septic patient receives timely antibiotics. "Since the nurse is a crucial member of the team, then she too will be accountable for her actions," says Ridgely. "If she knows that the patient appears septic, and she knows that antibiotics should be ordered and started and neither has occurred, she does have the responsibility to take action."
Ridgely says the bottom line is that the ED nurse's "action or nonaction may be the subject of a lawsuit. You will have to answer for the delay in obtaining the order to start antibiotics or the delay in administering ordered antibiotics."
Source
For more information about reducing delays for antibiotic administration, contact:
- Elisabeth Ridgely, RN, LNCC, Telford, PA. Phone: (610) 496-8610. E-mail: [email protected].
Don't miss early, vague signs of a septic patient Christine Macaulay, RN, MSN, CEN, nursing practice and safety specialist at The Children's Hospital of Philadelphia, notes that patients with impending sepsis may not even realize they have an infection. "An elderly patient can die from a urinary tract infection," Macaulay says. "Getting those antibiotics in a timely way is very important." If two antibiotics are due at the same time, Macaulay says you should give the antibiotic with the shortest time until the next dose. "The goal is to make sure you get all the antibiotics in the right time frame," she says. To avoid messing impending sepsis, consider these risk factors, says Helen Sandkuhl, RN, MSN, CEN, TNS, FAEN, director of nursing for emergency services at Saint Louis University Hospital: Extremes in age of younger than 1 and older than 65 years of age, malnutrition, trauma, substance abuse, chronic illness, immune deficiency disorders, and invasive procedures. "Once identified, nursing care and treatment need to be aggressive," says Sandkuhl. [The ED's pneumonia protocol is included.] At Baptist Hospital Miami, standing orders are being developed for ED nurses to give antibiotics to any patient with three of seven criteria. "This process helps to minimize delays, says Donna Sparks, MSN, RN, CEN, CNABC, director of emergency services. The criteria are:
"The nurse will anticipate the need for early goal-directed therapy for sepsis in the presence of three of these otherwise unremarkable signs and symptoms," says Sparks. "This includes specific antibiotics, fluid resuscitation, line placements, and various diagnostics." Sources For more information on caring for sepsis patients in the ED, contact:
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Septic shock may not be readily apparent in kids 'Children compensate very well' A 13-year old boy arrived at Atlanta-based Scottish Rite's ED with fever for the past two days, looking tired but responding verbally when nurses spoke to him. His vitals were mildly out of range. ED nurses started an intravenous line and administered normal saline bolus. "He was recognized as being sick but certainly still compensating. A few assessments later, it was noted by the nurse that he had developed a petechial rash," says Heather Ahnberg, RN, BSN, CPEN, clinical educator for emergency services. ED nurses gave another bolus, but a little more an hour later, the patient was much more lethargic, and his blood pressure dropped. The patient was moved to the trauma room with one more bolus administered, dopamine given, and transferred to the intensive care unit. "Although [septic shock] was obvious when the patient finally decompensated, for hours the patient compensated well and was still in 'warm shock,'" says Ahnberg. D.D. Fritch-Levens, RN, BSN, administrative resource nurse for emergency services at Children's Healthcare of Atlanta, says, "Remember that septic shock is the most common type of shock in pediatrics, and that children compensate very well!" Do these three things to identify septic shock early in children: • Look for early symptoms. "Blood pressure and peripheral perfusion changes in pediatrics are often the late symptoms," says Fritch-Levens. "Look for tachycardia, a change in behavior, and listen carefully to the history. Do not rely on the presence of a fever." Kathryn James, RN, MSN, CPNP, education and competency coordinator for the Egleston and Scottish Rite EDs of Children's Healthcare of Atlanta, says that in neonates with sepsis, clinical features can often be "vague but demand a high index of suspicion for early diagnosis. Medical personnel need to provide prompt attention to these patients." [The ED's Caregiver Initiated Protocol for Febrile Infants is included.] "Suspicion should not just focus on the fever aspect," says James. "Pay close attention to those who have been active and feeding well, and gradually or suddenly become lethargic, inactive and refuse to feed." Also, episodes of apneic spells or gasping need further investigation, says James. Watch for tachycardia, poor crying or excessive crying, irritability, and/or respiratory distress. • Pay attention to mental status. Ahnberg says, "Some people dismiss patients being more sleepy as 'it is nap time' or 'he is tired because he is sick.' Of course, sometimes that is true. But that can be the first sign of change in status and is a red flag for shock." • Turn on the lights. "As silly as it sounds, I always remind our nurses to always turn on the lights when assessing," says Ahnberg. "You can never accurately assess a patient with the lights off. It is amazing how different a patient can look with lights on." Sources For more information on caring for septic pediatric patients, contact:
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