No but if you're concerned enough about bacteremia to order blood cultures, they're tachycardic, acidotic and have a leukocytosis with a left shift, it doesn't seem unreasonable to order antibiotics.
Maybe. The tachycardia, leukocytosis, and acidosis in ED were all described as mild. Not sure what that means. Generally, leukocytosis (especially if mild) has poor test characteristics. Not sure what it's like at your hospital, but at my hospital a pre-occupation with occult sepsis results in everyone with SIRS getting BCX/Vanc/Zosyn, which can't be good. This patient was getting admitted, and didn't seem that sick at admission. Observation without antibiotics seems reasonable. I agree with you that 1 or 2 doses of abx is not a big deal in terms of stewardship, but I would reserve that for "sick" patients. Maybe if I saw the patient and lab values, I would agree this patient was "sick."
He had new inset weakness, leukocytosis, bandemia, and toxic granulations noted on his CBC. What would imply that he is not sick? Any ER physician with a modicum of common sense would pan-culture the patient and provide fluids, order appropriate sepsis blood work, and introduce antibiotics.
Good heavens, an otherwise healthy man COULDN’T WALK but he “didn’t seem that sick”?! There wasn’t just leukocytosis, but also a left shift, AND toxic granulations were noted on the smear? How is that consistent with a viral infection? How is any degree of acidosis “mild”? I would assign a higher percentage of blame to the ER doc, but this poor guy was also murdered by careless hand-offs.
Yeah, very important distinction here between a mild leukocytosis, neutrophilic predominance, or bandemia/left shift. Likelihood ratio for catastrophic infection is different for each of those.
I agree with the assignment of negligence to ED physician and hospitalist services. The lab data on admission clearly pointed towards sepsis among leading differential and ED physician should have considered this in his assessment. Admitting hospitalist, in my experience, just copy and paste ED assessment ( generally done by APP) and leave it to rounding hospitalist next day to figure out what to do. Unfortunately this scenario is quite common with modern medicine where care is extremely fragmented, and hospitalist have the excuse of having “too many patients”.
Any sick patient that comes to the ER with weakness, tachycardia, leukocytes with bandemia, acidosis… need to rule out sepsis. Check lactate, blood cultures. Treatment would include aggressive IV fluids, and broad-spectrum antibiotics. I think they focused too much on the neurological complaints and missed the big picture. I would put a lot more responsibility on the ER physician. I think they missed this.
I think the biggest mistake here should be "assuming" ? Everyone assumed that the other treating doctor has already started on antibiotics, so no one bother to check
This is a bad miss. Anchoring and other cognitive biases can be deadly in the hospital. We all need to continually rescrutinize patients' presentations and take all sign outs with a healthy grain of salt. It's so easy to take the "UTI" or whatever from the ED and run with it without reconsidering the diagnosis
The admitting doc is at fault. First for not starting abx and second for a crappy sign out. The receiving doc has a responsibility to double check orders.
Do you hold the admitting doc and the ED doc equally responsible? Or does the admitting doc have more responsibility because the patient became febrile shortly after admission?
hmmmm...leucopenia with bandemia and toxic granulation, low platelet count, lactic acidosis, genlized weakness, fevers....blood cultures + for GPC in less than 24 hours and EVERYBODY missed/ignored the obvious diagnosis!
hard for me to imagine an institution in which there could be such a protracted failure chain.
WBC differential was key with keukocytosis, bandemia, and toxic granulation. Pt was having generalized weakness and tachycardia, I did not see if he had a fever, but it would have been prudent to get lactic acid, pro-calcitonin levels and pan-culture the patient and start broad spectrum antibiotics and admit to the medical floor. I am shocked the ER doc got off. All caring team physicians dropped the ball.
I didn't see the abnormal LFT's addressed in the analysis. Patient likely septic from ascending cholangitis. Should have been better analyzed from the get-go (i.e. the ED doc) .Bedside POCUS would have clinched the case. Was there a post done?
I didn't see the abnormal LFT's addressed in the analysis. Patient likely septic from ascending cholangitis. Should have been better analyzed from the get-go (i.e. the ED doc) .Bedside POCUS would have clinched the case. Was there a post done?
I didn't see the abnormal LFT's addressed in the analysis. Patient likely septic from ascending cholangitis. Should have been better analyzed from the get-go (i.e. the ED doc) .Bedside POCUS would have clinched the case. Was there a post done?
WBC differential was key with keukocytosis, bandemia, and toxic granulation. Pt was having generalized weakness and tachycardia, I did not see if he had a fever, but it would have been prudent to get lactic acid, pro-calcitonin levels and pan-culture the patient and start broad spectrum antibiotics and admit to the medical floor. I am shocked the ER doc got off. All caring team physicians dropped the ball.
WBC differential was key with keukocytosis, bandemia, and toxic granulation. Pt was having generalized weakness and tachycardia, I did not see if he had a fever, but it would have been prudent to get lactic acid, pro-calcitonin levels and pan-culture the patient and start broad spectrum antibiotics and admit to the medical floor. I am shocked the ER doc got off. All caring team physicians dropped the ball.
WBC differential was key with keukocytosis, bandemia, and toxic granulation. Pt was having generalized weakness and tachycardia, I did not see if he had a fever, but it would have been prudent to get lactic acid, pro-calcitonin levels and pan-culture the patient and start broad spectrum antibiotics and admit to the medical floor. I am shocked the ER doc got off. All caring team physicians dropped the ball.
I am not surprised. I have seen doctors that I consider lazy and unreliable. It is just a matter of time before something like this happens to them. Hopefully they either get much better or go away.
So, every ED patient with generalized weakness and leukocytosis needs antibiotics? That does not seem like good medicine.
No but if you're concerned enough about bacteremia to order blood cultures, they're tachycardic, acidotic and have a leukocytosis with a left shift, it doesn't seem unreasonable to order antibiotics.
Maybe. The tachycardia, leukocytosis, and acidosis in ED were all described as mild. Not sure what that means. Generally, leukocytosis (especially if mild) has poor test characteristics. Not sure what it's like at your hospital, but at my hospital a pre-occupation with occult sepsis results in everyone with SIRS getting BCX/Vanc/Zosyn, which can't be good. This patient was getting admitted, and didn't seem that sick at admission. Observation without antibiotics seems reasonable. I agree with you that 1 or 2 doses of abx is not a big deal in terms of stewardship, but I would reserve that for "sick" patients. Maybe if I saw the patient and lab values, I would agree this patient was "sick."
He had new inset weakness, leukocytosis, bandemia, and toxic granulations noted on his CBC. What would imply that he is not sick? Any ER physician with a modicum of common sense would pan-culture the patient and provide fluids, order appropriate sepsis blood work, and introduce antibiotics.
Good heavens, an otherwise healthy man COULDN’T WALK but he “didn’t seem that sick”?! There wasn’t just leukocytosis, but also a left shift, AND toxic granulations were noted on the smear? How is that consistent with a viral infection? How is any degree of acidosis “mild”? I would assign a higher percentage of blame to the ER doc, but this poor guy was also murdered by careless hand-offs.
If they have bandemia, then yea
If they have bandemia, then yea
Yeah, very important distinction here between a mild leukocytosis, neutrophilic predominance, or bandemia/left shift. Likelihood ratio for catastrophic infection is different for each of those.
I agree with the assignment of negligence to ED physician and hospitalist services. The lab data on admission clearly pointed towards sepsis among leading differential and ED physician should have considered this in his assessment. Admitting hospitalist, in my experience, just copy and paste ED assessment ( generally done by APP) and leave it to rounding hospitalist next day to figure out what to do. Unfortunately this scenario is quite common with modern medicine where care is extremely fragmented, and hospitalist have the excuse of having “too many patients”.
Yeah in hindsight it was pretty obvious concern for sepsis. Bandemia especially should have been a big clue.
Any sick patient that comes to the ER with weakness, tachycardia, leukocytes with bandemia, acidosis… need to rule out sepsis. Check lactate, blood cultures. Treatment would include aggressive IV fluids, and broad-spectrum antibiotics. I think they focused too much on the neurological complaints and missed the big picture. I would put a lot more responsibility on the ER physician. I think they missed this.
I think the biggest mistake here should be "assuming" ? Everyone assumed that the other treating doctor has already started on antibiotics, so no one bother to check
You know what they say about assuming...
This is a bad miss. Anchoring and other cognitive biases can be deadly in the hospital. We all need to continually rescrutinize patients' presentations and take all sign outs with a healthy grain of salt. It's so easy to take the "UTI" or whatever from the ED and run with it without reconsidering the diagnosis
Agree 100%, especially if you're super busy. Hard to start with a fresh mental view but its critical.
The admitting doc is at fault. First for not starting abx and second for a crappy sign out. The receiving doc has a responsibility to double check orders.
Do you hold the admitting doc and the ED doc equally responsible? Or does the admitting doc have more responsibility because the patient became febrile shortly after admission?
I think the upper body weakness distracted everyone from a strong suspicion of sepsis.
I agree. They seemed to anchor on localizing the weakness when (in hindsight) it was generalized weakness from sepsis.
hmmmm...leucopenia with bandemia and toxic granulation, low platelet count, lactic acidosis, genlized weakness, fevers....blood cultures + for GPC in less than 24 hours and EVERYBODY missed/ignored the obvious diagnosis!
hard for me to imagine an institution in which there could be such a protracted failure chain.
Very hard to understand how so many people could miss this. All the holes of the swiss cheese lined up at once.
WBC differential was key with keukocytosis, bandemia, and toxic granulation. Pt was having generalized weakness and tachycardia, I did not see if he had a fever, but it would have been prudent to get lactic acid, pro-calcitonin levels and pan-culture the patient and start broad spectrum antibiotics and admit to the medical floor. I am shocked the ER doc got off. All caring team physicians dropped the ball.
I didn't see the abnormal LFT's addressed in the analysis. Patient likely septic from ascending cholangitis. Should have been better analyzed from the get-go (i.e. the ED doc) .Bedside POCUS would have clinched the case. Was there a post done?
I didn't see the abnormal LFT's addressed in the analysis. Patient likely septic from ascending cholangitis. Should have been better analyzed from the get-go (i.e. the ED doc) .Bedside POCUS would have clinched the case. Was there a post done?
I didn't see the abnormal LFT's addressed in the analysis. Patient likely septic from ascending cholangitis. Should have been better analyzed from the get-go (i.e. the ED doc) .Bedside POCUS would have clinched the case. Was there a post done?
WBC differential was key with keukocytosis, bandemia, and toxic granulation. Pt was having generalized weakness and tachycardia, I did not see if he had a fever, but it would have been prudent to get lactic acid, pro-calcitonin levels and pan-culture the patient and start broad spectrum antibiotics and admit to the medical floor. I am shocked the ER doc got off. All caring team physicians dropped the ball.
WBC differential was key with keukocytosis, bandemia, and toxic granulation. Pt was having generalized weakness and tachycardia, I did not see if he had a fever, but it would have been prudent to get lactic acid, pro-calcitonin levels and pan-culture the patient and start broad spectrum antibiotics and admit to the medical floor. I am shocked the ER doc got off. All caring team physicians dropped the ball.
WBC differential was key with keukocytosis, bandemia, and toxic granulation. Pt was having generalized weakness and tachycardia, I did not see if he had a fever, but it would have been prudent to get lactic acid, pro-calcitonin levels and pan-culture the patient and start broad spectrum antibiotics and admit to the medical floor. I am shocked the ER doc got off. All caring team physicians dropped the ball.
I am not surprised. I have seen doctors that I consider lazy and unreliable. It is just a matter of time before something like this happens to them. Hopefully they either get much better or go away.