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Positive blood cultures: Not reported? Not believed? Not shared?

Facts: A 17 yo male injures his left shoulder and arm while lifting several hundred pounds. Three days later he awakens at 4 AM in severe pain, so severe that his parents call 911. On arrival in the ED he c/o L shoulder pain radiating to his wrist. ROS includes fever, nausea, vomiting, mild headache and a cough for 1 day producing slight greenish sputum. Exam shows limited ROM of the L shoulder. X-rays of the chest and L humerus are negative. WBC is 19,000 (diff unavailable). An LP reveals normal CSF. Blood cultures (BC’s) are sent to the lab. After 11 hours in the ED, he is discharged with a dx of shoulder sprain, placed in a sling, treated with Motrin and Flexeril and advised to see his PCP the next day about the culture results. The next morning the lab notifies (and documents) that the preliminary report was given to the ED Health Unit Coordinator (HUC) showing that both BC’s are growing gram+ cocci. The report appears to have then been given to the ED nurse but is poorly documented. Nothing happens. The pt sees his PCP that afternoon, still febrile. Unaware of the BC results and suspecting a “deep tissue infection” in the shoulder, he appropriately orders BC’s – and an MRI of the shoulder to be done the following day. The PCP calls it a strain of the left shoulder and fever of unknown origin and sends him home. He worsens overnight and returns to the hospital. An MRI shows septic arthritis of the L shoulder. He is admitted, appropriately treated but dies after a long battle with sepsis. The family files a lawsuit against the ED physician, the hospital and the PCP. The case goes to arbitration.
Plaintiff: You did an LP for a “mild headache” yet ignored the shoulder pain so severe that EMS was called after it awakened him. Where was your differential diagnosis? You suspected infection and did blood cultures but didn’t consider the most likely source. The ED has a perfectly good protocol to review microbiology reports, i.e., an assigned “culture nurse.” Your policy says that they are to 1) share positive results with the ED physician, 2) notify the patient’s PCP, 3) fax the results to the PCP and 4) notify the patient about any change in treatment. Both the defendant ED RN and ED doc admit that the cultures indicate bacteremia requiring immediate tx but, if they were notified, they did nothing. If our son had gotten abx in a timely manner, in the ED or from his PCP, and been admitted to the hospital for his infection, he would be alive today – and we have an infectious disease expert who agrees. Your negligence caused or at least contributed substantially to our son’s death.
Defense: All defendants denied any violation of the standard of care and further denied a causal relationship between their actions and the pt’s death.
* ED HUC: I gave the report to the culture nurse.
* ED RN: I notified the ED doc. He told me to wait for the final results before calling anyone.
* ED Doc: I never told the nurse to wait for final results.
* PCP: I would have admitted the pt immediately had I known of the positive cultures.
Result: An arbitration settlement for the plaintiffs for an undisclosed amount against the hospital, ED RN and ED MD. The PCP was exonerated, despite discharging a patient suspected of having a “deep tissue infection.”
Takeaways:
* “Pain out of proportion” (POOP) is a red flag.
* This case had a unifying diagnosis if the doc had only focused on the CC and WBC. Other sx were side effects of the primary dx.
* Keep an open mind, broaden your differential and document your MDM.
* Avoid “anchoring bias” and “premature closure” based on a patient’s self-diagnosis. This teen’s report of a lifting injury does not comport with the signs and symptoms with which he presented.
* Address lab abnormalities, in this case a WBC count of 19,000 (likely accompanied by bandemia)
* Follow up on cultures. Every ED should have a “culture policy” and a “culture person.”
* Don’t write off “preliminary” BC results. They can be correct, especially when both bottles grow the same organism, even a known contaminant. Call the patient.
* Always r/o sepsis and necrotizing fasciitis in febrile patients with localized pain and an elevated WBC.
* Including “deep tissue infection” in the differential implies the possibility of nec fasc. In that case, a CRP and/or ESR should be ordered and will almost always be elevated, even early in the course of the disease. If normal, an MRI can be avoided. If not, an MRI should be done immediately.
* When sending a patient home with pending blood cultures and no antibiotics, your MDM should clearly show the rationale behind your decision.