Question: Does this expert testimony reflect the standard of care in emergency medicine: “Ordering blood cultures necessitates hospital admission and antibiotic administration”?
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ACEP Now: Vol 36 – No 05 – May 2017The patient’s emergency department records were not provided for this review, so the patient’s symptoms, physical examination, lab testing, and emergency department treatment were obtained solely from the expert witness deposition transcript.
ILLUSTRATION: Chris Whissen, Science Source & shutterstock.com
The patient was a 53-year-old male with a past medical history including hepatitis C and chronic anemia who presented to the emergency department with weakness, fever, vomiting, loose dark stools, and a rash. There were also notations that the patient had experienced “flu-like symptoms” for almost a month. The patient had been prescribed a course of ciprofloxacin for a urinary tract infection but discontinued it approximately one to two weeks prior to his emergency department visit due to the appearance of a rash. During his evaluation in the emergency department, he was persistently tachycardic with a heart rate of 120. He was given IV fluids, and multiple tests were performed, including blood cultures. Lab results showed that the patient was hyponatremic, had a stable hematocrit of 30, and had a positive nasal swab for influenza. His white blood cell count was normal without a left shift, and his lactate level, urinalysis, and chest X-ray were also normal. The following day, preliminary results of the blood cultures were positive for gram-positive cocci. That day, a message was left on the patient’s voicemail, instructing him to return to the hospital. He did not return until three days later. He died shortly thereafter from septic shock, disseminated intravascular coagulation, and multisystem organ failure.
The expert witness faulted the treating emergency physician for several issues. This review addresses the expert’s repeated assertions that because blood cultures were performed, the patient should have been admitted to the hospital and treated with intravenous antibiotics due to a suspicion of bacteremia.
Excerpts from the expert’s deposition testimony include the following:
“One would not order blood cultures and discharge a patient home with a suspicion for bacteremia,” although at the same time noting that bacteremia “sometimes resolves spontaneously.”
“If blood cultures are ordered, that means that bacteremia in the bloodstream is suspected. There is no test to prove that it exists immediately. So unless there is a reason to suspect that someone could have occult bacteremia, like the conditions I mentioned, the treatment is admission and intravenous antibiotics. Otherwise, this happens [referring to the patient’s death from sepsis]. You don’t send otherwise relatively immunocompetent patients home with bacteremia. You treat them.”
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5 Responses to “Should Emergency Department Patients with Pending Blood Cultures be Admitted?”
May 19, 2017
Christopher DarlingtonReally interesting read, thank you.
May 21, 2017
Robert J Halpern, MDThis article is especially important due to the advent of the surviving Sepsis campaigns. Early evaluation and treatment of sepsis has developed into protocols where blood cultures and lactate are obtained before the full clinical spectrum of the illness has been obtained.
Frequently we find that the patient has had blood cultures drawn, but subsequently the WBC does not support the diagnosis of Sepsis, or perhaps the patient has uncomplicated sepsis, and can be treated as an outpatient. The admission of all patients having had blood cultures drawn would be lead to untenable utilization of hospital beds, and untold illness of hospital acquired illnesses.
This admission of patients with blood cultures reflects the same unsupported dogma that a patient who receives parenteral antibiotics in the ED must be admitted.
May 21, 2017
Kathryn C. Peilen, MDMany blood cultured are ordered at triage as part of a triage protocol in order to meet (now antiquated) joint commission guidelines for pneumonia, etc. Often, full assessment of the patient indicates that bacteremia is unlikely, but the blood cultures have already been set up and the order is never removed (many EMR systems make deleting orders difficult.) On the other hand, no information was given about the liver function of this patient with history of Hepatitis C–patients with advanced liver disease are often immunocompromised.
May 21, 2017
Roderick FontenetteI guess the bigger question is why are we ordering blood cultures on patients we plan to discharge?
May 22, 2017
Tom BenzoniWell, yeah.
We know blood cultures are useless most of the time and order them only because we’re mandated to so do.
When we know the patient is ill, we order them and admit.
Most blood cultures ordered over my signature are too satisfy a process measure, not to improve patient care.