Travis Dove for The New York Times
Ryan Christensen, right, a medical resident, and Jeffrey Woodard, an actor portraying a new father, monitored a robotic baby for symptoms of sepsis at a training session at Carolinas Medical Center in Charlotte, N.C.
Long before 12-year-old Rory Staunton set foot in a hospital in March, the paths to the catastrophe awaiting him had been heavily trod.
Rory Staunton died of septic shock on April 1 after being sent home from the hospital days earlier. Told he had a minor bellyache, first by his pediatrician and then by a doctor in the emergency room at NYU Langone Medical Center, Rory was sent home with medicine to settle his stomach. Three days later, on April 1, he was dead from septic shock caused by an infection that had been present but not treated when he was seen by the doctors. Rory’s case has prompted doctors, nurses and hospital administrators across the country to make new efforts to head off the kinds of problems that may have contributed to his death — some specifically related to early identification of sepsis, and others, long lamented, that hobble treatment of many ailments.
|Rory Staunton died of septic shock on April 1 after being sent|
home from the hospital days earlier.
Among them: critical test results that were not communicated, a lapse that occurs with startling frequency; important observations that vanished during the handoff of Rory’s care from the family pediatrician to the emergency room; and an initial diagnosis that fit some of his symptoms, but no sign that the doctors considered alternatives. The fresh approaches now being put into place include simple measures like new checklists, as well as high-tech tactics like programming Rory’s symptoms into training robots. Some reforms, involving a mandatory pause to brief parents on test results, are being tried out in three emergency rooms in the New York area to see if they would work as the model for a “Rory’s Law.”
A symposium on detecting and treating sepsis, led by the New York State health commissioner, will be held Friday at the New York Academy of Medicine and will include a presentation by Rory’s father, Ciaran Staunton. The case will also be the subject of a panel next month at Johns Hopkins Medical Center during an international conference on medical errors.
For many doctors and nurses, Rory’s case resonated because so much of what seemed to go wrong was utterly familiar. “I think it could have happened almost anywhere,” said Dr. Jeremy Boal, the chief medical officer of 16 hospitals that are part of the North Shore-Long Island Jewish Health System, which has run aggressive sepsis-detection programs since 2008. “It absolutely could have happened here.”
In July, Rory’s parents, Ciaran and Orlaith Staunton, provided his medical records and a detailed chronology of his treatment for an About New York column in the New York Times. Their goal, the Stauntons said, was to wring from their grief a measure of redemption in better care for other children. In effect, they framed a challenge to the medical profession, Dr. Boal said: “It forced us to ask, if it could happen here, what can we do to make sure that it can’t happen in the future?”
Rory, a 5-foot-9, 169-pound sixth grader from Queens, cut his arm while diving for a basketball one spring afternoon in the school gym. He began vomiting after midnight. By the time he saw the family pediatrician later that day, he was running a high fever and suffering severe leg pain, and his skin was not returning to its normal color quickly when pressed with a finger. The vomiting and fever suggested a stomach bug to the pediatrician, who sent him to the emergency room at NYU Langone for fluids. A doctor in the emergency room thought he looked better after some intravenous liquids. He went home with an antinausea drug.
Rory’s body, however, was fighting an invader: a strain of bacteria that normally causes strep throat had gotten into his blood, apparently through the cut in his arm. His immune system was on the verge of a runaway, self-immolating response to the infection — a cascade of destructive processes known generally as sepsis. A number of signs pointed to the gathering intensity of that fight: the mottled skin noted by his pediatrician; the persistence of a very rapid pulse at NYU Langone; an abnormally high volume of immature white blood cells and significantly low numbers of platelets found by the hospital’s laboratory.
Taken together, those signs suggested that he could be in the grip of something more worrisome than a stomach virus.
Yet those signs were not put together until much later, when his organs were failing. Nothing in the emergency room chart reflects the mottling skin found by his pediatrician an hour earlier. The decision to discharge him from the hospital was made before a final set of vital signs showed that he continued to have a very fast heart rate. And the lab report with alarming blood results was time-stamped three hours after he was sent home.
That report, whether or not it would have inevitably led to the discovery of his sepsis, should have been a “red flag,” said Dr. Gordon Schiff, a researcher on patient safety and the editor of “Getting Results: Reliably Communicating and Acting on Critical Test Results.” NYU Langone will not say if the doctors who treated Rory in the emergency room saw the report, whether they were still on duty when it arrived or whether anyone in a position to take action was aware of the findings. The family pediatrician has said she knew nothing about the test.
The Stauntons say they did not know the blood work had been done until days after Rory’s funeral, when it was listed on a bill that came in the mail, tucked in with stacks of condolence cards. Quick, reliable sharing of important information from tests has proved to be vexing. Two decades ago, a national study “found that only 51 percent of ‘life threatening’ laboratory results were treated appropriately,” according to the Massachusetts Coalition for the Prevention of Medical Errors. “You would think this is low-hanging fruit,” said Dr. Schiff, an internist at Brigham and Women’s Hospital in Boston. “You’d think just getting the abnormal test result to the right person would be a straightforward matter.”
But, Dr. Schiff said, a barrage of automatic warnings has turned alerts from machines, laboratories and electronic records into the medical equivalent of the car alarm that is ignored because it never stops blaring. A leading hospital in Texas found that 99 percent of its alerts were overridden, he said. Next month, Dr. Schiff will lead a discussion on Rory’s case with Mr. Staunton at the Fifth International Conference on Diagnostic Error in Medicine, being held at the Johns Hopkins School of Medicine.
NYU Langone, which said Rory’s death in their care was “a matter of great remorse,” will not discuss its procedures on the night that he was in the emergency room. “We are committed to learning from this event to prevent this or a similar situation from happening again,” Lisa Greiner, a spokeswoman for the hospital, said. She said the hospital had changed its discharge procedures to require that a doctor and nurse both check off test results and vital signs. She also said the lab would notify a doctor immediately if it found signs of infections.
Mr. Staunton and Rory’s mother, Orlaith Staunton, who have sued NYU Langone, say all hospitals need to go further. They were bewildered that NYU Langone had not included parents in their checklist. “Keeping parents out of the loop is shortsighted and will inevitably lead to more tragedies such as Rory’s,” Ms. Staunton said.
The Stauntons have called for a law that would require hospitals to tell parents what tests were done, the results and whether any were outstanding. Parents should also be told what other explanations for an illness were considered and what to watch for at home, they said. Because North Shore has aggressive programs to search for early signs of sepsis, the Stauntons met with several officials, including Dr. John D’Angelo, the vice president for emergency medicine for the network. Their ideas were common sense, Dr. D’Angelo said, and North Shore drafted a four-point checklist incorporating them. It is now being tested by three hospitals in the group, Lenox Hill in Manhattan, Cohen Children’s Medical Center in Queens and Glen Cove Hospital on Long Island.
Going over the tests with parents is routine practice “probably 99.99 percent of the time,” Dr. D’Angelo said. But, he pointed out, emergency room physicians can be interrupted dozens of times every hour. They may think they have gone through all their usual mental checkpoints, when they have actually missed a step. “Stuff falls through the cracks; I can guarantee it does, occasionally,” Dr. D’Angelo said. “It’s not that there are bad people caring for the patient — it’s just the reality of a complex environment.”
Dr. Boal said the benefits of the checklist would go to any children seen in emergency rooms, not just those with possible sepsis. “Their idea would reduce the risks for all children who go to the emergency room with something serious,” he said. Every year, between 600,000 and one million patients in the United States are sent home from emergency rooms only to return within 72 hours because of medical errors, according to Dr. Michael Weinstock, an associate professor in the emergency department at Ohio State University. During a career of 30 to 35 years, the average emergency doctor “will send home 17 patients who will die an avoidable death within seven days,” he writes in “Bounceback: Medical and Legal,” a book on such situations. He plans to integrate the Staunton case into training materials for emergency doctors.
In its early stages, sepsis can look just like the body’s ordinary response to infections. Rory’s symptoms have been programmed into robots that will be used for simulation training of medical residents in more than 40 hospitals and urgent care centers in the Carolinas HealthCare System. The robots “talk, sweat, vomit, seize and have changing vital signs,” said Dr. Jo Anna Leuck, the director of simulation for the Department of Emergency Medicine at the Carolinas Medical Center in Charlotte, N.C. “I have also hired an actor to be the parent.” While the Carolinas teachers were preparing the lessons, Dr. Leuck said, they realized that their children’s hospital lacked a sepsis protocol specifically tailored to pediatric patients. Dr. Leuck said she hoped to start a program similar to one at Baylor Hospital in Houston.
Several years ago, Baylor began to screen children for possible sepsis by watching for a single abnormality: persistent, excessively fast heartbeat. Doctors and nurses must then consider the possibility of early sepsis, and be ready to quickly begin giving fluids and antibiotics, said Dr. Binita Patel, a pediatric emergency physician at Baylor. The screening tool results in false positives, she says, but it has significantly shortened the time to start treatment, improving the child’s chances of survival. “Our steps to improved care began when we stopped pointing fingers at each other,” Dr. Patel said.
In New York, after the Staunton case, a consortium of 55 hospitals in the Greater New York Hospital Association began “serious, substantive discussion about pediatric screening" for sepsis, said Brian Conway, a spokesman for the association. The Stauntons have started the Rory Staunton Foundation to increase awareness of the risks of sepsis, a leading cause of hospital deaths. Two days after they made the details of Rory’s care public, Nate Byington, 12, of Jacksonville, Fla., came down with a case of swimmer’s ear and was given antibiotics. When the pain got worse, he went back to the doctor and to an emergency room, and was told it would take a while for the drug to work, said Nate’s mother, Cara Byington. “His ear continued to swell and became hot to the touch,” she said. Once more, they returned to the emergency room. “The attending nurse and doctor took one look at him and said, ‘Possible mastoiditis,’ ” she said. That is an infection that has spread to the bone from the ear, and comes with the possibility of major complications, including sepsis. “The E.R. doctor told me that we were probably down to hours before he was in serious trouble,” Ms. Byington said.
After 24 hours of intravenous antibiotics, Nate was well enough to go home. “Rory’s story made me inclined to be skeptical when the pediatrician kept, in my opinion, blowing off my concerns,” Ms. Byington said. “I will always credit Rory’s parents’ willingness to tell his story for my son’s life.”