The death of a 12-year-old boy has led NYU Langone Medical Center to overhaul its discharge procedures.
The boy, Rory Staunton, died of septic shock on April 1, several days after he was discharged from the center with fever and a rapid heart rate.
The New York Times reports that a laboratory test showed the boy’s blood had extraordinarily high levels of cells associated with bacterial infections, but by the time the results were completed, he had already been discharged from the emergency room. His parents brought him back to the emergency room, where he subsequently went into shock and experienced organ failure, and died three days later. The Staunton family said they were not told about the lab results and were unaware of how seriously ill their son was.
In a statement released Wednesday, the hospital said that emergency physicians and nurses would be “immediately notified of certain lab results suggestive of serious infection.” The hospital has developed a new checklist to ensure that a doctor and nurse have conducted “a final review of all critical lab results and patient vital signs” before a patient leaves, Lisa Greiner, a spokeswoman, said in the statement. She added that if the results of a relevant test are only available after a patient has been discharged, the patient will be called and the referring physician will be notified.
Doctors believe that Rory’s sepsis was the result of a cut on his arm received while diving for a basketball at his school gym, most likely allowing bacteria into his blood.
A group of 55 hospitals has developed tactics for early diagnosis of sepsis. It places “an enhanced focus on pediatric patients, for whom identification and treatment can be especially challenging,” said Brian Conway, a spokesman for the Greater New York Hospital Association, which is leading the initiative.