This Signal is to increase awareness of how vulnerable patients with Systemic Lupus Erythematosus (SLE) are to rapid deterioration from infection.
A typical incident reads:
“[Patient had] known SLE which had been well controlled, she was admitted with cellulitis & sepsis ......seen initially in A&E 11.30 by a Physician’s Assistant and an F2 doctor then transferred to MAU, then seen in MAU by a medical SPR .....reviewed at a Consultant ward at 17:30, further reviewed by a medical Registrar at 01:00 and request for Critical Care Anaesthetic Registrar to review.... [found to have necrotising fasciitis]....was transferred to theatre as an emergency [but] did not survive .....”
SLE is an auto-immune disorder that is associated with a high propensity to thrombosis, with damage occurring to the skin, joints and nervous system. The course of the disease is unpredictable, with periods of illness (called flares) alternating with remissions. SLE is treated with a variety of medicines including anticoagulants, steroids and other immunosuppressants, many of which leave the patient highly vulnerable to infection. Together with the microthrombi associated with SLE this can lead to necrotising fasciitis. Urgent assessment and investigation to rule out this diagnosis are critical in these patients as delay in diagnosis and treatment can lead to disability and death.
All reports made to the National Reporting and Learning System (NRLS) from inception to June 2011 were searched, and 279 reports of patient safety incidents related to SLE were identified. There were four deaths and three admissions to critical care that were potentially related to a failure to provide sufficiently urgent treatment for these patients.
A key underlying cause appeared to be a lack of knowledge amongst medical and nursing staff of the vulnerability of patients with SLE to rapidly progressing infections and/or rapid deterioration from thrombi, and therefore a need to prioritise their review and treatment.
Patients under surgical care appeared particularly vulnerable, but incidents also occurred in obstetrics, emergency departments and outpatient services.
Discussions with clinical staff suggested that whilst staff are aware that patients undergoing chemotherapy for cancer are very vulnerable to rapidly progressing infection, they may be less aware in relation to SLE and other rare conditions that are treated with immunosuppression.
NHS organisations should:
• Use the Signal to remind staff of these vulnerable patient groups; and
• consider if their processes for urgent senior review and for medical-surgical liaison can be strengthened.
We would like to hear from you - please contact us with your initiatives to reduce risks in these areas.
Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.