[Sepsis Groups] CMS & Hour 1 Bundle

[Townsend, Sean, M.D.]

Dear Colleagues,

Many members of the listserv have asked if CMS will follow suit with the Hour 1 
Bundle.  As it turns out, that's simply not possible, even if it is a good 
idea.  I'll explain a couple reasons here, but please take note that the Hour 1 
Bundle in no way conflicts with SEP-1, and it can only help you with your SEP-1 
performance if you strive for the Hour 1 Bundle targets - you'll be well on 
your way to passing SEP-1.

The shortest answer as to why CMS can't simply adopt the Hour 1 Bundle is that 
government rulemaking requires typically that new measures are adopted after 
they have been approved at NQF.  This is not always so, but the government has 
chosen this path with sepsis measures.  Passing NQF requires that a measure has 
been extensively tested in the real world and that there is data to support 
advancing the measure to NQF.  As the Hour 1 Bundle is new, it will be 
necessary to allow time to pass for hospitals to accrue data applicable to its 
implementation before something could be ready for presentation to NQF (perhaps 
months to years) and then, assuming passage at NQF, converting to a measure 
suitable for the IQR would take up to a year with rulemaking.

None of this should stop hospitals from working on the Hour 1 Bundle.  That 
data supporting the importance of timely interventions is highly suggestive 
that getting therapies started in the first hour is a laudable goal.

If you have found that you have run out of interventions to promote change at 
your facility, optimizing your processes to come into compliance with the Hour 
1 Bundle gives you a great new place to start.

Thanks,

Sean

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Lori Harmon
Sent: Monday, May 21, 2018 6:17 AM
To: sepsisgroups@lists.sepsisgroups.org
Subject: [**External**] [Sepsis Groups] Hour-1 Bundle Announced


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Dear Colleagues,
A new Surviving Sepsis Campaign (SSC) Hour 1 
Bundle
 was released after being updated to reflect the latest evidence from the 
International Guidelines for Management of Sepsis and Septic Shock 2016.
The
 most important change in the revision of the SSC bundles is that the 3-hour 
and 6-hour bundles have been combined into a single "Hour-1 Bundle" with the 
explicit intention of beginning resuscitation and management immediately.
This new sepsis "Hour-1 Bundle" should be introduced to staff in the emergency 
department (ED), wards, and intensive care unit as the next iteration of 
ever-improving tools in the care of patients with sepsis and septic shock as we 
all work to lessen the global burden of sepsis.

Reflecting the latest evidence, the Hour-1 Bundle highlights five steps that 
healthcare professionals should begin as soon as sepsis is recognized:

  *   Measure the blood lactate level. A high lactate level indicates that the 
tissues are not getting enough oxygen from the blood.
  *   Perform blood cultures to identify the cause of the infection. Blood 
samples should be taken before antibiotics are administered, if possible.
  *   Administer broad-spectrum antibiotics that are active against the 
causative organism.
  *   Start intravenous fluids. Fluid resuscitation is an essential step to 
stabilize the patient's condition.
  *   Administer vasopressors to raise blood pressure. This is a critical 
resuscitation step in patients with septic shock.

"There is no reason to delay treatment for patients with sepsis and septic 
shock," comments lead author Mitchell Levy, MD, MCCM. "Recognizing the urgent 
need to treatment, clinicians must (and many already do) begin treatment 
immediately, rather than waiting for 3 or 6 hours in these critically ill 
patients." The authors point out that the new revision is based on the 2016 SSC 
guidelines update, which provides further discussion and evidence related to 
each step and to comprehensive management of sepsis. They also note some 
important gaps in current knowledge, including the need for further studies in 
important subgroups such as patients with burns and compromised immune 
function.  Thanks are extended to the members of the Surviving Sepsis Campaign 
Steering and Executive 

[Sepsis Groups] What variables influence compliance?

[Townsend, Sean, M.D.]

Dear All,

I’m working on developing a model to predict compliance with SEP-1.

I have a list below of variables that may be of interest, but I’m wondering if 
you might send me additional variables you think could be related.

Just to clarify, SEP-1 excludes transfers, CMO status.



  1.  Age at admission
  2.  Sex
  3.  Ethnicity (Hispanic)
  4.  Race
  5.  Initial hypotension (triggers fluid requirement, thus an opportunity to 
fail to comply)
  6.  Persistent hypotension (triggers vasopressors, thus an opportunity to 
fail to comply)
  7.  Septic shock
  8.  Lactate > 2 (triggers a repeat lactate, thus another opportunity to fail 
to comply)
  9.  Lactate > 4 (triggers shock as well as fluid administration = 
opportunities to fail to comply)
  10. Already on antibiotics prior to time of presentation (makes it easier to 
comply)
  11. Already had blood cultures collected prior to time of presentation (makes 
it easier to comply)
  12. CHF (less likely to comply given known physician behavior)
  13. Cardiomyopathy (less likely to comply given known physician behavior)
  14. ESRD (less likely to comply given known physician behavior)
  15. Morbid Obesity (less likely to comply given known physician behavior)
  16. Cirrhosis (less likely to comply given know physician behavior)
  17. Admitted during the day (more likely to comply given staff present)
  18. Admit type (Emergent, urgent, elective)
  19. Presence of an advanced directive
  20. Qualification to receive Medicare benefits (disabled, ESRD, old age)
  21. Type of insurance (Medicare part D implies more access to drugs, Medicare 
Part B implies better outpatient care, Medicare part C = better managed care)
  22. Surgery during the hospitalization
  23. Admit from SNF versus home
  24. DRG assigned
  25. Primary diagnosis
  26. Secondary diagnosis
  27. Zip code
  28. State

Sean

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Re: [Sepsis Groups] [**External**] Re: Focused exam

[Townsend, Sean, M.D.]

Key point is you do not need to reference an "exam" of any sort...  

CMS trusts physicians will reassess patients properly.  We do not want to know 
how it was done.  We want to know if the physician has reassessed the patient 
to their satisfaction.

-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Boyer, Suzette K
Sent: Friday, April 20, 2018 12:39 PM
To: Conaway, Pamela ; Fiona Winterbottom 
; sepsisgroups@lists.sepsisgroups.org
Subject: [**External**] Re: [Sepsis Groups] Focused exam

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It is my understanding that the focused exam will all be rolled into one 
question, not that is not necessary.
Suzette

-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Conaway, Pamela
Sent: Wednesday, April 18, 2018 5:32 AM
To: Fiona Winterbottom ; 
sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] Focused exam

The focused exam will not be necessary beginning with July 2018 discharges.  
This information can be found on Quality Net in the July 2018 inpatient quality 
reporting specifications.

-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Fiona Winterbottom
Sent: Thursday, April 12, 2018 2:12 PM
To: sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] Focused exam

Good Afternoon, I was recently at a large conference where the audience was 
told that the focused exam was no longer necessary.
Could someone clarify this with supporting data of where this can be found?
Thanks
Fiona

-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of sepsisgroups-requ...@lists.sepsisgroups.org
Sent: Monday, April 09, 2018 9:22 AM
To: sepsisgroups@lists.sepsisgroups.org
Subject: Sepsisgroups Digest, Vol 285, Issue 1

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Today's Topics:

   1. Re: Question re: documentation of attestation that focused
  exam was completed (Pamela Green)
   2. Re: Sepsisgroups Digest, Vol 284, Issue 3 (Pender.Linda)
   3. OB patients (richard.rutherf...@ventura.org)


--

Message: 1
Date: Thu, 5 Apr 2018 18:21:54 +
From: Pamela Green 
To: "Duane, Molly" ,
"Sepsisgroups@lists.sepsisgroups.org"

Cc: Alesha Collins , "Britni N. Fannin"
, Steven May 
Subject: Re: [Sepsis Groups] Question re: documentation of attestation
that focused exam was completed
Message-ID:



Content-Type: text/plain; charset="us-ascii"

Good  afternoon everyone,
We are having a difficult time getting the appropriate documentation to meet 
the bundle compliance even though everything is done correctly! Use of our 
Sepsis  Screening and Evaluation Documentation tool is hit and missed although 
I can see by the labs and treatment protocol that they are doing it.  On the IP 
side it  is the issue with getting them to document to the Sepsis 

Re: [Sepsis Groups] [**External**] Re: Focused exam

[Townsend, Sean, M.D.]

This is not correct that "the focused exam is still there."  Instead there is a 
new data element "repeat volume status and tissue perfusion assessment 
performed."  You may write nothing at all about an "exam" and pass.  In 
particular, you may right, "tissue perfusion reassessed" or "volume status 
reassessed" and pass.  There's no preference on how you reassess the patient 
and no declaration of the means is required.

That said, if for some reason you like the exam, you may also say "sepsis 
focused exam completed."

Essentially any documentation of a reassessment is sufficient.  That was the 
design intention.

Sean
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of DHILLON, ROOPINDER
Sent: Friday, April 20, 2018 10:55 AM
To: 'Conaway, Pamela' ; Fiona Winterbottom 
; sepsisgroups@lists.sepsisgroups.org
Subject: [**External**] Re: [Sepsis Groups] Focused exam


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The focused exam is still there in July 2018 Specs Manual. They have just 
changed the name to Data Element Name: "Repeat Volume Status and Tissue 
Perfusion Assessment Performed"



-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Conaway, Pamela
Sent: Wednesday, April 18, 2018 7:32 AM
To: Fiona Winterbottom; 
sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] Focused exam



The focused exam will not be necessary beginning with July 2018 discharges.  
This information can be found on Quality Net in the July 2018 inpatient quality 
reporting specifications.



-Original Message-

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Fiona Winterbottom

Sent: Thursday, April 12, 2018 2:12 PM

To: 
sepsisgroups@lists.sepsisgroups.org

Subject: [Sepsis Groups] Focused exam



Good Afternoon, I was recently at a large conference where the audience was 
told that the focused exam was no longer necessary.

Could someone clarify this with supporting data of where this can be found?

Thanks

Fiona



-Original Message-

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of 
sepsisgroups-requ...@lists.sepsisgroups.org

Sent: Monday, April 09, 2018 9:22 AM

To: 
sepsisgroups@lists.sepsisgroups.org

Subject: Sepsisgroups Digest, Vol 285, Issue 1



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Today's Topics:



   1. Re: Question re: documentation of attestation that focused

  exam was completed (Pamela Green)

   2. Re: Sepsisgroups Digest, Vol 284, Issue 3 (Pender.Linda)

   3. OB patients 
(richard.rutherf...@ventura.org)





--



Message: 1

Date: Thu, 5 Apr 2018 18:21:54 +

From: Pamela Green >

To: "Duane, Molly" >,


"Sepsisgroups@lists.sepsisgroups.org"


>

Cc: Alesha Collins 
>, "Britni N. 
Fannin"


>, Steven May 
>

Subject: Re: [Sepsis Groups] Question re: documentation of attestation

that focused exam was 

Re: [Sepsis Groups] Focused Exam in 5.4 requirements: [External] Sepsisgroups Digest, Vol 286, Issue 1

[Townsend, Sean, M.D.]

There remains a requirement to reassess volume status or perfusion.  There is 
no requirement to state how that reassessment occurred or what the outcome of 
that reassessment was.  You may literally write "perfusion reassessed."  How 
this was done is entirely up to the clinician.

The only thing you may not do to pass this element is to not document some type 
of attempt to reassess the patient, however robust (or weak) the attempt may be.

CMS continues to believe these high mortality patients deserve reassessment but 
is no longer demanding specifics of the reassessment.

Although I resist the implication of the phrase "check the box," you could 
level that accusation.  CMS believes that doctors are thoughtful and earnest 
and will actually perform the relevant assessment as they deem appropriate if 
they document having done so.


From: Sepsisgroups  on behalf of 
Sandy Tobar 
Sent: Monday, April 23, 2018 12:01:09 PM
To: sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] Focused Exam in 5.4 requirements: [External] 
Sepsisgroups Digest, Vol 286, Issue 1

I was reviewing the 5.4 notes from CMS and I do not see that the focused exam 
is being removed. The individual element requirement is but a requirement for 
post fluid exam titled Repeat Volume Status and Tissue Perfusion Assessment 
Performed, date and time. Remains as a required element for sepsis 
documentation.
Does anyone have additional information regarding this?

Sandy Tobar MSBA, BSN, RN, CPPS
Director, Clinical Transformation Sepsis, HAI & Patient Safety
Trinity Health
sandra.to...@trinity-health.org
W  734-343-1496
20555 Victor Parkway
Livonia, MI 48152
trinity-health.org | Facebook | Twitter | LinkedIn



-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of sepsisgroups-requ...@lists.sepsisgroups.org
Sent: Tuesday, April 17, 2018 4:06 PM
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Subject: [External] Sepsisgroups Digest, Vol 286, Issue 1

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Today's Topics:

   1. Focused exam (Fiona Winterbottom)


--

Message: 1
Date: Thu, 12 Apr 2018 18:12:15 +
From: Fiona Winterbottom 
To: "sepsisgroups@lists.sepsisgroups.org"

Subject: [Sepsis Groups] Focused exam
Message-ID:



Content-Type: text/plain; charset="us-ascii"

Good Afternoon, I was recently at a large conference where the audience was 
told that the focused exam was no longer necessary.
Could someone clarify this with supporting data of where this can be found?
Thanks
Fiona

-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of sepsisgroups-requ...@lists.sepsisgroups.org
Sent: Monday, April 09, 2018 9:22 AM
To: sepsisgroups@lists.sepsisgroups.org
Subject: Sepsisgroups Digest, Vol 285, Issue 1

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Contents of Sepsisgroups 

[Sepsis Groups] Corrected Annals of Internal Medicine Article

[Townsend, Sean, M.D.]

Dear Colleagues,

A recent article published in the February 20, 2018 edition of Annals of 
Internal Medicine that purported to review the evidence underpinning the SEP-1 
measure has been corrected by the editors of the journal due to 
misrepresentations of fact.  While the article contained several false 
assertions, perhaps the single correction that exposes the pervasive nature of 
the inaccuracies was that the editors believed it necessary to change even the 
title of the publication.

The letter to the editor prompting the correction can be found here: 
http://annals.org/aim/fullarticle/2675610/evidence-underpinning-centers-medicare-amp-medicaid-services-severe-sepsis-septic

Despite these required corrections, the authors maintain their assertion that 
have reviewed the evidence supporting SEP-1 properly in reaching their 
conclusions.  While this systematic review adjudicated the evidence based upon 
the assessments of the authors, the limitations of a single-center 
self-commissioned review without access to all CMS program data are 
self-revealing.  We note that the National Quality Forum which reviewed the 
measure in 2017 impanels a committee of national experts from a variety of 
institutions (vetted for conflicts of interest), is transparent, and includes 
an opportunity for an open notice and comment period to consider external 
expert and public feedback. In 2017, the NQF committee concluded that the level 
of evidence supporting the composite measure was "moderate." The measure was 
ultimately reendorsed with 4, 9, and 0 members evaluating the evidence as high, 
moderate, and low, respectively. The NQF review was multi-institutional, 
evaluated the evidence using the most up-to-date standards, and had access to 
program data that the Annals authors did not review.

Sean R. Townsend, M.D.
Vice President of Quality & Safety
California Pacific Medical Center
2351 Clay Street, 7th Floor
San Francisco, CA 94115
email towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541

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Re: [Sepsis Groups] [**External**] CMS Benchmarks for SEP-1 Sepsis Early Management Bundle

[Townsend, Sean, M.D.]

CMS is not presently releasing benchmark data except to individual hospitals 
via QualityNet.  If you log in there from your institution you can see your 
performance.

To give you a rough sense of the data, the top performing decile of hospitals 
has  approximately 70% compliance.

From: Morrell, Vicki [mailto:morre...@mlhs.org]
Sent: Wednesday, January 31, 2018 7:55 AM
To: sepsisgroups@lists.sepsisgroups.org
Cc: Townsend, Sean, M.D. <towns...@sutterhealth.org>
Subject: [**External**] CMS Benchmarks for SEP-1 Sepsis Early Management Bundle


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Good Morning! Our organization has recently formed a Performance Excellence 
2020 Sepsis Workgroup to initiate system standardization of processes and best 
practices for our sepsis patients.  My physician leads are querying if there is 
presently a CMS benchmark for this measure.
Dr. Townsend,
I know from our webinars that presently there is not, however, would you know 
at this time how hospitals are performing nationally with an estimated 
compliance rate, i.e.
30%-50% or higher. Any input would be appreciated. Thank you.


Vicki Morrell
System Manager, Quality Outcomes MLHS
Phone:  (484)337-3382
Pager:   3382
E-mail:  morre...@mlhs.org<mailto:morre...@mlhs.org>

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Re: [Sepsis Groups] [**External**] Sepsis Alert

[Townsend, Sean, M.D.]

I would agree this is a confounder. You could delete from your local focus 
study, but they will still hit the metric for purposes of SEP-1.  I'm not sure 
how often you see this to justify a change to SEP-1, but if common I'd take a 
look.

On May 17, 2017, at 10:52 AM, Mary Draper <mary.dra...@johnmuirhealth.com> 
wrote:

Hi Dr. Townsend, I have been looking through the Severe Sepsis guidelines with 
regards to patient who present in cardiac arrest to the ED. I have not found 
any information specific to this issue.  Most of them have an elevated lactate. 
It is difficult to determine what was the cause of the arrest.  We are 
proposing to our Sepsis committee that we delete these patients from the focus 
study.
What are your thoughts on this subject?
Thanks 

Mary Draper RN BSN
Coordinator Quality Improvement
Peer Review Support CV/CT
Quality Management JMH
Office (925) 674-2045
Cell (925) 451-8792
Fax (925) 674-2373
mary.dra...@johnmuirhealth.com

"O, let us always have a mountain within our soul,  with a peak so high that we 
never quite reach the top...
 For then we will always strive for greater things and will not be content  
with merely climbing hills." Ardath Rodale

-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Gwen S. Schneider
Sent: Saturday, May 13, 2017 10:20 AM
To: Townsend, Sean, M.D. <towns...@sutterhealth.org>; Parker, Erin 
<erin.par...@ascension.org>
Cc: sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] [**External**] Sepsis Alert

Hello,
I am interested in the responses you might receive from your question. We use 
EPIC, and we have for LA a value of >2.0 a call from lab as a critical. I am 
wondering if other hospitals are doing the same. And what does MS have to say 
about it?

Sierra Schneider
Salem Oregon

From: Sepsisgroups [sepsisgroups-boun...@lists.sepsisgroups.org] On Behalf Of 
Townsend, Sean, M.D. [towns...@sutterhealth.org]
Sent: Thursday, May 11, 2017 9:36 PM
To: Parker, Erin
Cc: sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] [**External**]  Sepsis Alert

Erin,

I'm sorry you received an inflammatory and obtuse response to your question.  
Such posts have earned the name "troll" or having been "trolled" for  for a 
reason.

Maybe to get a real answer to your question, you could share with us which EHR 
you use?

Sean



On May 5, 2017, at 7:05 AM, Parker, Erin 
<erin.par...@ascension.org<mailto:erin.par...@ascension.org>> wrote:


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Would any one like to share EHR sepsis alert criteria, and also be willing to 
share how it is working?
Thanks,
Erin

Erin Parker RN, BSN, ACM
Infection Preventionist, Epidemiology
Ascension  |  Genesys
One Genesys Parkway
Grand Blanc, MI 48439
Ascension.org/Michigan<https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2FAscension.org%2FMichigan=02%7C01%7CTownseSR%40sutterhealth.org%7Cbcf81d122f5642b45bbc08d49d4d8358%7Caef453eadaa243e0be62818066e9ff63%7C0%7C0%7C636306403617734269=mQq8Hjhaxl37u5wE%2FqOAyhW6JSn%2BvqAyXvPktgLYRnE%3D=0>
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Re: [Sepsis Groups] [**External**] Sepsis Alert

[Townsend, Sean, M.D.]

Erin,

I'm sorry you received an inflammatory and obtuse response to your question.  
Such posts have earned the name "troll" or having been "trolled" for  for a 
reason.

Maybe to get a real answer to your question, you could share with us which EHR 
you use?

Sean



On May 5, 2017, at 7:05 AM, Parker, Erin 
> wrote:


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Would any one like to share EHR sepsis alert criteria, and also be willing to 
share how it is working?
Thanks,
Erin

Erin Parker RN, BSN, ACM
Infection Preventionist, Epidemiology
Ascension  |  Genesys
One Genesys Parkway
Grand Blanc, MI 48439
Ascension.org/Michigan
T: 810.606.5093
F: 810-606-5495
M: erin.par...@ascension.org


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Re: [Sepsis Groups] [**External**] One low MAP can trigger Severe Sepsis presentation

[Townsend, Sean, M.D.]

This has been built into new specs effective Jan 2018.  Can't do it faster.

In these instances, in the meantime, if the doc states the value was erroneous 
it can be ignored.  This documentation can happen at the time the value was 
obtained, or via query with your clinical documentation integrity team.

On Apr 17, 2017, at 6:38 AM, Barnes-Daly, Mary Ann, MS, RN, CCRN, DC 
> wrote:

This sender failed our fraud detection checks and may not be who they 
appear to be. Learn about spoofing  
Feedback
Yes, I have feedback that occurs and it is problematic.

We need to bring this to CMS.
I would suggest that in the same way 2 consecutive BPs are required to identify 
SEPTIC SHOCK after fluids, the same should be true to signify the onset of 
hypotension.

Thanks,

MARY ANN BARNES-DALY MS RN CCRN DC  | Clinical Performance Improvement 
Consultant
Quality & Clinical Effectiveness Team | Office of Patient Experience
Sutter Health -2200 River Plaza Drive, Sacramento, CA 95833
Mobile 916.200.5604| barne...@sutterhealth.org

“You never change things by fighting the existing reality. To change something, 
build a new model that makes the existing model obsolete.”   ~R. Buckminster 
Fuller

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Nelson, Kathy
Sent: Friday, April 07, 2017 12:43 PM
To: 
sepsisgroups@lists.sepsisgroups.org
Subject: [**External**] [Sepsis Groups] One low MAP can trigger Severe Sepsis 
presentation


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Question posed by our physician leadership:

Is anyone else having a problem with their CMS bundles when it comes to a low 
MAP.  Our EMR captures every vital sign and if the auto-calculated MAP falls 
only momentarily to 64, it will trigger our data abstractors to establish a 
diagnosis of hypotension and put the patient into the severe sepsis category 
without necessarily having any of the other organ dysfunction criteria for the 
diagnosis.  This results in a fall out on the bundle and makes us non-compliant 
from CMS data collection purposes.  Has anyone else had a similar EMR issue and 
if so, how did you deal with it?

Thanks!

Kathy Nelson, MBA, CPHQ, RHIA
Public Data Manager
Advocate Health Care
Center for Health Information Services (CHIS)

3075 Highland Parkway, Suite 600
Downers Grove, IL 60515
P: 630- 929-6782 (Internal: 55-6782)
kathy.nel...@advocatehealth.com

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Re: [Sepsis Groups] [EXTERNAL] Re: [**External**] Focused exam 2017

[Townsend, Sean, M.D.]

If you write that a focused physical exam was reviewed that will pass.  The 
doctor does not have to perform the exam.

On Feb 3, 2017, at 12:47 PM, Swash, Pat <swa...@mlhs.org> wrote:

Hi Dr. Townsend,
The guidelines state use Physician/APN/PA documentation only for Examine 
findings so are you saying they can refer to Nurses examine documentation? Can 
you please clarify? Thanks Pat

Pat Swash
Quality Outcomes Coordinator
Bryn Mawr Hospital
swa...@mlhs.org
484-337-3388
FAX-484--337-3729

T Together
E Everyone
A Achieves
M More


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-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Townsend, Sean, M.D.
Sent: Friday, February 03, 2017 2:28 AM
To: Tish Poserina
Cc: sepsisgroups@lists.sepsisgroups.org
Subject: [EXTERNAL] Re: [Sepsis Groups] [**External**] Focused exam 2017

You no longer need to document the individual elements in the record.  A 
provider may simple write that a focused exam was performed or reviewed.

Yes, they can review a nurse's exam now.



On Feb 2, 2017, at 7:42 AM, Tish Poserina 
<pposer...@stmaryhealthcare.org<mailto:pposer...@stmaryhealthcare.org>> wrote:


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Can I get a clarification re focused assessment?
Most recently, if a physician documents "a sepsis exam" or "perfusion exam" 
completed, would that prompt the abstractor to say "yes" to the components 
required for a focused exam?
And if so, would that still mean the components must be documented individually 
in the record?
I may be mis-interpreting the latest CMS update.
Thank you

Tish Poserina RN, MSN-Ed, CCRN-CMC, CNRN Sepsis Coordinator St Mary Medical 
Center
1201 Langhorne-Newtown Road
Langhorne, PA
pposer...@stmaryhealthcare.org<mailto:pposer...@stmaryhealthcare.org>
Contact: 215-710-4347
Spectralink: 215-710-7644



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Re: [Sepsis Groups] [**External**] Re: question

[Townsend, Sean, M.D.]

No. Initial lactate is the one that counts.

On Feb 3, 2017, at 12:16 PM, Haywood, Pamela 
> wrote:


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OR is it septic shock only if lactic acid is still at >= 4 AFTER appropriate 
30ml/kg IVF given?



Pamela J Haywood, BSN, RN

Clinical Documentation Specialist

Jones Memorial Hospital

191 N Main St

Wellsville, NY 14895

585-593-1100 ext 5209


From: Sepsisgroups 
[sepsisgroups-boun...@lists.sepsisgroups.org]
 on behalf of 
deborah.chambl...@hcahealthcare.com 
[deborah.chambl...@hcahealthcare.com]
Sent: Wednesday, February 01, 2017 9:13
To: 
Sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] question

Hello group,

I am being told by our quality department that if a patient is documented with 
severe sepsis and has a lactic acid greater than 4 that it is automatically 
coded as septic shock even though it’s not documented. Is this true?

Thanks,
Debbie Chambless
Sepsis Coordinator
Osceola Regional Medical Center
Kissimmee, Fl 34371
407-518-3949
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Re: [Sepsis Groups] [**External**] Question for core measure

[Townsend, Sean, M.D.]

Courtney has it right.  I hope this makes it clear:

If Severe sepsis criteria are not documented or met, BUT there is MD 
documentation of “Severe Sepsis”, that is they just assert it's there, then you 
choose “1” for severe sepsis present.
Same for Septic shock: even if the criteria are not documented or met, BUT 
there is MD documentation of “Septic Shock”, as a simple assertion, then you 
also choose “1” for severe sepsis and septic shock present.

On Feb 2, 2017, at 7:42 AM, Prejean, Evelyn 
> wrote:

I have the same questions.  This is getting more confusing to me.  Thanks y’all 
for sharing, at least I know I’m not alone.  Ep

Evelyn Prejean  MSN

PI Nurse Analyst

University Medical Center New Orleans | Proud Member of LCMC Health

2000 Canal Street | New Orleans, LA 70112

OFFICE (504)702-2920

evelyn.prej...@lcmchealth.org | 
www.UMCNO.org







From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Merwin, Courtney C.
Sent: Tuesday, January 24, 2017 3:06 PM
To: Barnes-Daly, Mary Ann 
>; Crowley Amy 
>; 
sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] [**External**] Question for core measure

Mary Ann,

Not sure if I followed your clarification.

If Severe sepsis criteria are not met, BUT there is MD documentation of “Severe 
Sepsis”, then you choose “1” for severe sepsis present.
Same for Septic shock: even if the criteria are not met, BUT there is MD 
documentation of “Septic Shock”, then you also choose “1” for severe sepsis and 
septic shock present.

Isn’t that correct??

Courtney Merwin BS, RRT
Clinical Quality Analyst
East Jefferson General Hospital
4200 Houma Blvd.
Metairie, LA  70006
504-503-5968
ccmer...@ejgh.org




From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Barnes-Daly, Mary Ann
Sent: Saturday, January 14, 2017 12:24 PM
To: Crowley Amy; 
sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] [**External**] Question for core measure

Yes Amy, you are correct – that means if what IS documented does not meet 
criteria, or if:

1. Nothing is documented – not done

2. Done but not documented – not done
All = fallout

Thanks,

MARY ANN BARNES-DALY MS RN CCRN DC  | Clinical Performance Improvement 
Consultant
Quality & Clinical Effectiveness Team | Office of Patient Experience
Sutter Health -2200 River Plaza Drive, Sacramento, CA 95833
Mobile 916.200.5604| barne...@sutterhealth.org

“You never change things by fighting the existing reality. To change something, 
build a new model that makes the existing model obsolete.”   ~R. Buckminster 
Fuller

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Crowley Amy
Sent: Thursday, January 12, 2017 2:26 PM
To: 
sepsisgroups@lists.sepsisgroups.org
Subject: [**External**] [Sepsis Groups] Question for core measure


WARNING: This email originated outside of the Sutter Health email system!
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I just abstracted a pt with this exact scenario. The wording below of “if 
criteria is not documented” confuses me. What if the criteria is not met AT 
ALL? Not documented or met? Is that not the same thing? The criteria being met 
within 6 hours is the ENTIRE premise for being able to say that the pt had 
severe sepsis, EVEN IF the provider documents septic shock when the pt doesn’t 
really have it… Maybe I’m not thinking straight or I’m not getting something, 
but it doesn’t make sense to me.. Thoughts? I am highlighting with green.

I do not want to have to say yes to pt’s such as these when the severe sepsis 
criteria was never met during the entire pt stay. The only thing they had was a 
source that grew out from an infected dialysis catheter. The pt was never on 
any pressors or had any organ dysfunction.

Severe Sepsis Present
Documentation of the presence of severe sepsis.

Was severe sepsis present?
Allowable Values
1 (Yes)

Severe Sepsis was present.

2 (No)

Severe Sepsis was not present, or Unable to Determine.


One of the rules for abstraction:
“If criteria for severe sepsis are not documented and there is not 
physician/APN/PA documentation of severe sepsis, but there is physician/APN/PA 
documentation of septic shock, choose 

Re: [Sepsis Groups] [**External**] question

[Townsend, Sean, M.D.]

That is true, but I think you mean that the quality department "abstracts" it 
that way, not that it is coded that way.  Coding and abstraction have different 
rules.

On Feb 2, 2017, at 7:46 AM, 
"deborah.chambl...@hcahealthcare.com"
 
>
 wrote:


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DO NOT CLICK links if the sender is unknown and never provide your User ID or 
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Hello group,

I am being told by our quality department that if a patient is documented with 
severe sepsis and has a lactic acid greater than 4 that it is automatically 
coded as septic shock even though it’s not documented. Is this true?

Thanks,
Debbie Chambless
Sepsis Coordinator
Osceola Regional Medical Center
Kissimmee, Fl 34371
407-518-3949
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Re: [Sepsis Groups] [**External**] Focused exam 2017

[Townsend, Sean, M.D.]

You no longer need to document the individual elements in the record.  A 
provider may simple write that a focused exam was performed or reviewed.

Yes, they can review a nurse's exam now.



On Feb 2, 2017, at 7:42 AM, Tish Poserina 
> wrote:


WARNING: This email originated outside of the Sutter Health email system!
DO NOT CLICK links if the sender is unknown and never provide your User ID or 
Password.




Can I get a clarification re focused assessment?
Most recently, if a physician documents "a sepsis exam" or "perfusion exam" 
completed, would that prompt the abstractor to say "yes" to the components 
required for a focused exam?
And if so, would that still mean the components must be documented individually 
in the record?
I may be mis-interpreting the latest CMS update.
Thank you

Tish Poserina RN, MSN-Ed, CCRN-CMC, CNRN
Sepsis Coordinator
St Mary Medical Center
1201 Langhorne-Newtown Road
Langhorne, PA
pposer...@stmaryhealthcare.org
Contact: 215-710-4347
Spectralink: 215-710-7644



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Re: [Sepsis Groups] [**External**] Re: SOFA and qSOFA

[Townsend, Sean, M.D.]

This is just an absolute mess.  qSOFA will do nothing but mess up your bills 
and quality metrics since billing for "sepsis" under sepsis-3 will code to the 
old simple sepsis under ICD-10 rather than the better paying "severe sepsis."  
ICD-10 has no means to bill for the term "sepsis" as defined in sepsis-3.  Also 
abstractors cannot abstract a diagnosis of "sepsis" (meaning the old severe 
sepsis) employing sepsis 3 under SEP-1, thus if a provider writes "sepsis" 
nobody know what it means for quality abstraction or billing purposes.

This is a calamity the authors of sepsis-3 didn't think to worry about, but in 
fact not having a strategy to deal with these problems means sepsis-3 can never 
be adopted.

This is why hospitals should head CMS advice and ignore sepsis-3.

Sean

On Feb 2, 2017, at 7:42 AM, Carissa Hicks 
> wrote:


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We have incorporated qSOFA in our floor screening tool. Our tool is set up as 
SIRS: yes/no, qSOFA yes/no, if yes to either they move to the next question: 
does the patient have infection or suspected infection. If yes to infection we 
have a nurse driven lactate order set. (The tool also includes organ 
dysfunction screening)


From: "Karla A. Cleveland" 
To: "Lewandowski Susan" , 
sepsisgroups@lists.sepsisgroups.org
Sent: Wednesday, January 25, 2017 5:32:03 AM
Subject: Re: [Sepsis Groups] SOFA and qSOFA
Hi Sue,

Our hospitalist group is routinely using qSOFA in their documentation.  
However, I have not seen the ED physicians using either.


Karla Cleveland BS RN
Sepsis Coordinator
Mercy Health Muskegon
1560 E. Sherman Blvd, Ste 334
Muskegon, MI 49444
231.672.2221
231.672.3965 (FAX)
karla.clevel...@mercyhealth.com
www.MercyHealth.com



From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Lewandowski Susan
Sent: Tuesday, January 24, 2017 12:49 PM
To: sepsisgroups@lists.sepsisgroups.org
Subject: [External] [Sepsis Groups] SOFA and qSOFA

I was curious if any facilities have implemented SOFA and qSOFA? Our facility 
will be implementing both the SOFA and qSOFA in addition to continuing the use 
of SIRS. If these tools are being used, at what frequency is the assessment 
being completed? Also, is SOFA being initiated in the ED upon decision to admit?

Thank you, Sue

Sue Lewandowski RN
Sepsis Coordinator /Nursing Supervisor
Meadville Medical Center
751 Liberty Street
Meadville, Pa 16335
Phone: 814-373-3328
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Re: [Sepsis Groups] [**External**] Core measure: VS in the OR

[Townsend, Sean, M.D.]

I think vitals from the OR should be excepted.  I'll work on that.

On Feb 2, 2017, at 7:47 AM, Jeanie Bollinger 
> wrote:


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We have received some fall outs of the Sepsis Measure due to vital signs in the 
OR being used for time zero.  I sent this to QNet and below is the response 
that I received:

Unless there is physician documentation that the low BP or MAP is due to the 
medications or other condition within the OR, the BP's may be used to meet 
criteria.

The anesthesiologist or CRNA does not document a narrative note as to “why” the 
BP dropped.  Is this a reasonable expectation?  The patient is in the OR for 
source control and is being monitored constantly.  Is there consideration for 
excluding these patients from the measure or at least excluding vital signs 
recorded in the OR?

Jeanie Bollinger MSN,RN,ACCNS-AG, CCRN
Clinical Nurse Specialist
Acute Medicine
Mission Health
Asheville, NC

Phone:828-213-7171


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Re: [Sepsis Groups] [External] RE: Re: SEP-1 Specification Manual for January 2017 Discharges

[Townsend, Sean, M.D.]

Patricia,

It appears that the question you asked is in relation to v5.1 (cases discharged 
7/1/16 - 12/31/16). I think this may be more confusion than anything else given 
that the concept you question is not unique to this data element.

Conceptually the concern you ask about is the same in v5.0b and v5.1 with 
differences in specific documentation requirements noted below for each version.
What qualifies as a Vital Sign Review does change significantly in v5.2, also 
noted below.

General background

 *   The name of the data element is Vital Signs Review Performed. Because of 
this the Definition, Suggested Data Collection Question, Allowable Values, and 
Notes for Abstraction refer to a Vital Signs Review being Performed. This is a 
consistent reference used in many other data elements.
 *   The Notes for Abstraction provide the details of what constitutes a Vital 
Signs Review for purposes of the Vital Signs Review Performed data element. 
Again this is not a new concept and is consistent with ALL other data elements.
Common factors between v5.0b and v5.1

 *Both versions require the physician document the actual vitals they 
reviewed and it must include that they reviewed the following:
*   temperature
*   pulse
*   respiratory rate
*   systolic and diastolic blood pressure
 *   The Exclusion Guidelines for Abstraction identify documentation or wording 
that is not acceptable. Documentation of vital signs reviewed is not considered 
acceptable for either v5.0b or v5.1 because it lacks the detail required in the 
Notes for Abstraction. This is consistent with other data elements.
Differences between v5.0b and v5.1

 *   v5.0b requires the actual values for the temperature, pulse, resp rate and 
BP be included in the physician documentation.
 *   v5.1 does NOT require physician documentation of the actual values for the 
temperature, pulse, resp rate and BP. The physician must still document the 
names of the vitals they reviewed but they do not need to document the values 
as this was deemed redundant.
v5.2 (cases discharged 1/1/2017 - 12/31/2017)

 *   There are more flexible options to meet the data element.
 *   Vital signs review has been removed from The Exclusion Guidelines for 
Abstraction because this is now acceptabel
 *   The physician can document that they:
reviewed the temperature, pulse, resp rate and BP.
 OR
reviewed, performed or attested to reviewing or performing a vital signs review 
(if documented this way do not need to include names of the vital signs)
 OR
performed or attested to performing a physician exam, perfusion assessment of 
sepsis (severe sepsis of septic shock) focused exam (if documented this way do 
not need to include names of the vital signs)

I hope this helps you.


Sean Townsend





-Original Message-
From: Humiston, Patricia [mailto:patricia.humis...@baystatehealth.org]
Sent: Saturday, August 27, 2016 7:33 AM
To: Townsend, Sean, M.D.; Marlett Amy; Clement, Joseph (DPH)
Cc: sepsisgroups@lists.sepsisgroups.org
Subject: RE: [Sepsis Groups] [External] RE: Re: SEP-1 Specification Manual for 
January 2017 Discharges



Interesting regarding the vital signs review as I recently sent the question to 
QNET around vital signs review, see the discussion thread response below





Subject

Vital signs review performed /septic shock





Customer By Web Form (Patricia Humiston) 08/16/2016 08:05 AM

When abstracting the element of vital signs for the focused exam, the specs 
identify choose value #1 (Yes) Vital signs review was documented by a 
physician/APN/PA in the time window beginning at the crystalloid fluid 
administration date and time and ending six hours after the presentation of 
septic shock date and time.

But under Exclusion Guidelines for Abstraction:

• Vitals signs reviewed

The terminology vital signs reviewed is exclusion terminology, I find this a 
bit confusing if MD documents vital signs reviewed one part of spec's 
identifies it is acceptable and an additional part it is not. Is there any 
additional clarity around this element?



Discussion Thread

Response Via Email (Char Teed) 08/16/2016 01:56 PM

Second bullet: Vital signs review is done to assess overall status. The review 
must include temperature, pulse (also referred to as heart rate), respirations, 
and systolic and diastolic blood pressure reading.  They cannot just say 
"vitals signs reviewed" need readings.





Patricia Humiston, MBA RN-C

Division of Healthcare Quality

Baystate Health Systems

(413) 794-0194

patricia.humis...@baystatehealth.org<mailto:patricia.humis...@baystatehealth.org>



-Original Message-

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Townsend, Sean, M.D.

Sent: Friday, August 26, 2016 10:54 AM

To: Marlett Amy; Clement, Joseph (DPH)

Cc: 
sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org>

Subject: Re: [Sepsis Groups] [E

Re: [Sepsis Groups] [External] RE: Re: SEP-1 Specification Manual for January 2017 Discharges

[Townsend, Sean, M.D.]

Allow me to research this and get back to you.

On Aug 27, 2016, at 7:33 AM, Humiston, Patricia 
<patricia.humis...@baystatehealth.org> wrote:

Interesting regarding the vital signs review as I recently sent the question to 
QNET around vital signs review, see the discussion thread response below


Subject
Vital signs review performed /septic shock


Customer By Web Form (Patricia Humiston)   08/16/2016 08:05 AM
When abstracting the element of vital signs for the focused exam, the specs 
identify choose value #1 (Yes) Vital signs review was documented by a 
physician/APN/PA in the time window beginning at the crystalloid fluid 
administration date and time and ending six hours after the presentation of 
septic shock date and time.
But under Exclusion Guidelines for Abstraction:
• Vitals signs reviewed
The terminology vital signs reviewed is exclusion terminology, I find this a 
bit confusing if MD documents vital signs reviewed one part of spec's 
identifies it is acceptable and an additional part it is not. Is there any 
additional clarity around this element?

Discussion Thread
Response Via Email (Char Teed) 08/16/2016 01:56 PM
Second bullet: Vital signs review is done to assess overall status. The review 
must include temperature, pulse (also referred to as heart rate), respirations, 
and systolic and diastolic blood pressure reading.  They cannot just say 
"vitals signs reviewed" need readings.


Patricia Humiston, MBA RN-C
Division of Healthcare Quality
Baystate Health Systems
(413) 794-0194
patricia.humis...@baystatehealth.org

-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Townsend, Sean, M.D.
Sent: Friday, August 26, 2016 10:54 AM
To: Marlett Amy; Clement, Joseph (DPH)
Cc: sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] [External] RE: Re: SEP-1 Specification Manual for 
January 2017 Discharges

One more thing --



I was also unclear below as regards the cardiopulmonary exam.  From today until 
Jan 1 an LIP still has to perform the cardiopulmonary exam.  However after that 
time  to satisfy the concept of a reperfusion assessment for a shock patient, 
an MD/NP/PA may then document simply that they “attest to having reviewed or 
performed a sepsis focused exam and findings were .”  The findings can 
include “within normal limits.”   The provider DOES NOT need to state, nor 
include, nor specifically reference the terms vital signs, cardiopulmonary 
exam, capillary refill, peripheral pulses, or skin exam.  This simple statement 
of reassessment satisfies the intent that the patient was closely observed.  
Note as well the LIP can attest to a nurse’s review of the same.



Hope that's more clear.



Sean



On Aug 25, 2016, at 5:06 PM, Townsend, Sean, M.D. 
<towns...@sutterhealth.org<mailto:towns...@sutterhealth.org>> wrote:





Amy, you were correct.  I mean to say “blood culture” acceptable delay and too 
quickly typed “antibiotic” acceptable delay.







To summarize:







To further ensure that blood culture collection does not delay appropriate 
care, the next specification update, Version 5.2, has a new data element 
entitled Blood Culture Collection Acceptable Delay which allows for a case to 
pass the measure if a clinician indicates that “the IV antibiotic was started 
before the blood culture was drawn because waiting for the blood culture to be 
drawn would have resulted in a delay of 45 minutes or more in starting the IV 
antibiotic.” SEP-1 Version 5.2 was published July 1st, 2016, and will cover 
discharges from January 1st, 2017 through December 31st, 2017.











Sean R. Townsend, M.D.



Vice President of Quality & Safety



California Pacific Medical Center



2330 Clay Street, #301



San Francisco, CA  94115



email towns...@sutterhealth.org<mailto:towns...@sutterhealth.org>



office (415) 600-5770



fax (415) 600-1541











-Original Message-

From: Marlett Amy [mailto:amygossett.marl...@hcahealthcare.com]

Sent: Thursday, August 25, 2016 1:21 PM

To: Townsend, Sean, M.D.; Clement, Joseph (DPH)

Cc: 
sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org>

Subject: [External] RE: Re: [Sepsis Groups] SEP-1 Specification Manual for 
January 2017 Discharges







I am looking at the following below from Dr. Townsend " As regards antibiotic 
acceptable delay the provider has to state a delay of 45 minutes or longer 
would have transpired."



My question is- was this this answer to J. Clement comment below " I see that a 
new element was added "Blood Culture Collection Acceptable Delay" - but I'm not 
clear from the manual what constitutes an acceptable delay.  Am I missing 
something?  Can anybody clarify?"







If so, I do not understand the reply. I only see a change to the BC part of the 
measure, not Abx. So why I do not understand. If there is another question 

Re: [Sepsis Groups] [External] RE: Re: SEP-1 Specification Manual for January 2017 Discharges

[Townsend, Sean, M.D.]

One more thing --

I was also unclear below as regards the cardiopulmonary exam.  From today until 
Jan 1 an LIP still has to perform the cardiopulmonary exam.  However after that 
time  to satisfy the concept of a reperfusion assessment for a shock patient, 
an MD/NP/PA may then document simply that they “attest to having reviewed or 
performed a sepsis focused exam and findings were .”  The findings can 
include “within normal limits.”   The provider DOES NOT need to state, nor 
include, nor specifically reference the terms vital signs, cardiopulmonary 
exam, capillary refill, peripheral pulses, or skin exam.  This simple statement 
of reassessment satisfies the intent that the patient was closely observed.  
Note as well the LIP can attest to a nurse’s review of the same.

Hope that's more clear.

Sean

On Aug 25, 2016, at 5:06 PM, Townsend, Sean, M.D. 
<towns...@sutterhealth.org<mailto:towns...@sutterhealth.org>> wrote:


Amy, you were correct.  I mean to say “blood culture” acceptable delay and too 
quickly typed “antibiotic” acceptable delay.



To summarize:



To further ensure that blood culture collection does not delay appropriate 
care, the next specification update, Version 5.2, has a new data element 
entitled Blood Culture Collection Acceptable Delay which allows for a case to 
pass the measure if a clinician indicates that “the IV antibiotic was started 
before the blood culture was drawn because waiting for the blood culture to be 
drawn would have resulted in a delay of 45 minutes or more in starting the IV 
antibiotic.” SEP-1 Version 5.2 was published July 1st, 2016, and will cover 
discharges from January 1st, 2017 through December 31st, 2017.





Sean R. Townsend, M.D.

Vice President of Quality & Safety

California Pacific Medical Center

2330 Clay Street, #301

San Francisco, CA  94115

email towns...@sutterhealth.org<mailto:towns...@sutterhealth.org>

office (415) 600-5770

fax (415) 600-1541





-Original Message-
From: Marlett Amy [mailto:amygossett.marl...@hcahealthcare.com]
Sent: Thursday, August 25, 2016 1:21 PM
To: Townsend, Sean, M.D.; Clement, Joseph (DPH)
Cc: 
sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org>
Subject: [External] RE: Re: [Sepsis Groups] SEP-1 Specification Manual for 
January 2017 Discharges



I am looking at the following below from Dr. Townsend " As regards antibiotic 
acceptable delay the provider has to state a delay of 45 minutes or longer 
would have transpired."

My question is- was this this answer to J. Clement comment below " I see that a 
new element was added "Blood Culture Collection Acceptable Delay" - but I'm not 
clear from the manual what constitutes an acceptable delay.  Am I missing 
something?  Can anybody clarify?"



If so, I do not understand the reply. I only see a change to the BC part of the 
measure, not Abx. So why I do not understand. If there is another question in 
these emails regarding Abx, then I missed it. Thank you for clarifying and for 
this workgroup. I have never sent in a question before, but I find most of the 
posts very useful and know that eventually someone will ask my questions.



Amy Gossett Marlett

BSN, RN, CCRN

Sepsis Coordinator

Denton Regional Medical Center

Office: 940.384.3254

Cell: 214.801.2950

amygossett.marl...@hcahealthcare.com<mailto:amygossett.marl...@hcahealthcare.com>







Enhancing community health through service

 with compassion, excellence and efficiency.







This email and any files transmitted with it may contain PRIVILEGED or 
CONFIDENTIAL information and may be read or used only by the intended 
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-Original Message-

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Townsend, Sean, M.D.

Sent: Wednesday, August 24, 2016 5:53 PM

To: Clement, Joseph (DPH) 
<joseph.clem...@sfdph.org<mailto:joseph.clem...@sfdph.org>>

Cc: 
sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org>

Subject: [EXTERNAL] Re: [Sepsis Groups] SEP-1 Specification Manual for January 
2017 Discharges



You are correct in your reading.  The LIP can now attest to the reperfusion 
assessment without giving greater detail.  What is more, nursing documentation 
and a nursing exam can be the basis of that attestation.  The only requirement 
is that the one exam item LIP has to do as part of that attestation is a 
cardiopulmonary exam.



This is huge. I ho

Re: [Sepsis Groups] Bundle compliance rates

[Townsend, Sean, M.D.]

At my institutions we have seen 55% compliance on average (20+ hospitals).  
Most success come with severe sepsis.  Still a lot of work to do for shock.

On Jan 28, 2016, at 12:38 PM, Nielsenshultz, Yara 
<yara.nielsenshu...@emcare.com> wrote:

Back in October, Dr. Townsend stated he expected a bundle compliance rate of 
30-50% (see below). Does this estimate seem congruent with your experience with 
this measure? We're seeing a wide range in compliance rates at our various 
locations. 

Thank you,

YARA NIELSENSHULTZ, RN, BSN, MS
Clinical Quality Manager
EmCare, North Division
Direct: (215) 442-5122
yara.nielsenshu...@emcare.com
www.EmCare.com


-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Townsend, Sean, M.D.
Sent: Saturday, October 03, 2015 1:29 AM
To: Brown, Sheree
Cc: sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] Bundle compliance rates

I expect that compliance will be very low, 30% at best for most facilities.  
Some facilities will be 15-20%.  This I also will reach 50% by 6-12 months 
experience with this metric, but getting there will not be easy.

Remember, however, CMS will report performance as a benchmark with deciles of 
performance.  If 30% is the best anyone can do, that will be P90.  That said, 
changes will be sharp -- P50 may be 27%.

All metrics accomplish one thing -- they focus facilities on improving the 
metric.  This will create conversations, meetings, collaborations, arguments, 
disagreements, settlements, etc.  And it's all good -- it means people will 
improve.  Probably with pain as well as pleasure in accomplishment.

This is a tough measure.  Very very tough.  But if you focus your energies on 
the patient and trying to work with it, it will pay off.

The first SSC paper I think is most illustrative.  Compliance went from low 
30's to mid 30's on an all or nothing basis, but mortality dropped 7%.  So, 
small gains with this measure result in tangible benefits.  It just doesn't 
"feel" good while it's happening.

See:

Levy MM, Dellinger RP, Townsend SR et al, The Surviving Sepsis Campaign: 
results of an international guideline-based performance improvement program 
targeting severe sepsis, Crit Care Med. 2010 Feb;38(2):367-74. doi: 
10.1097/CCM.0b013e3181cb0cdc.




On Oct 2, 2015, at 12:50 PM, Brown, Sheree 
<sheree.br...@allegiancehealth.org<mailto:sheree.br...@allegiancehealth.org>> 
wrote:

Does anyone know if CMS has established an expected minimal rate of compliance 
with the Sep-1 measure? Or if not, is there is a reported compliance rate with 
the SSC 3 hr and 6 hr bundles?

Thanks,
Sheree

Sheree Brown MSN, RN, CNL
Manager, Performance Excellence
Phone: 517 205-4209 ext. 4209
Pager:  517 534-0127
Fax: 517 788-4715
sheree.br...@allegiancehealth.org
[cid:image001.gif@01D0FB7B.1349D7A0]

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Re: [Sepsis Groups] Septic Shock Presentation Time

[Townsend, Sean, M.D.]

I have to retract my comment.  I think 10:47 is accurate.

On Jan 26, 2016, at 7:41 PM, Townsend, Sean, M.D. <towns...@sutterhealth.org> 
wrote:

I don't see criteria met at 10:47.  MD say so is not enough.

On Jan 25, 2016, at 1:02 PM, Belfi, Karen 
<bel...@mlhs.org<mailto:bel...@mlhs.org>> wrote:

10:47 would be septic shock time. It’s the earliest time criteria is met.

Karen Belfi, RN, MSN
Quality Outcomes Coordinator
Lankenau Medical Center
484-476-8092
Pager: 5240


From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of karen.k...@hcahealthcare.com<mailto:karen.k...@hcahealthcare.com>
Sent: Wednesday, January 20, 2016 9:15 PM
To: 
sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org>
Subject: [Sepsis Groups] Septic Shock Presentation Time

Clinical criteria for severe sepsis is met at 1002. Crystalloid bolus completed 
at 1247. SBP=79 @ 1300. SBP=87 @1330.
Initial lactic acid =4.0 resulted at 1126.
ED physician note started at 1047 containing documentation of possible septic 
shock.
Would septic shock presentation time be 1047, 1126 or 1300?

Karen King, RN MSN
Quality Management Core Measures Specialist, Lead
Lakeview Regional Medical Center
95 Judge Tanner Boulevard
Covington, LA  70433
Office: (985) 867-4467
Cell:  (985) 788-0585
Fax: (985) 867-4263
Email: karen.k...@hcahealthcare.com<mailto:karen.k...@hcahealthcare.com>

This email and any files transmitted with it may contain privileged or 
confidential information and may be read or used only by the intended 
recipient. If you are not the intended recipient of the email or any of its 
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that any use, dissemination, distribution, forwarding, printing, or copying of 
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Re: [Sepsis Groups] Septic Shock Presentation Time

[Townsend, Sean, M.D.]

I don't see criteria met at 10:47.  MD say so is not enough.

On Jan 25, 2016, at 1:02 PM, Belfi, Karen 
> wrote:

10:47 would be septic shock time. It’s the earliest time criteria is met.

Karen Belfi, RN, MSN
Quality Outcomes Coordinator
Lankenau Medical Center
484-476-8092
Pager: 5240


From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of karen.k...@hcahealthcare.com
Sent: Wednesday, January 20, 2016 9:15 PM
To: 
sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] Septic Shock Presentation Time

Clinical criteria for severe sepsis is met at 1002. Crystalloid bolus completed 
at 1247. SBP=79 @ 1300. SBP=87 @1330.
Initial lactic acid =4.0 resulted at 1126.
ED physician note started at 1047 containing documentation of possible septic 
shock.
Would septic shock presentation time be 1047, 1126 or 1300?

Karen King, RN MSN
Quality Management Core Measures Specialist, Lead
Lakeview Regional Medical Center
95 Judge Tanner Boulevard
Covington, LA  70433
Office: (985) 867-4467
Cell:  (985) 788-0585
Fax: (985) 867-4263
Email: karen.k...@hcahealthcare.com

This email and any files transmitted with it may contain privileged or 
confidential information and may be read or used only by the intended 
recipient. If you are not the intended recipient of the email or any of its 
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that any use, dissemination, distribution, forwarding, printing, or copying of 
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the sender by reply email or contact the sender at the number listed.



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Re: [Sepsis Groups] Severe Sepsis Time Zero and documentation of infection

[Townsend, Sean, M.D.]

I would simply provide the clinical advice that for a provider it's best 
thought of as the time that you first suspected severe sepsis or shock.  Give 
yourself 6 hours from that point.  You likely have much more time than that 
given that the shock click starts later than the severe sepsis clock, do they 
should be fine.

It simply requires then getting comfortable with saying, "I first suspected 
sepsis at 11:30.  I'll start the block then."  If they want a "real" time, 
that's probably not possible to ascertain in the clinical domain, it needs to 
be abstacted.

On Dec 14, 2015, at 11:27 AM, CARIANN M DAHLQUIST 
> wrote:

Hello,
I am inquiring if other facilities are still facing the barriers of physicians 
and nurses actually knowing when presentation time starts? I am looking for any 
ideas that you may be utilizing to help aide in the understanding or 
identification of time zero.
Thank you greatly!
CariAnn

CariAnn Dahlquist RN
Quality Management
Altru Health System | Grand Forks, ND
701.780.5339 phone | 701.780.1942 fax | 
cdahlqu...@altru.org


>>> "Downs, Brenda - PHX" 
>>> > 
>>> 11/18/2015 11:53 AM >>>
Per the spec manual - all elements need to meet within the 6 hours - so I would 
say yes, it needs to be mentioned again unfortunately - whether it makes sense 
or not...

Brenda ☺

Brenda Downs MSN, APRN, ACNS-BC
Cell: 480-720-6102
Program Director Clinical Performance Improvement – ICU Care



-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Prabhakar, Brenda
Sent: Wednesday, November 18, 2015 9:08 AM
To: Cynthia Wells; 
sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] Severe Sepsis Time Zero and documentation of 
infection

Hello-
I am looking for an answer to the question below posed some time ago.  If an 
infectious source is documented on admission and a patient develops signs of 
severe sepsis more than 6hrs later, must infection be documented again to 
determine start time and to be included in the measure?  It makes sense that 
the infectious source is known, but for data abstraction, must it be documented 
again within 6 hrs?
Any help would be appreciated.
Thank you,
Brenda Prabhakar RN BSN
Sepsis Steering Committee Co-Chair
Doylestown Hospital
Doylestown, PA


From: Sepsisgroups 
[sepsisgroups-boun...@lists.sepsisgroups.org]
 on behalf of Cynthia Wells 
[cynthia.we...@steward.org]
Sent: Wednesday, September 30, 2015 1:48 AM
To: 
sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] Severe Sepsis Time Zero

Hello,

If infection/suspect infection is already established however the patient does 
not meet criteria until 8 hours after documentation of infection (SIRS + Organ 
Dysfunction) do we have to tie in the infection documentation again within 6 
hours or is it already assumed since infection has been documented/confirmed 
before the vital signs/abnormal lab values.

For Example: Patient presents to ED with Fever 09:00 and Chest X-Ray shows 
Pneumonia subsequently documented by ED at 9:30 no other abnormal labs or 
vitals. 16:00 Fever Persists, HR elevated, Lab work shows 16:20 lactate = 2.1 
and progress note 21:00 with documented interventions for PN. Do we have to tie 
the infection documentation timing back into the evaluation or because Patient 
already noted to have PN by ED at 9:30 that counts as 1 of the three criterion 
and 16:20 = Time Zero. Or do we account for all three criterion and 21:00 is 
new time zero as all three criterion within 6 hours of each other.

Cindy

Cynthia Wells
Steward Health Care
Director of Clinical Performance Analytics
(508) 404-8647

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Re: [Sepsis Groups] Vasopressor Administration

[Townsend, Sean, M.D.]

Did you look at nursing documentation?

On Nov 4, 2015, at 7:58 AM, Mary Draper <mary.dra...@johnmuirhealth.com> wrote:

I have a case where the patient met the criteria for severe sepsis and septic 
shock on admission to the ED, lactate >4, BP < 90, required intubation from 
aspiration.  There wasn't any documentation of an infection or severe sepsis 
and septic shock until the next day at 0229.
Do I have to use the physician documented time or can I use the criteria that 
ruled the patient in on admission?
Appreciate any thoughts or feedback.
Thanks


Mary Draper RN BSN
Coordinator Quality Improvement
Peer Review Support CV/CT
Quality Management
Office (925) 674-2045
Cell (925) 451-8792
Fax (925) 674-2373
mary.dra...@johnmuirhealth.com

“O, let us always have a mountain within our soul, 
 with a peak so high that we never quite reach the top…
 For then we will always strive for greater things 
 And will not be content  with merely climbing hills.” Ardath Rodale


-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Townsend, Sean, M.D.
Sent: Monday, November 02, 2015 10:28 AM
To: Myran, Robin
Cc: Sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] Vasopressor Administration

The decision to measure the application of vasopressors is unfortunate in my 
view.

However, since it is measured, it is important to recall that the any time a 
vasopressor is applied, the goal is to wean it, not maintain it.  Thus while 
the measure checks to see that vasopressors were applied (ostensibly to prevent 
imminent cardiovascular collapse) they can be immediately weaned to off as long 
as MAP > 65, perhaps with additional fluids.

On Nov 2, 2015, at 9:52 AM, Myran, Robin 
<robin.my...@hoag.org<mailto:robin.my...@hoag.org>> wrote:

All –

I submitted this question through QualityNet, but was interested in your 
thoughts…

The sepsis protocol at our hospital includes the administration of 30 cc/kg 
crystalloid for hypotension or lactate >=4. If the patient remains hypotensive 
after the initial bolus, we have the option of administering an additional 30 
cc/kg. Often this second bolus works to achieve a sustained MAP >=65.

According to the specifications manual for SEP-1, we *must* start a vasopressor 
by the 6th hour if the patient remains hypotensive in the hour after the 
initial bolus is complete, correct? The Surviving Sepsis Campaign's 
recommendations include "a minimum of 30 mL/kg of crystalloids" and that 
"greater amounts of fluid may be needed in some patients." They go on to say 
that "fluid administration is continued as long as there is hemodynamic 
improvement". My physicians will always go to more fluids first (if the patient 
remains fluid responsive) before starting vasopressors. Can you provide 
additional information/clarification so I can educate my clinicians?


Robin Myran, MSN, RN, PCCN
Sepsis Coordinator
Hoag Memorial Hospital Presbyterian
One Hoag Drive
Newport Beach, CA 92658
Office: (949) 764-4588
Fax: (949) 764-5387
Cell: (949) 300-9137
robin.my...@hoag.org<mailto:jodi.caggi...@hoag.org>


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Re: [Sepsis Groups] Vasopressor Administration

[Townsend, Sean, M.D.]

The decision to measure the application of vasopressors is unfortunate in my 
view.

However, since it is measured, it is important to recall that the any time a 
vasopressor is applied, the goal is to wean it, not maintain it.  Thus while 
the measure checks to see that vasopressors were applied (ostensibly to prevent 
imminent cardiovascular collapse) they can be immediately weaned to off as long 
as MAP > 65, perhaps with additional fluids.

On Nov 2, 2015, at 9:52 AM, Myran, Robin 
> wrote:

All –

I submitted this question through QualityNet, but was interested in your 
thoughts…

The sepsis protocol at our hospital includes the administration of 30 cc/kg 
crystalloid for hypotension or lactate >=4. If the patient remains hypotensive 
after the initial bolus, we have the option of administering an additional 30 
cc/kg. Often this second bolus works to achieve a sustained MAP >=65.

According to the specifications manual for SEP-1, we *must* start a vasopressor 
by the 6th hour if the patient remains hypotensive in the hour after the 
initial bolus is complete, correct? The Surviving Sepsis Campaign's 
recommendations include "a minimum of 30 mL/kg of crystalloids" and that 
"greater amounts of fluid may be needed in some patients." They go on to say 
that "fluid administration is continued as long as there is hemodynamic 
improvement". My physicians will always go to more fluids first (if the patient 
remains fluid responsive) before starting vasopressors. Can you provide 
additional information/clarification so I can educate my clinicians?


Robin Myran, MSN, RN, PCCN
Sepsis Coordinator
Hoag Memorial Hospital Presbyterian
One Hoag Drive
Newport Beach, CA 92658
Office: (949) 764-4588
Fax: (949) 764-5387
Cell: (949) 300-9137
robin.my...@hoag.org


Please note that the information contained in this message and any files 
transmitted with it are privileged and confidential and are protected from 
disclosure under the law, including the Health Insurance Portability and 
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recipient, or an employee or agent responsible for delivering this message to 
the intended recipient, you are hereby notified that any dissemination, 
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subject you to criminal or civil penalties. If you have received this 
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delete the material from any computer. Thank you, Hoag Memorial Hospital 
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Re: [Sepsis Groups] DNR, DNI, and comfort care with regards to the septic shock requirements

[Townsend, Sean, M.D.]

True.  I think it's a small problem, but I'll add it to our list.

On Oct 22, 2015, at 7:27 AM, Delude, Dale <dale.del...@advocatehealth.com> 
wrote:

However, without the central line vasopressors can't be administered.

Dale DeLude
P.I. Specialist
Advocate Condell Medical Center
801 S. Milwaukee Ave.
Libertyville, IL 60048
Telephone:  847-990-5863
Fax:  847-573-4251
dale.del...@advocatehealth.com

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-Original Message-
From: Townsend, Sean, M.D. [mailto:towns...@sutterhealth.org]
Sent: Thursday, October 22, 2015 9:25 AM
To: Delude, Dale
Cc: Prabhakar, Brenda; sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] DNR, DNI, and comfort care with regards to the 
septic shock requirements

The reason for no exclusion for central line placement is that the physical 
exam option means the line is not mandatory.

The vasopressor issue wasn't envisioned as something a patient would refuse, 
but I suppose it is conceivable.  In any case as others have said here there is 
no refusal option for vasopressors.

Sean

On Oct 22, 2015, at 5:15 AM, Delude, Dale 
<dale.del...@advocatehealth.com<mailto:dale.del...@advocatehealth.com>> wrote:

Good Morning Dr. Townsend,

I respectfully disagree that the patient refusing vasopressors will be excluded 
from the measure.  The abstraction guideline and algorithm only excludes 
patients who are refusing blood draw, fluid administration, or antibiotic 
administration, or those patients who have a directive for comfort care 
documented within 6 hours of septic shock presentation.  There is also no out 
for those patients who refuse to have a central line inserted for 
administration of vasopressors.

Dale DeLude
P.I. Specialist
Advocate Condell Medical Center
801 S. Milwaukee Ave.
Libertyville, IL 60048
Telephone:  847-990-5863
Fax:  847-573-4251
dale.del...@advocatehealth.com<mailto:dale.del...@advocatehealth.com>

This e-mail, and any attachments thereto, is intended only for use by the 
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From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Townsend, Sean, M.D.
Sent: Wednesday, October 21, 2015 5:16 PM
To: 'Prabhakar, Brenda'; 
sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org>
Subject: Re: [Sepsis Groups] DNR, DNI, and comfort care with regards to the 
septic shock requirements

As regards your questions, yes if they are refusing a required intervention 
then they may be excluded (vasopressors).

With respect to the later question on DNI patients, I think to get to use the 
comfort measures exclusion I would document that rather than being intubated 
the patient prefers comfort strategies and thus trigger the exclusion.

Sean R. Townsend, M.D.
Vice President of Quality & Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA  94115
email towns...@sutterhealth.org<mailto:towns...@sutterhealth.org>
office (415) 600-5770
fax (415) 600-1541

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Prabhakar, Brenda
Sent: Wednesday, October 21, 2015 4:50 AM
To: 
sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org>
Subject: [Sepsis Groups] DNR, DNI, and comfort care with regards to the septic 
shock requirements

Hello everyone.  Thank you all for you questions and answers online.  They've 
been very helpful.
My physicians are wondering how to handle those patients who have advanced 
directives but are not yet comfort care.

*   If they are refusing vasopressors, is it correct that they would NOT be 
included in the measure for septic shock with persistent hypotension?  They are 
refusing one the measure components to give vasopressors.
*   If they are a DNI (Do Not Intuba

Re: [Sepsis Groups] shock

[Townsend, Sean, M.D.]

It's the first choice.  You don't need to give 30 ml/kg before obtaining 
lactate if 4 to define shock.

On Oct 24, 2015, at 8:00 AM, 
"deborah.chambl...@hcahealthcare.com"
 
>
 wrote:

Ok, listserve friends….there is an ongoing debate here.  Is Septic Shock 
defined as hypotension in spite of fluid resuscitation OR lactate greater than 
4? Or is septic shock defined as hypotension in spite of fluid resuscitation or 
lactate greater than 4 after fluid resuscitation?

Our intensivists are saying septic shock is only septic shock if they are on 
vasopressors or the patient’s lactic acid remains greater than 4 after fluid 
resuscitation.

Thank you,
Debbie

Debbie Chambless, MSN, RN, ARNP-C
Sepsis Coordinator
Osceola Regional Medical Center
Kissimmee, Fl 34741
Office: 407-518-3949
Cell: 772-807-0525

~~Recognizing sepsis as a global enemy.  Hoping for global unity in finding a 
solution~~

[cid:image003.jpg@01D10CDD.487332F0]

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Re: [Sepsis Groups] severe sepsis determination

[Townsend, Sean, M.D.]

There may be cases that fall out of the measure as you are all describing.  
Falling out of the measure is not the end of the world (and treating clinicians 
for the most part do not understand the fallout, so treat accordingly).  
Improperly failing the measure is bad, improperly passing the measure is bad.

All that said, I do think if you expand your search for suspicion of infection 
to nursing notes which happen at greater frequency you can make a time of 
presentation.  This is a permissible strategy.

Sean R. Townsend, M.D.
Vice President of Quality & Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA  94115
email towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541


-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Wightman, Mary
Sent: Wednesday, October 21, 2015 6:19 AM
To: 'Clement, Joseph (DPH)'; Rona Capps; sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] severe sepsis determination

Good Day-

We have a similar concern & would greatly appreciate a definitive answer from 
CMS.  
Since we have not received a clear cut answer from Qnet after multiple 
inquiries, we continue to look into the chart for all 3 criterion met within a 
6 hour period.  Case abstraction is extremely time consuming; but, is leading 
to opportunities for improvement & education to staff.  
In addition, we are finding many cases excluded due to IV abx for more than 24 
hrs prior to severe sepsis met.

Take care-
Mary 

Mary Wightman, MAOM
Manager, Quality & Operations Improvement Wexner Medical Center Hospital East 
Hawthorne House, Room 113, 1492 East Broad Street, Columbus, OH, 43205
614-257-2821 Office / 614-257-2234 Fax
mary.dr...@osumc.edu
We are committed to improving people’s lives through personalized health care. 
P  Please consider the environment before printing this e-mail
 
This information is confidential per Ohio Revised Code Sec 2305.25 and may not 
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notified that any dissemination, distribution or copying of this communication 
is strictly prohibited. 

-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Clement, Joseph (DPH)
Sent: Monday, October 19, 2015 3:35 PM
To: Rona Capps; sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] severe sepsis determination

Thanks for asking this questions - I have a similar one.  My read of the 
specification manual suggests to me that when using the 3-criteria method 
(meaning there was no documentation of severe sepsis by an MD/NP/PA), you need 
to have all 3 within a six hour period.  In the instance you gave below, if 
this is truly the only relevant data points that exist, then I would say that 
this patient does not have a Severe Sepsis Time and would fall out of the 
measure.

A related question is  for our presentations on a medsurg unit after admission. 
 MD progress notes are for the most part daily.  If we already have infection 
documented on a daily progress note, do we also need to find it documented 
again within that six hour window?  My read says yes, but I want to make sure 
I'm correct.

Thanks

Joe

Joseph Clement, MS, RN, CCNS
Clinical Nurse Specialist
San Francisco General Hospital
ph: 415206-6174
pg: 415 327-0220


From: Sepsisgroups  on behalf of 
Rona Capps 
Sent: Friday, October 16, 2015 11:20 AM
To: sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] severe sepsis determination

Please help. The Spec manual states that criteria must be found within 6 hours 
of each other to qualify for the severe sepsis diagnosis but many charts that I 
review are delayed in one thing or another. Current chart example that meets 
specific criteria:
9-22 @ 2121 lactate =2.1organ dys
9-22 @ 2255 HR = 111SIR
9-23 @ 1600 documentation of pneumonia  Infection
9-24 @ 0550 WBC = 14.3  SIR
9-24 @ 0832 RR = 24 SIR
As you can see the time span is great.
2 SIRs, Infection and organ dysfunction all met at 9-24 @ 0550 but did not take 
place within 6 hours of each other but rather days. Severe sepsis is NOT 
documented by physician. Do I say NO to severe sepsis question?
Thank you
Rona Capps, RN
Sepsis/VTE/Meaningful Use Quality Coordinator Jackson Hospital Montgomery, AL  
36116 cap...@jackson.org


*
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Re: [Sepsis Groups] Documentation source for suspicion of clinical infection

[Townsend, Sean, M.D.]

Yes, RN documentation of suspected infection is acceptable.  I'm pretty 
concerned that hospitals do not know this.  The language in the specs did not 
help much. I believe it refers to a variety of sources then says ",or 
MD/APN/PA" documentation.  The "or" was not meant to limit documentation to 
those sources rather list them as an option.  The right thing would have been 
to say "or" RN documentation as well.

As proof, if you visit qnet and review screening questions several responses by 
CMS indicate RN screening and documentation of infection is acceptable.  These 
are official CMS answers to queries.

Finally because this question is recurrent, we have updated in the yet to be 
released specs version 5.1 that, "Nursing documentation referencing an 
infection, suspected infection, or current treatment of an infection is 
acceptable."

Rapid uptake and acceptance of this standard is critical because MD 
documentation will not be timely.

On Oct 21, 2015, at 3:42 AM, Delude, Dale 
<dale.del...@advocatehealth.com<mailto:dale.del...@advocatehealth.com>> wrote:

Dr. Townsend,

Are you saying that nursing notes may be utilized to determine infection or 
suspicion of infection for abstraction?

Dale DeLude
P.I. Specialist
Advocate Condell Medical Center
801 S. Milwaukee Ave.
Libertyville, IL 60048
Telephone:  847-990-5863
Fax:  847-573-4251
dale.del...@advocatehealth.com<mailto:dale.del...@advocatehealth.com>

This e-mail, and any attachments thereto, is intended only for use by the 
addressee(s) named herein and may contain legally privileged and/or 
confidential information. If you are not the intended recipient of this e-mail 
(or the person responsible for delivering this document to the intended 
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prohibited. If you have received this e-mail in error, please respond to the 
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of any e-mail and any printout thereof.



-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Townsend, Sean, M.D.
Sent: Sunday, October 18, 2015 9:32 AM
To: Karen Young
Cc: 
sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org>
Subject: Re: [Sepsis Groups] Documentation source for suspicion of clinical 
infection

Yes, you need to look at all notes from nursing as well.  Simply relying on md 
documentation will be too late.

On Oct 18, 2015, at 7:08 AM, Karen Young 
<karen_yo...@valleymed.org<mailto:karen_yo...@valleymed.org><mailto:karen_yo...@valleymed.org>>
 wrote:

Please share what data source your organization is using for a date/time stamp 
for suspicion of clinical source of infection.  Are you using an RN progress 
note time? How specific about suspicion are you requiring in documentation? 
Have you standardized the question to a yes or no?

Our ED physicians say their Note Time does not reflect suspicion time as a 
Severe Sepsis criteria fulfilled, because progress notes are opened before labs 
are resulted or exams performed.  File Time of the note is several hours after 
the care is delivered and using that time admittedly would not drive early 
treatment.
>From where are you taking a date/time stamp for physician diagnosis or 
>suspicion?

Karen Young RN CPHQ
QI Specialist
Valley Medical Center
Renton WA 98055
425-228-3440 ext 5963
karen_yo...@valleymed.org<mailto:karen_yo...@valleymed.org><mailto:karen_yo...@valleymed.org>


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Re: [Sepsis Groups] DNR, DNI, and comfort care with regards to the septic shock requirements

[Townsend, Sean, M.D.]

As regards your questions, yes if they are refusing a required intervention 
then they may be excluded (vasopressors).

With respect to the later question on DNI patients, I think to get to use the 
comfort measures exclusion I would document that rather than being intubated 
the patient prefers comfort strategies and thus trigger the exclusion.

Sean R. Townsend, M.D.
Vice President of Quality & Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA  94115
email towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Prabhakar, Brenda
Sent: Wednesday, October 21, 2015 4:50 AM
To: sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] DNR, DNI, and comfort care with regards to the septic 
shock requirements

Hello everyone.  Thank you all for you questions and answers online.  They've 
been very helpful.
My physicians are wondering how to handle those patients who have advanced 
directives but are not yet comfort care.

 *   If they are refusing vasopressors, is it correct that they would NOT be 
included in the measure for septic shock with persistent hypotension?  They are 
refusing one the measure components to give vasopressors.
 *   If they are a DNI (Do Not Intubate), often times the physicians are 
concerned they could put their patients into CHF if they order the full 30ml/kg 
fluid bolus without the ability to intubate if required.  I've read the prior 
lively discussions about fluid resuscitation and the lack of data reporting any 
harm from administering the boluses, but Dr. Townsend also brought up the good 
point that intubation isn't always an adverse outcome.
Any insight with how to manage these patients would be greatly appreciated.

Thank you,
Brenda Prabhakar RN BSN
Sepsis Steering Committee Co-Chair
Doylestown Hospital
Doylestown, PA
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Re: [Sepsis Groups] severe sepsis determination

[Townsend, Sean, M.D.]

Probably you say no, but if you expand the pneumonia search to things like 
nursing notes for suspicion of infection, not a formal diagnosis, I bet you can 
get an earlier time.

However, if they don't overlap, no big deal -- you are only excluding a chart, 
not failing the measure.

On Oct 18, 2015, at 7:08 AM, Rona Capps  wrote:

Please help. The Spec manual states that criteria must be found within 6 hours 
of each other to qualify for the severe sepsis diagnosis but many charts that I 
review are delayed in one thing or another. Current chart example that meets 
specific criteria: 
9-22 @ 2121 lactate =2.1organ dys
9-22 @ 2255 HR = 111SIR
9-23 @ 1600 documentation of pneumoniaInfection
9-24 @ 0550 WBC = 14.3SIR
9-24 @ 0832 RR = 24SIR
As you can see the time span is great.  
2 SIRs, Infection and organ dysfunction all met at 9-24 @ 0550 but did not take 
place within 6 hours of each other but rather days. Severe sepsis is NOT 
documented by physician. Do I say NO to severe sepsis question?
Thank you
Rona Capps, RN
Sepsis/VTE/Meaningful Use Quality Coordinator Jackson Hospital
Montgomery, AL  36116
cap...@jackson.org


*
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Re: [Sepsis Groups] Clock and Fluids

[Townsend, Sean, M.D.]

I wish to advise the group we have devised a fix for this problem that will be 
released in version 5.1 of the specs.  This version is effective for discharges 
7/2016.  I will not detail the matter here, but it provides an earlier 
verification of 30ml/kg delivered in the algorithm.  If that is failed, the 
measure is failed so one may not pass with under-resuscitating a patient.

On Oct 8, 2015, at 3:37 PM, Townsend, Sean, M.D. 
<towns...@sutterhealth.org<mailto:towns...@sutterhealth.org>> wrote:

This question initially brought by Cynthia and now carried forward by Kathy has 
been eye opening and I am working to see how we may rectify the apparent 
dilemma.  What I can say in the meantime is


a)  In the scenario below, and for the present set of specifications, the 
physician documented shock time would stand, unfortunately as the shock clock 
start time.  (And that late documentation is probably not helpful either, 
putting earlier performed elements at being at risk of outside abstraction time 
limits.)

b)  While as individuals involved with abstraction of charts (or just 
voracious readers of dense measure material) you have caught a problem which is 
not obvious to providers – that if the full infusion of fluids has not occurred 
a shock clock start time cannot be determined (unless the LIP documents shock). 
 It appears that patient would only qualify for severe sepsis start time and 
not the rest of the measure requirements in the present set of specifications.  
I would ask you to keep in mind though that clinicians are very unlikely to 
understand this and while it is being remedied, that ignorance is probably a 
good thing.  In other words, a provider will know only that they are supposed 
to give 30 ml/kg of fluids, it is extraordinarily unlikely they will be aware 
that a “glitch” in the measure specification could permit them to willfully 
under-resuscitate a patient and pass the measure (for severe sepsis and never 
reach shock).  My guess is that SEP-1 will still perform as intended – to get 
providers cognizant of giving the right amount of fluids.  The inner workings 
of the measurement will remain blind to many of them allowing an opportunity to 
resolve this issue.

c)  There is a solution to this … we will figure out a way to remedy it.  
It will come in a future specification and can’t take effect likely for many 
months to come.

Sean R. Townsend, M.D.
Vice President of Quality & Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA  94115
email towns...@sutterhealth.org<mailto:towns...@sutterhealth.org>
office (415) 600-5770
fax (415) 600-1541

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Cynthia Wells
Sent: Monday, October 05, 2015 4:29 PM
To: Nelson, Kathy
Cc: 
sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org>
Subject: Re: [Sepsis Groups] Clock and Fluids

I agree as well with the comments below.  It is odd that if the patient doesn't 
have lactate >4 and no documentation of septic shock in the case where didn't 
order enough fluids the case would be excluded from 6 hour instead of outlier. 
The fluids and antibiotics are the major components of saving lives.


Cindy Wells

Sent from my iPhone

On Oct 5, 2015, at 7:04 PM, Nelson, Kathy 
<kathy.nel...@advocatehealth.com<mailto:kathy.nel...@advocatehealth.com>> wrote:

My understanding of the measure definition and guidelines brings me to similar 
answers to these questions:



Questions:

1. The patient develops severe sepsis at 0300 and BP drops to 80/40 at 0600.  
30ml/kg was given and completed at 0730.  BP 60/40 at 0830.  Is the 
presentation time 0830?  YES (my thoughts: agree, YES, based on the septic 
shock criterion that there is persistent hypotension in the one hour following 
fluid administration)



2. If the presentation time is 0830, then we have already completed the 3 hour 
bundle prior to presentation and have until 1430 to complete the 6 hour bundle, 
correct?  YES (my thoughts: agree, YES, ASSUMING you took an initial Lactate, 
obtained a blood culture, administered antibiotics in the 3 hours following 
severe sepsis presentation time)



3. What would presentation time be if the patient did not receive the full 
30ml/kg?  BP 80/40 0600, received 20ml/kg at 0730 and Levophed gtt was 
initiated at 0830 for BP 60/40.  MD documents septic shock at 1500.   Is the 
presentation time 0830 with the hypotension following fluids or 1500 when the 
MD documents septic shock since the full amount of fluids were not received to 
determine if the patient truly had persistent hypotension?   MYUNDERSTANDING IS 
THAT BECAUSE 30 ML/KG WERE NOT GIVEN, YOU CANNOT USE PERSISITANT HYPOTENSION AS 
A CRITERIA AND SO DOCUMENTATION OF SEPTIC SHOCK WOULD BE REQUIRED.  SO IN THIS 
INSTANCE, 1500 WOULD BE YOUR START TIME. (my thoughts:



Please see QNET Q 150527-44, which states:

Re: [Sepsis Groups] Clock and Fluids

[Townsend, Sean, M.D.]

Here's why the reasoning is not circular for every case.  It had me stuck for a 
while too, so I know this will help.  You have to remember there are 3 ways to 
get to the time of presentation with septic shock:

1) the patient has lactate > 4 at a certain time;

2) a timed provider note says so;

3) the patient presents with initial hypotension, they receive 30 ml/kg of 
crystalloid, and after the full amount of fluid is infused there is recurrent 
hypotension at a specific time -- that time of recurrent hypotension is the 
presentation time.

You see scenario three and say:

 "30 cc/kg is required to be administered within the first 3 hours of 
presentation of septic shock
…however…
Septic shock isn’t determined until 30 cc/kg is administered and the patient 
remains hypotensive."

But actually that reasoning applies to the first two cases.  In the first two 
cases, and especially the lactate case, the septic shock presentation time is 
probably before the fluid is administered.  Once lactate returns at 4 that 
triggers the bolus.

In the instance of persistent hypotension (case 3) as the way to start the 
clock, all the 30 ml/kg of fluid has to go in first before I can even look to 
see if hypotension is recurrent.  Then, if present that time is the shock clock 
start time.  Because all that fluid went in before you look for that start 
time, you are permitted to use the preceding 3 hours to count toward the 
delivery of the 30 ml/kg.

Thus, it's not circular, it's just that you can't define a start time until 
that much fluid has gone in.

So, your choice to start the clock after 20 ml/kg goes in and count the rest 
afterwards will not meet the measure for case 3.  You must infuse the full 30 
ml/kg first.  To be more specific, when you say "Guided by the fact that the 30 
cc/kg is never mentioned in the CMS algorithm until *after* septic shock is 
determined to be present, we..." you are incorrect.  In case #3 above its just 
the opposite -- septic shock start time is never determined until after the 
30ml/kg is infused (and it can be "within 3 hours" because credit is assigned 
for fluid given 3 hours antecedent to the start time).

Sean



On Oct 9, 2015, at 1:22 PM, Myran, Robin 
<robin.my...@hoag.org<mailto:robin.my...@hoag.org>> wrote:

Dr. Townsend –

First of all, thank you again for your patience with all of our questions and 
for taking the time to share your expertise.

Your conversation below covers the part of the SEP-1 measure that has bothered 
me from the very beginning:

30 cc/kg is required to be administered within the first 3 hours of 
presentation of septic shock
…however…
Septic shock isn’t determined until 30 cc/kg is administered and the patient 
remains hypotensive.

To me, this is circular reasoning.

Guided by the fact that the 30 cc/kg is never mentioned in the CMS algorithm 
until *after* septic shock is determined to be present, we interpret it as 
follows:
Patient comes in hypotensive, we give a fluid bolus (undefined by CMS, but for 
our protocol usually 20 cc/kg). If they don’t respond to that initial bolus, 
then they are determined to be in “septic shock” and we make sure they get a 
total of 30 cc/kg by the 3rd hour and that we meet the 6 hour goals.

Your thoughts?


Robin Myran, MSN, RN, PCCN
Sepsis Coordinator
Hoag Memorial Hospital Presbyterian
One Hoag Drive
Newport Beach, CA 92658
Office: (949) 764-4588
Fax: (949) 764-5387
Cell: (949) 300-9137
robin.my...@hoag.org<mailto:jodi.caggi...@hoag.org>








From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Townsend, Sean, M.D.
Sent: Tuesday, October 06, 2015 12:34 PM
To: 'Cynthia Wells'; Nelson, Kathy
Cc: 
sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org>
Subject: Re: [Sepsis Groups] Clock and Fluids

This question initially brought by Cynthia and now carried forward by Kathy has 
been eye opening and I am working to see how we may rectify the apparent 
dilemma.  What I can say in the meantime is


a)  In the scenario below, and for the present set of specifications, the 
physician documented shock time would stand, unfortunately as the shock clock 
start time.  (And that late documentation is probably not helpful either, 
putting earlier performed elements at being at risk of outside abstraction time 
limits.)

b)  While as individuals involved with abstraction of charts (or just 
voracious readers of dense measure material) you have caught a problem which is 
not obvious to providers – that if the full infusion of fluids has not occurred 
a shock clock start time cannot be determined (unless the LIP documents shock). 
 It appears that patient would only qualify for severe sepsis start time and 
not the rest of the measure requirements in the present set of specifications.  
I would ask you to keep in mind though that clinicians are very unlikely to 
understand this and while it is

Re: [Sepsis Groups] Determining Septic Shock PRESENT -if 30ml/kg not given

[Townsend, Sean, M.D.]

I do think what I have typed is exactly where the algorithm leads you.  I am 
suggesting that in this one instance the algorithm deviates from what we 
intended.  I think my logic is the logic of the algorithm.

On Oct 9, 2015, at 6:13 AM, Ryan Arnold 
<ryanarnol...@mac.com<mailto:ryanarnol...@mac.com>> wrote:

Sean,
Thanks for the quick response, while I understand the intention may not be as 
is currently written, all hospitals are looking to these published definitions 
to guide our policy. Do you have specific examples within the CMS data 
dictionary to which you can refer? We are all left what is published and 
released by CMS, and where we all have our ideas about what the best care 
maybe, we recognize the need to meet the CMS goals as the minimal care.  My 
comments are below to your reply:

On Oct 8, 2015, at 9:34 PM, Townsend, Sean, M.D. 
<towns...@sutterhealth.org<mailto:towns...@sutterhealth.org>> wrote:

Hi Ryan, I think you do have it incorrect.  Answering you in reverse, if 
lactate is greater than 4, that's shock at that point provided all the other 
elements of severe sepsis exist.  There is no assessment of a lactate level 
after some fluids are given to ensure it remains greater than 4 after those 
fluids.  Those patients do qualify for the fluid challenge element however, 
which does not assess volume, and they also qualify for the crystalloid fluid 
administered element, so the total volume is assessed.

The metric reads: “tissue hypoperfusion persists after crystalloid fluid 
administration, evidenced by SBP < 90, MAP <65, SBP decrease by 40, or lactate 
>4”. Do you have a source that you are referring to that infers any lactate ≥ 4 
defines shock?

Operationally, I can tell you we are using any lactate ≥4 to trigger the septic 
shock workflow, however, per CMS definitions, if the subsequent lactate after 
fluid administration is ≤4, they are severe sepsis only (assuming normal bp, 
etc).


As regards the case of a patient who would be qualifying for septic shock on 
the basis of persistent hypotension however, that patient has to pass the fluid 
challenge element, which does not specify a volume, then also the crystalloid 
fluid administered element which does contain a volume.

The patient who develops hypotension after the unspecified fluid volume is now 
a septic shock patient, and then requires the 30 cc/kg. I can not infer intent, 
but the guidelines clearly state that the preferred data source for the timing 
of severe sepsis is physician/APN/PA documentation, taking precedence over hard 
signs. Missing the 30 cc/kg mark does not downgrade their diagnosis, it means 
you didn’t meet the treatment metric.

The time of presentation has to be the time of the next episode of hypotension 
in the hour after the full 30 ml/kg is infused.

I do not think this is correct. When you go through the multitude of case 
examples they provide, there is not one I am aware of that waited until the 
full 30 cc/kg bolus was infused before declaring septic shock.

Also, on page 1-162, they define in the “Notes for Abstraction” that “A fluid 
challenge is the rapid infusion of 0.9% normal saline or full strength Lactated 
Ringers, typically 500 mL in fifteen minutes or 1000 mL in 30 minutes.” This is 
the guidance given on defining the fluid challenge to hypotension. Seems 
somewhat arbitrary but is not vague.

Thus, if that patient ends up only getting 29 ml/kg, and is hypotensive in the 
hour after that infusion, I can never define a septic shock start time -- 
unless the md has documented a time in their note (just because they say so) or 
if lactate returns greater than 4.  This means the patient will pass the severe 
sepsis with hypotension metric and never qualify for the septic shock 
components of the measure.

I think there is a mis-read here and I agree with you that a persistent 
hypotensive patient after 29 ml/kg is a septic shock patient, regardless. 
However, you are referring to the recommended treatment once septic shock is 
diagnosed, not to define it. Again, there is no fluid administration required 
by CMS for severe sepsis patients.

Thanks
Ryan


This is not what was intended.

The most likely solution is a future version of the specs will have to have the 
fluid challenge element specify a volume. If that were the case, the measure 
would have failed for giving 29 ml/kg.

Sean

On Oct 8, 2015, at 6:10 PM, Ryan Arnold 
<ryanarnol...@mac.com<mailto:ryanarnol...@mac.com><mailto:ryanarnol...@mac.com>>
 wrote:

Sean,
I am reading the amount of fluids in order to treat the initial hypotension 
episode differently differently than you are.

My source is the “Specifications Manual for the National Hospital Inpatient 
Quality Measures: Discharges 10-1-15 through 6-30-16” in which all new measures 
of SEP-1 are defined. page 1-331.

Per these metric definitions, septic shock is present if “tissue hypoperfusion 
persists after crystallo

Re: [Sepsis Groups] Determining Septic Shock PRESENT -if 30ml/kg not given

[Townsend, Sean, M.D.]

Hi Ryan, I think you do have it incorrect.  Answering you in reverse, if 
lactate is greater than 4, that's shock at that point provided all the other 
elements of severe sepsis exist.  There is no assessment of a lactate level 
after some fluids are given to ensure it remains greater than 4 after those 
fluids.  Those patients do qualify for the fluid challenge element however, 
which does not assess volume, and they also qualify for the crystalloid fluid 
administered element, so the total volume is assessed.

As regards the case of a patient who would be qualifying for septic shock on 
the basis of persistent hypotension however, that patient has to pass the fluid 
challenge element, which does not specify a volume, then also the crystalloid 
fluid administered element which does contain a volume.  The time of 
presentation has to be the time of the next episode of hypotension in the hour 
after the full 30 ml/kg is infused.  Thus, if that patient ends up only getting 
29 ml/kg, and is hypotensive in the hour after that infusion, I can never 
define a septic shock start time -- unless the md has documented a time in 
their note (just because they say so) or if lactate returns greater than 4.  
This means the patient will pass the severe sepsis with hypotension metric and 
never qualify for the septic shock components of the measure.

This is not what was intended.

The most likely solution is a future version of the specs will have to have the 
fluid challenge element specify a volume. If that were the case, the measure 
would have failed for giving 29 ml/kg.

Sean

On Oct 8, 2015, at 6:10 PM, Ryan Arnold 
<ryanarnol...@mac.com<mailto:ryanarnol...@mac.com>> wrote:

Sean,
I am reading the amount of fluids in order to treat the initial hypotension 
episode differently differently than you are.

My source is the “Specifications Manual for the National Hospital Inpatient 
Quality Measures: Discharges 10-1-15 through 6-30-16” in which all new measures 
of SEP-1 are defined. page 1-331.

Per these metric definitions, septic shock is present if “tissue hypoperfusion 
persists after crystalloid fluid administration, evidenced by SBP < 90, MAP 
<65, SBP decrease by 40, or lactate >4”.

I am unaware of any further definition that specifies what volume has to be 
administered in order to define the presence of septic shock. For severe 
sepsis, there is no mandated fluid administration. If hypotension is the 
qualifying organ dysfunction for severe sepsis, they need a fluid challenge, 
but not a 30 ml/kg challenge per se, at least not require per CMS. They need 
“fluid”, amount unspecified.

Once the patient meets septic shock criteria, after meeting criteria, then they 
need 30 ml/kg administered within 3 hours for the metric.
The patient, to my read, does not require 30 ml/kg before septic shock can be 
diagnosed.

Technically, per the strict interpretation of this section, if lactate is >4 
after IVF, then the patient meets septic shock. A lactate measured without any 
fluid resuscitation ≥ 4 should not then meet septic shock criteria unless it 
remains > 4 after fluid, correct?

Are there documents from CMS that better specify this differently than I have 
understood?

Ryan



On Oct 2, 2015, at 4:31 PM, Townsend, Sean, M.D. 
<towns...@sutterhealth.org<mailto:towns...@sutterhealth.org>> wrote:

I would say that is incorrect.  The 30 ml/kg is triggered by the "initial 
hypotension."  Initial hypotension requires the fluid administration.  Thus you 
would fail for not giving fluids for initial hypotension.

It's only shock if you become recurrently hypotensive after fluids.



On Oct 2, 2015, at 12:59 PM, Cynthia Wells 
<cynthia.we...@steward.org<mailto:cynthia.we...@steward.org>> wrote:

Hello,

It is my interpretation from the CMS algorithm,
In the scenario below the patient would not fail fluids because they would be 
excluded from that component.  In the algorithm you would have to answer no to 
shock present (because enough fluid was not given) and the case would not make 
it to the fluid step. It looks like in the algorithm first you determine if 
shock is present and then evaluate fluids. It seems backwards.

Correct? It definitely does not make sense.

Cindy

Cynthia Wells
Steward Health Care
Director of Clinical Performance Analytics
(508) 404-8647


-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Townsend, Sean, M.D.
Sent: Tuesday, September 29, 2015 8:20 PM
To: Jennifer L Halligan [SJGH]
Cc: 
sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org>
Subject: Re: [Sepsis Groups] Determining Septic Shock PRESENT -if 30ml/kg not 
given

In thinking about this more, although it feels clinically odd, by the CMS 
definition we cannot formally declare shock.  While I agree any clinician after 
a prolonged period of hypotension even if under-resuscitate

Re: [Sepsis Groups] coding

[Townsend, Sean, M.D.]

You have it correct: if the patient meets criteria for septic shock with SIRS 
criteria, Sepsis, and Severe Sepsis and has a lactic acid >4, that patient will 
code as septic shock even if the provider does not document it.

Sean R. Townsend, M.D.
Vice President of Quality & Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA  94115
email towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of deborah.chambl...@hcahealthcare.com
Sent: Tuesday, October 06, 2015 9:04 AM
To: Sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] coding

So, just need clarificationif the patient meets criteria for septic shock 
with SIRS criteria, Sepsis, and Severe Sepsis and has a lactic acid >4, that 
patient will code as septic shock even if the provider does not document it??  
The guidelines say septic shock is hypotension unresponsive to fluids AND/OR 
lactic acid >4.  But, many of our physicians are resistant to the lactic acid, 
stating it can be elevated for many other reasons besides sepsis.

Thank you,
Debbie

Debbie Chambless, MSN, RN, ARNP-C
Sepsis Coordinator
Osceola Regional Medical Center
Kissimmee, Fl 34741
Office: 407-518-3949
Cell: 772-807-0525

~~Recognizing sepsis as a global enemy.  Hoping for global unity in finding a 
solution~~

[cid:image001.jpg@01D10033.8B8227B0]

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Re: [Sepsis Groups] Rate of Infusion in Fluid Orders and PlasmaLyte use

[Townsend, Sean, M.D.]

I will answer the second question because I know the answer.  The first one I'm 
sure the folks out here can be helpful about.

It was simply based on the fact that common things are common and the studies 
in septic shock (Rivers, ARISE, ProCESS, ProMISE) used common crystalloids.  
Frankly, those of us involved in drafting the measure all have very little 
experience with some of the other suggestions that have come up and remain 
unconvinced that landmark papers tell us there is a great advantage to using 
them.  Thus, they weren't even considered.  I know you may take issue with 
decision, and perhaps it can be revisited if there is a compelling reason, but 
it seems to amount to little mortality advantage in the scheme of things.


From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Clement, Joseph (DPH)
Sent: Tuesday, October 06, 2015 8:08 AM
To: sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] Rate of Infusion in Fluid Orders and PlasmaLyte use


Hello,



I have a couple of questions about Fluids:



[]  My understanding is there is a requirement for the rate (or duration) of 
fluid administration to be present in the order in order to be counted against 
the 30 ml/kg volume.  I think I've heard others say, however, that if there is 
clear documentation of the actual rate of administration (for example, in 
nursing documentation such as a MAR or a flowsheet), then this is not required. 
Does anybody know for sure?



[] I understand that plasmaLyte can not be counted against the 30ml/kg volume 
(though Lactated Ringers can).  Is anybody aware of a rationale for this?



Thank you,



Joe




Joseph Clement, MS, RN, CCNS
Clinical Nurse Specialist
San Francisco General Hospital
ph: 415206-6174
pg: 415 327-0220
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Re: [Sepsis Groups] Determining Septic Shock PRESENT -if 30ml/kg not given

[Townsend, Sean, M.D.]

I would say that is incorrect.  The 30 ml/kg is triggered by the "initial 
hypotension."  Initial hypotension requires the fluid administration.  Thus you 
would fail for not giving fluids for initial hypotension.

It's only shock if you become recurrently hypotensive after fluids.



On Oct 2, 2015, at 12:59 PM, Cynthia Wells <cynthia.we...@steward.org> wrote:

Hello, 

It is my interpretation from the CMS algorithm, 
In the scenario below the patient would not fail fluids because they would be 
excluded from that component.  In the algorithm you would have to answer no to 
shock present (because enough fluid was not given) and the case would not make 
it to the fluid step. It looks like in the algorithm first you determine if 
shock is present and then evaluate fluids. It seems backwards.

Correct? It definitely does not make sense.

Cindy

Cynthia Wells
Steward Health Care
Director of Clinical Performance Analytics
(508) 404-8647


-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Townsend, Sean, M.D.
Sent: Tuesday, September 29, 2015 8:20 PM
To: Jennifer L Halligan [SJGH]
Cc: sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] Determining Septic Shock PRESENT -if 30ml/kg not 
given

In thinking about this more, although it feels clinically odd, by the CMS 
definition we cannot formally declare shock.  While I agree any clinician after 
a prolonged period of hypotension even if under-resuscitated would eventually 
call that shock (and it probably would be given prolonged hypoperfusion) for 
purposes of this measure it's not shock.

Of course it doesn't clearly matter however because the measure will be failed 
for not giving the fluid.  So it's a failure in any event.  It's just that the 
bucket it would be assigned to is a severe sepsis failure rather than shock if 
you had the ability to parse these out.



On Sep 29, 2015, at 2:34 PM, Jennifer L Halligan [SJGH] 
<jhalli...@sjgh.org<mailto:jhalli...@sjgh.org>> wrote:

Hi,
This question is for those abstractors out there (or maybe Dr. Townsend knows 
the answer), Am I correct to say that I cannot determine using "clinical 
criteria" if Septic Shock was PRESENT (septic shock present data element) if 
the crystalloids given did not total 30ml/kg needed? In my scenario the pt 
weight is 68.8 kg. (requires 2064 ml to meet 30ml/kg). Pt received 2 liters NS 
and in the hour after receiving this 2 L the BP did not respond (remained less 
than 90/map<65). In this scenario I can only use MD documentation of septic 
shock present, correct???
Thank you!!

Jennifer Halligan, RN
Quality Review Nurse
San Joaquin General Hospital
Tel: 209-468-7471
Fax: 209-468-7011

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Re: [Sepsis Groups] Determining Septic Shock PRESENT -if 30ml/kg not given

[Townsend, Sean, M.D.]

That's a loophole I hadn't thought of and an interesting problem...

I'll have to do some consulting.



On Sep 29, 2015, at 2:34 PM, Jennifer L Halligan [SJGH] 
> wrote:

Hi,
This question is for those abstractors out there (or maybe Dr. Townsend knows 
the answer),
Am I correct to say that I cannot determine using "clinical criteria" if Septic 
Shock was PRESENT (septic shock present data element) if the crystalloids given 
did not total 30ml/kg needed? In my scenario the pt weight is 68.8 kg. 
(requires 2064 ml to meet 30ml/kg). Pt received 2 liters NS and in the hour 
after receiving this 2 L the BP did not respond (remained less than 90/map<65). 
In this scenario I can only use MD documentation of septic shock present, 
correct???
Thank you!!

Jennifer Halligan, RN
Quality Review Nurse
San Joaquin General Hospital
Tel: 209-468-7471
Fax: 209-468-7011

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Re: [Sepsis Groups] Shock clock

[Townsend, Sean, M.D.]

Clock starts at 20:20.

The presumption should be new or worsened renal failure. If that's not 
explicit, it should be and I can request the change.



On Sep 29, 2015, at 2:33 PM, Pesek, Elizabeth 
 wrote:

With the example of SIRs+, documented infection, and then a lactate >2 or 4, OR 
any other Lab showing organ dysfunction, does the clock start with the last 
piece of the puzzle:
Example:
2 SIRs + at triage time =  2000
Lactate >2 OR any other lab [Creatinine 2.0 or >, MAP <65, Bilirubin >2, INR 
>1.5] at 2015
Doctor note indicating infection at 2020

Does the clock start at 2020?

Another question I have: what if the patient has Chronic renal failure, is the 
Creatinine thrown out as organ dysfunction? Is there a rule or guideline to 
follow in that instance, that ANOTHER organ must show signs of ACUTE 
dysfunction?

Betsy Pesek MN, BSN, RN, CCRN, CPHQ


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Sent: Saturday, September 26, 2015 4:46 AM
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Subject: Sepsisgroups Digest, Vol 172, Issue 8

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Today's Topics:

1. Re: Shock clock (CARIANN M DAHLQUIST)
2. Physician/APN/PA Assessment (gayle.por...@hcahealthcare.com)
3. Re: stroke volume index (Kramer, George C.)


--

Message: 1
Date: Fri, 25 Sep 2015 14:13:07 -0500
From: "CARIANN M DAHLQUIST" 
To: 
Subject: Re: [Sepsis Groups] Shock clock
Message-ID: <560556730268000fd...@gwmail.altru.org>
Content-Type: text/plain; charset="utf-8"




Just for clarification purposes-

A patient comes in at 2000 with SIRS criteria + documented pneumonia + lactate 
level of 5.47 = severe sepsis, however wouldn't this also be the time clock for 
the septic shock due to the lactate level > 4? I was thinking that both severe 
sepsis and septic shock time clocks would had started at the same time due to 
the lactate level.
Thanks,

CariAnn






CariAnn Dahlquist RN

Quality Management

Altru Health System | Grand Forks, ND

701.780.5339 phone | 701.780.1942 fax | cdahlqu...@altru.org ( 
mailto:lhelle...@altru.org)

>>> "Jennifer L Halligan [SJGH]"  9/23/2015 1:42 PM

Hi Dr. Townsend,

I completely understand now the CMS SEP-1 measure ?shock clock? time zero 
starts when the you have tissue hypoperfusion, evidenced by either initial 
lactate > 4 or persistent hypotension in the hour after crystalloids fluids 
given. Am I the only one that was totally mixed up thinking the shock clock 
started with severe sepsis with hypotension or lactate greater than 4? I feel a 
little foolish as I posted a few things. I am now cleared up but just wondering 
if you can help explain if there was/is a difference at all with how the SSC 
did ?shock clock time zero? and how CMS is doing shock clock time zero.
Thank you so much for all your hard work!

Jennifer Halligan, RN
Quality Review Nurse
San Joaquin General Hospital
Tel: 209-468-7471
Fax: 209-468-7011


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Re: [Sepsis Groups] Physician/ANP/PA Assessment

[Townsend, Sean, M.D.]

Gayle, my comments are not directed at just your situation, but at this issue 
in general.  So here it goes:

Please don't take this the wrong way, but ask those docs who protest if at 
their next full check-up if it would be okay if the nurse in the office did the 
exam, instead of their internist.

Or, you might ask them if they feel the bedside nurse would see significance to 
even report the finding of a fixed split S2 (if he noticed it) in the setting 
of new mild upper extremity swelling (if he noticed it) after IJ central line 
placement (on the same side) just a few hours earlier.  

<>

These guys and gals went to med school and did residency and fellowship for a 
reason.  

We do not always need to resort to the lowest common denominator in care -- 
i.e. if there's no evidence that a doc does an exam in a critically ill person 
better than a nurse, use a nurse.  Why not frame it the other way -- if there's 
no evidence a nurse can do it as well as a doctor, use a doctor until such 
evidence emerges.

It's extraordinarily hard to have sympathy for docs who hitherto would have had 
to place central lines in patients and who are now only being asked to 
re-examine their patient.  I'll make them a deal -- I'll push for a change in 
the rules so that a nurse can do the exam if the doc is brave enough to tell 
the family and document that, "I will not be coming back in the first few hours 
of your mother's critical illness to see her.  The nurse will do everything and 
call me if there's a problem she detects and I'll fix by phone unless there's 
an emergency." Isn't critical illness an emergency for every patient and family?

Finally, if they want evidence that high levels of MD care are essential 
evidence based elements for septic shock patients in the first 6 hours of care, 
I recommend they review the ProCESS trial where 31 academic medical centers 
with 24 hour intensivists and ED attending a managed these patients in house 
for the first 6 hours of care (and beyond).  If you can't meet the standard of 
that trial for direct care by physician teams in the first 6 hours, then 
arguably you should not reap the benefits of that new trial which permits 
non-invasive monitoring via usual care. In other words, they are welcome to not 
see their patients and place central lines and have nurse driven protocols 
execute EGDT instead.  

Truthfully, these docs are asking for their cake (no lines to monitor and 
direct goal driven care) and to eat it too (no constant direct MD observation 
in the first 6 hours of care as in the new trials ProCESS, ProMISE, ARISE). 

There's no evidence basis to draw the line where they'd prefer, and so they are 
willing to err on the side of less safety.  

Doesn't seem like excellent practice to me.  CMS (and you as taxpayers) pay for 
the value you get by such lax standards in critical care.  CMS doesn't just 
measure evidence based care -- consider HCAHPS -- patient satisfaction is not 
evidence based, it's the right thing to do.  Here the right thing to do is both 
evidence based and upstanding.  

It's about making healthcare better in every way not just what can be proven 
with big trials or what can be asserted as maybe true when big trials don't 
fill in the gaps.

Sean


On Sep 23, 2015, at 7:27 AM, "gayle.por...@hcahealthcare.com" 
<gayle.por...@hcahealthcare.com> wrote:

Dr. Townsend,

Thank you for your response. While I understand the rationale of providing the 
best care for every patient every time, I am really looking for clinical 
evidence to defend that bedside physician assessments correlate with 
measureable, superior care; my physicians are asking for a reason besides, the 
opinion of CMS is that “it’s just better this way.”

Thank you for discussing this issue with me.

Respectfully,
Gayle

-Original Message-
From: Townsend, Sean, M.D. [mailto:towns...@sutterhealth.org] 
Sent: Tuesday, September 22, 2015 5:45 PM
To: Porter Gayle
Cc: sepsisgroups@lists.sepsisgroups.org
Subject: [EXTERNAL] Re: [Sepsis Groups] Physician/ANP/PA Assessment

The reason is that these patients are critically ill and the expectation of CMS 
is that patients accessing critical care services should be seen by a licensed 
provider skilled in assessing volume status and adequacy of perfusion.

The expectation as well is that only a licensed provider can issue orders to 
react to inadequate perfusion.  Relying on telephone communication and time 
delays associated with nursing report of information gathered second hand 
dilutes the information.  In essence, "seeing is believing" and direct 
observation is more likely to result in well considered orders to correct 
underlying hypoperfusion.

This is especially true in the early phases of a patient's critical illness 
where it is eminently reasonable that a patient be re-evaluated by trained eyes 
and hands.

Imagine families' expectations as well that a loved one in the 

Re: [Sepsis Groups] Sepsis Core Measure Follow Up

[Townsend, Sean, M.D.]

In discussing this issue, I always start from the premise that you should never 
do anything that you truly believe will cause actual harm to your patient, 
regardless of the CMS core measure.  That's just common sense.  I typically 
imagine this type of situation applying to a true reason not to resuscitate 
with 30 mL/kg  - critical aortic stenosis in a 90 year old frail female with 
chronic renal failure and peripheral vascular disease.  In that case, I'm 
willing to fail the core measure and not worry too much.

That said, I would ask you to consider that we have EXACTLY ZERO evidence that 
patients who receive the full 30ml/kg bolus suffer adverse consequences from 
any large trial in septic shock patients.

Moreover, mechanical ventilation is not necessarily an adverse outcome.  I have 
facetiously said before, "I'd rather be intubated than dead."  Sometimes 
patients will need to be ventilated to restore adequate perfusion.  If we do 
not intubate in those cases we risk further organ failure due to hypoperfusion. 
 Fear of the ventilator is largely overblown, especially when VAP rates are 
uniformly low across the country.  Typically if I gave someone too much fluid 
in the morning and they were intubated, I'd extubate  in the afternoon with a 
little furosemide.

Interesting data as far back as the Rivers trial suggest that patients who 
received more fluids in the EGDT arm of his trial sustained a LOWER rate of 
intubation than those who did not receive fluids EVEN WITH CONCOMMITANT CHF as 
a diagnosis.  In Rivers, 70.6% of patients were intubated by 72 hours, whereas 
those who received EGDT and significantly more fluid 55.6% of patients were 
intubated.  These data were statistically significant and it should be noted 
that 30.2% of controls had CHF and 36.7% in EGDT had CHF.  So despite having 
more CHF patients in the intervention group and receiving more fluids fewer 
patients were intubated.

Why?  The reason is that these patients are not presenting to you with their 
co-morbidity of renal failure or CHF as their primary problem - they are 
presenting with shock.  Shock needs resuscitation.

Consider that the American College of Surgeons Trauma guidelines suggest that 
Class III trauma patients have lost 1500-2000 mL of blood.  This represents a 
30-40% blood volume loss and results in symptoms we see in established septic 
shock: pulse greater than 120, detectably low blood pressure and pulse 
pressure, tachypnea 30-40 per minute and diminished urine output 5-15 mL/hour.  
The fluid replacement rule in this circumstance in trauma is to administer both 
crystalloid and fluid in a 3:1 ratio compared to the loss.

A Class II patient has lost 750-1500 mL or a 15-30% volume loss, blood pressure 
may remain normal, pulse pressure is decreased, respiratory rate 20-30 and the 
fluid replacement for those patients is crystalloid (no blood) in a 3:1 ratio.

Clearly the 3:1 ratio in trauma exceeds needs in septic shock because ongoing 
losses are less rapid, however even with these degrees of quantifiable initial 
volume loss (up to 2 liters in Class III patients), a 30 mL/kg bolus is 
essentially just replacing the loss that produced the observable physiology in 
an 70 kg patient.

Thus, in shock states, these rates of fluid resuscitation are not unusual and 
correspond to signs and symptoms we see clinically with our "attentive 
evaluation" of septic shock patients.

Finally, to make the final point, in the three most recent trials, again 
patients with CHF and chronic renal failure were not excluded from enrollment 
in the trials.  If you look at the volume of fluid these patients received it 
quickly reaches the 30mL/kg threshold and goes beyond.

In ProCESS the EGDT group received 2805 +/- 1957 mL, the usual care group 
received 2279 +/- 1881 mL.  In ARISE, EGDT received 1964 +/1 1415 mL, usual 
care 1713 +/1 1401 mL.  In ProMISE EGDT received 2000 mL average, usual care 
1784 mL average.

In general, I usually present this information to others by saying, "first do 
not harm, but think about whether the harm you are not doing is really there."  
Second, decide if mechanical ventilation (if the evidence were wrong that rates 
are lower with fluid resuscitation) is really that harmful.  Third, remember 
you are treating shock, comorbidities are secondary issues at best if 
physiological parameters are as abnormal as we see in Class II and Class III 
trauma patients.  Lastly, in all the large trials patients tolerated these 
fluid boluses.

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Reynolds, Stuart
Sent: Wednesday, September 16, 2015 4:20 PM
To: sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] Sepsis Core Measure Follow Up

I agree with Dr Allen's comments below.

The mandated 30ml/kg IVF bolus may  be harmful; if 20ml/kg or 10ml/kg is 
sufficient to improve perfusion; particularly in patients with acute lung 
injury, or those with 

Re: [Sepsis Groups] Sepsis Core Measures Follow-up

[Townsend, Sean, M.D.]

It's really important to be careful in the language I use, and if I left 
misconceptions, I apologize.

I'm sure not all of my answers will satisfy everyone -- but a great starting 
point here would be to remember we are in an "improvement" mode with sepsis 
care nationally now, and that science and evidence is part of that process, but 
much improvement in care moves in ways that only compliments science and best 
evidence, but does not derive strictly from it.

I have great appreciation for many of your ideas and thoughts below.

To your specific points...see below...


On Sep 15, 2015, at 9:31 AM, Allen, Gilman B 
> wrote:

Sean,

I attended your webinar on Sepsis Core measures last week and was left with a 
number of concerning questions:

1. If we are using the logic that “there is no evidence to show it doesn’t 
hurt” to justify follow-up physical exam measures for evaluation of response to 
resuscitation, then why does the same logic not apply to the use of Normsol and 
other chloride-balanced crystalloids? I would argue that there is a growing 
body of evidence that normal saline may indeed “hurt” (JAMA. 
2012;308(15):1566-1572.; Br J Surg 102 (1):24-36. Crit Care Med 2014; 
42:1585–1591.

***Yes, maybe, but I haven't seen a body of evidence that we should all live 
normsol?  I also haven't seen sophisticated trials comparing a lot of this head 
to head.  I have seen 4 large trials in septic shock that premise their results 
in use of saline -- Rivers and the three new trials in NEJM.  Personally I'm 
not invested in this much, and to the extent I could loosen choice if 
resuscitation fluids and remain consistent with international guidelines, I'm 
happy to advocate for that.  I'm not sure on a macro level this debate is a big 
driver of mortality in septic shock, so you really think the treatment effect 
here is large enough to be worried about this?  I'm asking -- I'm thinking its 
minor.***

2. In defending the use of many of these unproven metrics of volume 
responsiveness and distal perfusion, you described many of these measures as a 
“proxy” measure of “attentive evaluation” and intensive care.  I full agree, 
and practice this way.  I believe these measures help represent a collective 
epi-phenomenon of intensive and regimented care. Using the same reasoning, why 
then is there no provision in any of this for providers to document their own 
rationale for diverging from some of these restrictive mandates when judged to 
be clinically justified. Is this not also a worthy “proxy” of intensive and 
attentive care?

***I guess simply said you have to have some standard for measurement purposes 
even if you are willing to practice in a way where you feel you are gathering 
much information and making informed decisions.  I would hope that the expanded 
palette of choices you have here helps you to have freedom from the previous 
hegemony of cvp and scvo2.  There's lots of choice.  But unless there's some 
standard I can't measure and if I can't measure I cannot improve.***

3. When does the clock really start ticking? Our hospitals still don’t have a 
solid and reliable answer to this question. Is it when the physician documents 
their suspicion of sepsis, 3 hours after a fever and hypotension? When blood 
cultures are first ordered one hour after the fever? Or when an MD orders 
Tylenol, a CBC, lactate, and blood cultures on someone he/she suspects may be 
either bleeding, in pain, or possibly infected post-Op? When do these types of 
patients really “declare” themselves septic.

***Here, it will be hard for docs.  As a doc, you can always start the clock by 
documenting severe sepsis is present with a time stamp.  That's always your 
choice and the data abstractors are expected to obey that.  If you don't, they 
are going to pull from assorted documentation -- flow sheets nursing mutes, lab 
reports -- to build the time all elements of severe sepsis were present.***

The efforts to try to “capture” every element of Goal-directed care in an 
“all-or-none” pass/fail algorithm dooms itself from the beginning. Why didn’t 
CMS just start off with the 3 hour bundle, monitor how others do with the 6 
hour bundle, and try to figure out where (and why) their algorithm is 
succeeding, or failing, to capture (and enforce) best practice?

***There were a number of reasons this didn't happen, going back to the time 
ProCESS was published and public hearings were happening at the NQF.  Part of 
the answer is that processes of care up to 6 hours were important in the 
control and intervention arms. Another part is that the vote to suspend EGDT at 
NQF as a strategy was actually not without a large minority that still 
supported hemodynamics assessment despite the findings of the new trials 13-9 
(I believe) was the vote to reject EGDT as a requirement.  Basically things 
moved fast, people wanted choices, 6 hours was thought to be important.  Since 
EGDT 

Re: [Sepsis Groups] Sepsis Core Measures Follow-up

[Townsend, Sean, M.D.]

While I appreciate many points of view, I can't engage in a reasoned discussion 
that brings out advantages and disadvantages to certain approaches if we must 
toss terms such as insanity, imposition, nefarious, unacceptable, misuse, and 
disastrous.

It would we useful, I think, to remember that such dialogue has been used since 
the inception of the Surviving Sepsis Campaign's efforts to improve care 14 
years ago, and the proof of the effect of such efforts is that mortality in 
Rivers' control arm was 46% versus 18.8 in ProCESS.

Working together carefully and patiently is an important tenet of our 
improvenent efforts.

As for the remarks below, I would simply note that the approach to antibiotics 
is fully supported in the 2012 SSC Guidelines, and those were endorsed by the 
infectious Disease Society of America.  The standard of broad spectrum 
antibiotics for a disease that carries lethal potential if you guess 
incorrectly is not in dispute.

Finally, the definitions if severe sepsis and shock have not changed.  How one 
*measures* persistent hypotension after fluid administration is the issue.  If 
the author has a measurement strategy to propose, I am certain we can carry 
this forward as a consideration.

On Sep 15, 2015, at 11:03 AM, Ram Parekh 
> wrote:

Thank you, Dr. Allen, for speaking up on this insanity that is being imposed on 
hospitals and providers.

I'll add 2 more questions, and one comment.


 *   First, NS and LR are ok, but Isolyte is unacceptable. How is this 
possible? NS may cause harm, as you have already mentioned, and LR may affect 
trending lactates particularly in shock states, yet those are the only CMS 
sanctioned crystalloids, while balanced solutions like Isolyte or Plasmalyte do 
not qualify.

 *   Secondly, on what evidentiary basis and by what rationale have the Severe 
Sepsis and Septic Shock definitions been changed? Infection + 2+ SIRS + lactate 
> 4mmol/L has been been the Severe Sepsis definition since the Rivers EGDT 
trial and was also used in the RCT triumvirate of PROMISE, ARISE, and PROCESS. 
Now, this Severe Sepsis criteria has been subsumed by the 'Septic Shock' 
definition and the new Severe Sepsis definition includes a myriad of end organ 
surrogates such as platelet count and bilirubin level. Again, on what 
evidentiary basis are hospitals and providers being held to this arbitrary 
definition? The best evidence we have to date uses the Rivers definition of 
severe sepsis and septic shock, yet this has been scrapped in favor of a more 
complicated and arbitrary definition. Adding complexity is not in the best 
interest of patient care, if that is indeed the goal.

 *   And last, and most important, is the expectations involving broad spectrum 
antibiotics. This is a more nefarious reincarnation of the disastrous 
antibiotics for pneumonia CMS core measure. The effect this will have on 
antibiotic overuse and misuse will be disastrous.


On Tue, Sep 15, 2015 at 12:25 PM, Allen, Gilman B 
> wrote:
Sean,

I attended your webinar on Sepsis Core measures last week and was left with a 
number of concerning questions:

1. If we are using the logic that “there is no evidence to show it doesn’t 
hurt” to justify follow-up physical exam measures for evaluation of response to 
resuscitation, then why does the same logic not apply to the use of Normsol and 
other chloride-balanced crystalloids? I would argue that there is a growing 
body of evidence that normal saline may indeed “hurt” (JAMA. 
2012;308(15):1566-1572.; Br J Surg 102 (1):24-36. Crit Care Med 2014; 
42:1585–1591.

2. In defending the use of many of these unproven metrics of volume 
responsiveness and distal perfusion, you described many of these measures as a 
“proxy” measure of “attentive evaluation” and intensive care.  I full agree, 
and practice this way.  I believe these measures help represent a collective 
epi-phenomenon of intensive and regimented care. Using the same reasoning, why 
then is there no provision in any of this for providers to document their own 
rationale for diverging from some of these restrictive mandates when judged to 
be clinically justified. Is this not also a worthy “proxy” of intensive and 
attentive care?

3. When does the clock really start ticking? Our hospitals still don’t have a 
solid and reliable answer to this question. Is it when the physician documents 
their suspicion of sepsis, 3 hours after a fever and hypotension? When blood 
cultures are first ordered one hour after the fever? Or when an MD orders 
Tylenol, a CBC, lactate, and blood cultures on someone he/she suspects may be 
either bleeding, in pain, or possibly infected post-Op? When do these types of 
patients really “declare” themselves septic.

The efforts to try to “capture” every element of Goal-directed care in an 
“all-or-none” pass/fail algorithm dooms itself from the beginning. Why didn’t 

Re: [Sepsis Groups] SCCM guidelines verse CMS core measure

[Townsend, Sean, M.D.]

We are aware of the seeming contradiction.  We intend to update the CMS data 
dictionary to fix this.  The bolus should be given for hypotension or lactate 
=4.  While we all shorthand this for shock, to read the guidelines and measure 
consistently, we have to think of that as simply hypotension.  Lactate doesn't 
matter here -- greater than equal to 4 is shock and we don't expect the bolus 
to rectify that initial lactate and take away the diagnosis of shock during the 
6 hour bundle time frame.  But hypotension becomes shock when refractory to 
fluids.  So what's on pages 1-15 will get reworded to give it for hypotension.

The obvious difficulty is we are assigning hard times to what is clearly a 
spectrum of disease.  So, it will be artificial at times.  90+ percent of the 
time it's smooth enough, but you can define flawed spaces in such a measure.



On Jun 9, 2015, at 4:56 AM, Jeanie Bollinger 
jeanie.bollin...@msj.orgmailto:jeanie.bollin...@msj.org wrote:


This list serve has been very helpful for those of us working on sepsis and the 
CMS core measure.  The SCCM guidelines state that 30ml/kg is to be given for 
severe sepsis (organ dysfunction and 2 SIRS due to a suspected or documented 
infection) at a rate of 30ml/kg.  See table page 596 of the SCCM guidelines.  
If hypotension persists or LA 4, the SCCM defines this as septic shock.  This 
is where I am confused.  On page 1-15 of the CMS rules, our team is 
interpreting that that fluids 30ml/kg are given after presentation of septic 
shock.  This seems to contradict the SCCM new bundle guidelines.

How is CMS defining septic shock?  Any other thoughts?


Jeanie Bollinger RN,MSN,ACCNS-AG, CCRN
Sepsis Clinical Nurse Specialist
Center For Nursing Excellence
Mission Health
Asheville, NC.

Phone 828-213-7171
Pager 207-2363




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Re: [Sepsis Groups] SCCM guidelines: vasopressors

[Townsend, Sean, M.D.]

I like Greg's answer!



On Apr 24, 2015, at 7:07 AM, Martin, Greg 
greg.mar...@emory.edumailto:greg.mar...@emory.edu wrote:


There are two recent studies that have examined the timing of vasopressor 
administration in septic shock. One from Anand Kumar, known for demonstrating 
the impact of delayed antibiotics on septic shock mortality, and the other from 
a group in China.  Both studies conclude that earlier administration is 
associated with better outcomes (survival).  The exact timing of administration 
is difficult – we all agree it is difficult to not administer vasopressors to a 
hypotensive patient when their blood pressure does not improve quickly for 
initial aggressive fluid administration.



http://ccforum.com/content/18/3/R97/abstract



http://ccforum.com/content/18/5/532/abstract



Greg


Greg S. Martin, M.D., M.Sc.
Professor and Associate Division Director for Critical Care
 Division of Pulmonary, Allergy and Critical Care
 Emory University School of Medicine
Director, Clinical Research Network
 Atlanta Clinical and Translational Science Institutehttp://www.actsi.org/
Director of Research, Emory Center for Critical 
Carehttp://emoryhealthcare.org/Critical-Care
Associate Director, Emory/Georgia Tech Predictive Health 
Institutehttp://predictivehealth.emory.edu/
 Director, Center for Health Discovery and Well 
Beinghttp://predictivehealth.emory.edu/chd/index.html
Section Chief, Pulmonary, Allergy, Critical Care and 
Sleephttp://medicine.emory.edu/pulmonary-allergy-critical-care/
 Grady Memorial Hospital
Administrative Coordinator:
   Paula Massey, (404) 616-­0148
greg.mar...@emory.edumailto:greg.mar...@emory.edu

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-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Townsend, Sean, M.D.
Sent: Thursday, April 23, 2015 11:26 AM
To: Jeanie Bollinger
Cc: 
sepsisgroups@lists.sepsisgroups.orgmailto:sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] SCCM guidelines: vasopressors



Since both groups in ARISE did receive vasopressors, although usual care 
received marginally fewer applications, I don't think you can conclude they 
make no difference.  You would have to assert that the small number who 
received fewer applications somehow had statistical significance and I'm sure 
that number is far too small.  Plus that's a secondary analysis of a test not 
intended by the trial -- long and short, don't draw this false conclusion.



That said nobody really knows if vasopressors save lives in sepsis.



Truth is really very simple -- most docs cannot stand to look at a BP of 70/40 
and sit on it after a good fluid bolus fails.  If you've got docs that feel 
comfortable doing that, I'd say they are daredevils unlike the average ED doc 
or intensivist!







On Apr 23, 2015, at 7:17 AM, Jeanie Bollinger 
jeanie.bollin...@msj.orgmailto:jeanie.bollin...@msj.orgmailto:jeanie.bollin...@msj.org%3cmailto:jeanie.bollin...@msj.org
 wrote:



Hello group,



I have a question on the CMS bundle and the revised SCCM guidelines concerning 
volume resuscitation and application of vasopressors.   The 3 hours bundle 
states fluid 30ml/kg for hypotension or lactate 4.  The 6 hour bundle states 
to apply vasopressors for hypotension that does not respond to initial fluid 
resuscitation.   Is the recommendation to add vasopressor after 30ml/kg or can 
the provider give more fluid and then within the 3-6 hour window then apply 
vasopressors for sustained hypotension?  There is discussion among our team 
referring to the ARISE trial and that the variable of  vasopressor therapy did 
not change outcomes.  Any insight on the perspective of others is appreciated.  
Jeanie Bollinger





Jeanie Bollinger MSN,RN,ACCNS-AG, CCRN

Sepsis Clinical Nurse Specialist

Nursing Department of Excellence

Mission Health

Asheville, NC



Phone: 828-213-7171

Beeper: 828-207-2363









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Re: [Sepsis Groups] SCCM guidelines: vasopressors

[Townsend, Sean, M.D.]

Since both groups in ARISE did receive vasopressors, although usual care 
received marginally fewer applications, I don't think you can conclude they 
make no difference.  You would have to assert that the small number who 
received fewer applications somehow had statistical significance and I'm sure 
that number is far too small.  Plus that's a secondary analysis of a test not 
intended by the trial -- long and short, don't draw this false conclusion.

That said nobody really knows if vasopressors save lives in sepsis.

Truth is really very simple -- most docs cannot stand to look at a BP of 70/40 
and sit on it after a good fluid bolus fails.  If you've got docs that feel 
comfortable doing that, I'd say they are daredevils unlike the average ED doc 
or intensivist!



On Apr 23, 2015, at 7:17 AM, Jeanie Bollinger 
jeanie.bollin...@msj.orgmailto:jeanie.bollin...@msj.org wrote:

Hello group,

I have a question on the CMS bundle and the revised SCCM guidelines concerning 
volume resuscitation and application of vasopressors.   The 3 hours bundle 
states fluid 30ml/kg for hypotension or lactate 4.  The 6 hour bundle states 
to apply vasopressors for hypotension that does not respond to initial fluid 
resuscitation.   Is the recommendation to add vasopressor after 30ml/kg or can 
the provider give more fluid and then within the 3-6 hour window then apply 
vasopressors for sustained hypotension?  There is discussion among our team 
referring to the ARISE trial and that the variable of  vasopressor therapy did 
not change outcomes.  Any insight on the perspective of others is appreciated.  
Jeanie Bollinger


Jeanie Bollinger MSN,RN,ACCNS-AG, CCRN
Sepsis Clinical Nurse Specialist
Nursing Department of Excellence
Mission Health
Asheville, NC

Phone: 828-213-7171
Beeper: 828-207-2363




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Re: [Sepsis Groups] CMS Quality Measure

[Townsend, Sean, M.D.]

The measure will be part of the inpatient data reporting program and will 
gather data over the next year or so until determinations are made as to 
whether it would be useful to use it in the prospective payment system to alter 
reimbursement.  Basically, any new measure has to be proven before those types 
of determinations would be made.  Thus, I cannot say when the data will be 
publicly reported.  I cannot also say when or if there will be a tie to 
reimbursement.

There is no credit for fluids given in the field.  It has to happen in the ER.  
That has always been how we measured fluids in the SSC database and with the 
hospitals with which we work.

Sean

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Jeanie Bollinger
Sent: Friday, April 10, 2015 6:22 AM
To: sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] CMS Quality Measure

Sepsis group,

Does anyone know when the Sepsis quality measures will be publically reported 
and when and if this measure will be tied to reimbursement?

In addition to the question of fluids given in the field, will there be a “time 
credit” retrospectively for fluids that are given prior to hypotension or LA4? 
If so, what might that time period be?  For example, if one liter of fluids is 
given one hour before hypotension criteria, would that could toward the total 
volume bundle measure?

Jeanie Bollinger MSN,RN,ACCNS-AG, CCRN
Sepsis Clinical Nurse Specialist
Nursing Department of Excellence
Mission Health
Asheville, NC

Phone: 828-213-5878
Beeper: 828-207-2363



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Re: [Sepsis Groups] Sepsisgroups Digest, Vol 151, Issue 8

[Townsend, Sean, M.D.]

This is impressive that you are doing all of this in the field.  There is a 
negative time provision of 180 minutes for abx and blood cultures so if you 
document those as having happened you will get credit.  I'm not sure anyone 
conceived of lactic acid in the field, so there's no similar provision.  I 
would simply time and date the collection (and state the result since that 
matters) as arrival time in an LIP's note.  As to fluids, it's going to be 30 
ml/kg from arrival on top of whatever they got in the field.

Sean R. Townsend, MD
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street #301
San Francisco, CA  94115
towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
415-600-5770 office
415-600-1541 fax

On Apr 10, 2015, at 6:08 AM, Sue Beswick 
sbesw...@ghs.orgmailto:sbesw...@ghs.org wrote:

I agree - we are drawing cultures, starting fluids, drawing LA, and giving abx 
in the field and wondering how this will impact.

Sue

Sue Beswick APRN, MS, CCNS, CCRN
CNS Critical Care
Greenville Health System
701 Grove Road l Greenville, SC 29605
Office:  864-455-4884


-Original Message-
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of 
sepsisgroups-requ...@lists.sepsisgroups.orgmailto:sepsisgroups-requ...@lists.sepsisgroups.org
Sent: Wednesday, April 08, 2015 5:21 PM
To: 
sepsisgroups@lists.sepsisgroups.orgmailto:sepsisgroups@lists.sepsisgroups.org
Subject: Sepsisgroups Digest, Vol 151, Issue 8

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Today's Topics:

  1. Sepsis CMS Core measure/lactate
 (Carlson, Barbara A. (Lincoln, NE))
  2. Re: CMS Abstraction for Severe Sepsis/Septic  Shock
 PRESENTATION TIME (Townsend, Sean, M.D.)


--

Message: 1
Date: Wed, 8 Apr 2015 16:16:42 +
From: Carlson, Barbara A. (Lincoln, NE) 
bcarls...@stez.orgmailto:bcarls...@stez.org
To: 
'sepsisgroups@lists.sepsisgroups.orgmailto:sepsisgroups@lists.sepsisgroups.org'
   
sepsisgroups@lists.sepsisgroups.orgmailto:sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] Sepsis CMS Core measure/lactate
Message-ID:
   
35dbb1774783904fb66a013e4e110d3f367cd...@chiex011.chi.catholichealth.netmailto:35dbb1774783904fb66a013e4e110d3f367cd...@chiex011.chi.catholichealth.net

Content-Type: text/plain; charset=us-ascii

I saw a provision on Quality Net/CMS Sepsis Bundle Project to draw blood 
cultures and time IV antibiotics before time zero.

Clarifications:


1.   Is there a provision to draw the lactate before time zero i.e. in the 
field or acute care clinic?


2.   If so, please share the timing.

Thank you,

Barbara Carlson RN, BAN, CPHQ
Performance Improvement
CHI Health St. Elizabeth

555 S 70th St, Lincoln, NE 68510
P 402-219-7332   F 402-219-8992
bcarls...@stez.orgmailto:bcarls...@stez.orgmailto:bcarls...@stez.org
CHIhealthStElizabeth.comhttp://CHIhealthStElizabeth.com

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Message: 2
Date: Wed, 8 Apr 2015 08:17:59 -0700
From: Townsend, Sean, M.D. 
towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
To: Brown, Sheree 
sheree.br...@allegiancehealth.orgmailto:sheree.br...@allegiancehealth.org
Cc: 
sepsisgroups@lists.sepsisgroups.orgmailto:sepsisgroups@lists.sepsisgroups.org
   
sepsisgroups@lists.sepsisgroups.orgmailto:sepsisgroups@lists.sepsisgroups.org

Re: [Sepsis Groups] CMS Abstraction for Severe Sepsis/Septic Shock PRESENTATION TIME

[Townsend, Sean, M.D.]

Good detective work!

Still verifying details as I do not want to distribute misleading information 
here.  Please stay tuned.

Sean R. Townsend, MD
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street #301
San Francisco, CA  94115
towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
415-600-5770 office
415-600-1541 fax

On Apr 8, 2015, at 8:11 AM, Brown, Sheree 
sheree.br...@allegiancehealth.orgmailto:sheree.br...@allegiancehealth.org 
wrote:

Good Morning All,

I found all of this information in the Alphabetical Data Dictionary.
image004.jpg


For patients who enter the Emergency Department with septic shock, the Septic 
Shock Presentation Time is the time they were triaged in the Emergency 
Department.

Hypotension and lactate are included in the definition of severe sepsis:

In order to establish the presence of severe sepsis, there are three criteria, 
all three of which must be met within 6 hours of each other. a. Documentation 
of a suspected source of clinical infection. There may be reference to 
“possible infection from xx”, “suspect infection from xx”, or similar reference 
in progress notes, consult notes, or similar physician/APN/PA documentation

b. Two or more manifestations of systemic infection according to the Systemic 
Inflammatory Response Syndrome (SIRS) criteria, which are: i. Temperature  
38.3 C or  36.0 C

ii. Heart rate (pulse)  90

iii. Respiration  20 per minute

iv. White blood cell count  12,000 or  4,000 or  10% bands



c. Organ dysfunction, evidenced by any one of the following:

i. Systolic blood pressure  90, or mean arterial pressure  65, or a systolic 
blood pressure decrease of more than 40 points

ii. Creatinine  2.0, or urine output  0.5 mL/kg/hour for 2 hours

iii. Bilirubin  2 mg/dL (34.2 mmol/L)

iv. Platelet count  100,000

v. INR  1.5 or aPTT  60 sec

vi. Lactate  2 mmol/L (18.0 mg/dL)



And the definition of septic shock:

The criteria for determining that Septic Shock is present are as follows:

a. There must be documentation of severe sepsis present.

AND

b. Tissue hypoperfusion persists after crystalloid fluid administration, 
evidenced by either

• systolic blood pressure  90, or

• mean arterial pressure  65 or

• a decrease in systolic blood pressure by  40 points



OR

• Lactate level is  4 mmol/L






Sheree Brown MSN, RN, CNL
Manager, Performance Excellence
Phone: 517 788-4800 ext. 4209
Pager:  517 534-0127
Fax: 517 788-4715
sheree.br...@allegiancehealth.orgallegiancehealth.org
image001.gif

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Andrew Markowski
Sent: Wednesday, April 08, 2015 12:00 AM
To: Ryan Arnold
Cc: 
sepsisgroups@lists.sepsisgroups.orgmailto:sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] CMS Abstraction for Severe Sepsis/Septic Shock 
PRESENTATION TIME

Likewise, I didn't see, in the CMS core measure, clear definitions of elevated 
lactate or hypotension.
-Andy



Andrew Markowski, MD, MPH
Department of Emergency Medicine
Johns Hopkins | Suburban Hospital
214-766-0665tel:214-766-0665



Sent from my iPhone

On Apr 6, 2015, at 10:36 AM, Ryan Arnold 
ryanarnol...@mac.commailto:ryanarnol...@mac.com wrote:
Sean,
There is no mention of ED triage time in the new CMS guidelines in my reading. 
Do you have a specific reference you found within CMS that refers to ED triage 
time?
The guidelines mention “presentation” of severe sepsis or septic shock, not 
arrival or triage time. The only time based reference they use is whether the 
patient has been hospitalized for ≤ 120 days.

A patient who does not meet criteria for severe sepsis at ED triage does not 
have severe sepsis at ED triage, and would thus not meet the criteria for the 
CMS measure until they meet the clinical criteria for severe sepsis, whether it 
is in the ED or inpatient days later.

Ryan


Ryan Arnold, MD
Research Director, Department of Emergency Medicine
Clinical Investigator, Value Institute
Christiana Care Health System
Newark, DE

On Apr 3, 2015, at 9:23 PM, Townsend, Sean, M.D. 
towns...@sutterhealth.orgmailto:towns...@sutterhealth.org wrote:


Jennifer, your interpretation is correct.  For patients presenting to the ED, 
triage time is time zero under the CMS measure.

Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA 94115
email towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541


From: Sepsisgroups 
[sepsisgroups-boun...@lists.sepsisgroups.orgmailto:sepsisgroups-boun...@lists.sepsisgroups.org]
 On Behalf Of Jennifer L Halligan [SJGH] 
[jhalli...@sjgh.orgmailto:jhalli...@sjgh.org]
Sent: Thursday, April 02, 2015 8:44 AM
To: 
sepsisgroups@lists.sepsisgroups.orgmailto:sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] CMS Abstraction

Re: [Sepsis Groups] time zero

[Townsend, Sean, M.D.]

Working on these issues with CMS to clarify their intent.  I will share more as 
soon as I can.

Please disregard any remarks I have made regarding time zero up into this point.

There may be alterations that I will share when I am able to do so.

Sean R. Townsend, MD
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street #301
San Francisco, CA  94115
towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
415-600-5770 office
415-600-1541 fax

On Apr 8, 2015, at 6:28 AM, Mary Draper 
mary.dra...@johnmuirhealth.commailto:mary.dra...@johnmuirhealth.com wrote:

We use “triage time”.  This is based on the 2012 SCCM Surviving Sepsis 
Guidelines.



Mary Draper RN BSN CCRN
Quality Manager-Best Practice Support
Quality Management Supervisor
Office (925) 674-2045
Cell (925) 451-8792
Fax (925) 674-2373
mary.dra...@johnmuirhealth.commailto:mary.dra...@johnmuirhealth.com
image001.png

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Gerolamo, Jeannine
Sent: Monday, April 06, 2015 8:12 AM
To: 
sepsisgroups@lists.sepsisgroups.orgmailto:sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] time zero

I am looking for information on how you identify “time zero” and where/how in 
the EMR you are documenting.  Thanks.







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Re: [Sepsis Groups] CMS Abstraction for Severe Sepsis/Septic Shock PRESENTATION TIME

[Townsend, Sean, M.D.]

Working on these issues with CMS to clarify their intent.  I will share more as 
soon as I can.

Sean

Sean R. Townsend, MD
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street #301
San Francisco, CA  94115
towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
415-600-5770 office
415-600-1541 fax

On Apr 7, 2015, at 9:00 PM, Andrew Markowski 
and...@me.commailto:and...@me.com wrote:

Likewise, I didn't see, in the CMS core measure, clear definitions of elevated 
lactate or hypotension.

-Andy


Andrew Markowski, MD, MPH
Department of Emergency Medicine
Johns Hopkins | Suburban Hospital
214-766-0665tel:214-766-0665


Sent from my iPhone

On Apr 6, 2015, at 10:36 AM, Ryan Arnold 
ryanarnol...@mac.commailto:ryanarnol...@mac.com wrote:

Sean,
There is no mention of ED triage time in the new CMS guidelines in my reading. 
Do you have a specific reference you found within CMS that refers to ED triage 
time?
The guidelines mention “presentation” of severe sepsis or septic shock, not 
arrival or triage time. The only time based reference they use is whether the 
patient has been hospitalized for ≤ 120 days.

A patient who does not meet criteria for severe sepsis at ED triage does not 
have severe sepsis at ED triage, and would thus not meet the criteria for the 
CMS measure until they meet the clinical criteria for severe sepsis, whether it 
is in the ED or inpatient days later.

Ryan


Ryan Arnold, MD
Research Director, Department of Emergency Medicine
Clinical Investigator, Value Institute
Christiana Care Health System
Newark, DE

On Apr 3, 2015, at 9:23 PM, Townsend, Sean, M.D. 
towns...@sutterhealth.orgmailto:towns...@sutterhealth.org wrote:

Jennifer, your interpretation is correct.  For patients presenting to the ED, 
triage time is time zero under the CMS measure.

Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA 94115
email towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541


From: Sepsisgroups 
[sepsisgroups-boun...@lists.sepsisgroups.orgmailto:sepsisgroups-boun...@lists.sepsisgroups.org]
 On Behalf Of Jennifer L Halligan [SJGH] 
[jhalli...@sjgh.orgmailto:jhalli...@sjgh.org]
Sent: Thursday, April 02, 2015 8:44 AM
To: 
sepsisgroups@lists.sepsisgroups.orgmailto:sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] CMS Abstraction for Severe Sepsis/Septic Shock 
PRESENTATION TIME


Question to the group. I have been and currently still am abstracting TRIAGE 
TIME for “time zero”. With the release of the new measure specification 
manual/abstraction guidelines I want to clarify that I will still abstract 
TRIAGE time as severe sepsis/septic shock PRESENTATION TIME even though ALL the 
criterion may NOT be met yet at the time of triage, i.e. for severe sepsis -1) 
documentation of suspected source of infection, 2) 2 SIRS criteria, and 3) 
organ dysfunction?


Thank you,
Jennifer

Jennifer Halligan, RN
Quality Review Nurse
San Joaquin General Hospital
Tel: 209-468-7471
Fax: 209-468-7011

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Re: [Sepsis Groups] CMS Abstraction for Severe Sepsis/Septic Shock PRESENTATION TIME

[Townsend, Sean, M.D.]

Time of presentation is defined in the originating NQF documents.  If asked to 
clarify my belief is CMS will resort to the NQF definition which states:

“time of presentation” is defined as the time of triage in the Emergency 
Department or, if presenting from another care venue, from the earliest chart 
annotation consistent with all elements severe sepsis or septic shock 
ascertained through chart review.



Sean R. Townsend, MD
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street #301
San Francisco, CA  94115
towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
415-600-5770 office
415-600-1541 fax

On Apr 6, 2015, at 7:36 AM, Ryan Arnold 
ryanarnol...@mac.commailto:ryanarnol...@mac.com wrote:

Sean,
There is no mention of ED triage time in the new CMS guidelines in my reading. 
Do you have a specific reference you found within CMS that refers to ED triage 
time?
The guidelines mention “presentation” of severe sepsis or septic shock, not 
arrival or triage time. The only time based reference they use is whether the 
patient has been hospitalized for ≤ 120 days.

A patient who does not meet criteria for severe sepsis at ED triage does not 
have severe sepsis at ED triage, and would thus not meet the criteria for the 
CMS measure until they meet the clinical criteria for severe sepsis, whether it 
is in the ED or inpatient days later.

Ryan


Ryan Arnold, MD
Research Director, Department of Emergency Medicine
Clinical Investigator, Value Institute
Christiana Care Health System
Newark, DE

On Apr 3, 2015, at 9:23 PM, Townsend, Sean, M.D. 
towns...@sutterhealth.orgmailto:towns...@sutterhealth.org wrote:

Jennifer, your interpretation is correct.  For patients presenting to the ED, 
triage time is time zero under the CMS measure.

Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA 94115
email towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541


From: Sepsisgroups 
[sepsisgroups-boun...@lists.sepsisgroups.orgmailto:sepsisgroups-boun...@lists.sepsisgroups.org]
 On Behalf Of Jennifer L Halligan [SJGH] 
[jhalli...@sjgh.orgmailto:jhalli...@sjgh.org]
Sent: Thursday, April 02, 2015 8:44 AM
To: 
sepsisgroups@lists.sepsisgroups.orgmailto:sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] CMS Abstraction for Severe Sepsis/Septic Shock 
PRESENTATION TIME


Question to the group. I have been and currently still am abstracting TRIAGE 
TIME for “time zero”. With the release of the new measure specification 
manual/abstraction guidelines I want to clarify that I will still abstract 
TRIAGE time as severe sepsis/septic shock PRESENTATION TIME even though ALL the 
criterion may NOT be met yet at the time of triage, i.e. for severe sepsis -1) 
documentation of suspected source of infection, 2) 2 SIRS criteria, and 3) 
organ dysfunction?


Thank you,
Jennifer

Jennifer Halligan, RN
Quality Review Nurse
San Joaquin General Hospital
Tel: 209-468-7471
Fax: 209-468-7011

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Re: [Sepsis Groups] CMS Abstraction for Severe Sepsis/Septic Shock PRESENTATION TIME

[Townsend, Sean, M.D.]

Jennifer, your interpretation is correct.  For patients presenting to the ED, 
triage time is time zero under the CMS measure.

Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA 94115
email towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541


From: Sepsisgroups [sepsisgroups-boun...@lists.sepsisgroups.org] On Behalf Of 
Jennifer L Halligan [SJGH] [jhalli...@sjgh.org]
Sent: Thursday, April 02, 2015 8:44 AM
To: sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] CMS Abstraction for Severe Sepsis/Septic Shock 
PRESENTATION TIME


Question to the group. I have been and currently still am abstracting TRIAGE 
TIME for “time zero”. With the release of the new measure specification 
manual/abstraction guidelines I want to clarify that I will still abstract 
TRIAGE time as severe sepsis/septic shock PRESENTATION TIME even though ALL the 
criterion may NOT be met yet at the time of triage, i.e. for severe sepsis -1) 
documentation of suspected source of infection, 2) 2 SIRS criteria, and 3) 
organ dysfunction?


Thank you,
Jennifer

Jennifer Halligan, RN
Quality Review Nurse
San Joaquin General Hospital
Tel: 209-468-7471
Fax: 209-468-7011

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Re: [Sepsis Groups] CMS Abstraction for Severe Sepsis/Septic Shock PRESENTATION TIME

[Townsend, Sean, M.D.]

Please do not be concerned about this at this time.  The possibility of 
changing definitions will not affect CMS's abstraction of this measure in the 
near term or long term.  In fact, if the clinical definition of sepsis were to 
somehow change, for better or worse, it is very unlikely CMS, AHA, or ICD-10 
will follow suit for a long time, if ever.

For administrative purposes, from now until the foreseeable future, sepsis will 
remain defined as you currently understand the disease.  If clinicians attempt 
to change the definition in the future, it will take many years for 
administrators to become cognizant (and then interested) in the change.

Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA 94115
email towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541


From: Sepsisgroups [sepsisgroups-boun...@lists.sepsisgroups.org] On Behalf Of 
Mary Kay Bader [marykay.ba...@stjoe.org]
Sent: Friday, April 03, 2015 10:54 AM
To: Jennifer L Halligan [SJGH]; sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] CMS Abstraction for Severe Sepsis/Septic Shock 
PRESENTATION TIME


Hi
I attended the ISICEM meeting in Brussels 2 weeks ago. There were several 
presentations on March 17 that reported on the march 12-14 International Forum 
on Sepsis. The roundtable included experts from the international world and 
focused on Reducing the Global Burden of Sepsis. Amongst the topics presented – 
there was dialogue of creating a new definition of sepsis as well as exploring 
the true validity (limited sensitivity , lack of face validity, lack of 
construct validity, lack of predictive validity) of the SIRS criteria.   The 
analysis leads me to believe that the SIRS criterial will more than likely be 
replaced by criteria from SOFA (ICU) and qSOFA (ED and the floor). The three 
critical criteria mentioned on qSOFA were Respiratory Rate, BP , and Mental 
Status changes. There is more to come but it was an enlightening presentation.

Mary Kay Bader RN, MSN, CCNS, FAHA, FNCS
Neuro/Critical Care CNS
Mission Hospital

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Jennifer L Halligan [SJGH]
Sent: Thursday, April 02, 2015 8:45 AM
To: sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] CMS Abstraction for Severe Sepsis/Septic Shock 
PRESENTATION TIME

Question to the group. I have been and currently still am abstracting TRIAGE 
TIME for “time zero”. With the release of the new measure specification 
manual/abstraction guidelines I want to clarify that I will still abstract 
TRIAGE time as severe sepsis/septic shock PRESENTATION TIME even though ALL the 
criterion may NOT be met yet at the time of triage, i.e. for severe sepsis -1) 
documentation of suspected source of infection, 2) 2 SIRS criteria, and 3) 
organ dysfunction?


Thank you,
Jennifer

Jennifer Halligan, RN
Quality Review Nurse
San Joaquin General Hospital
Tel: 209-468-7471
Fax: 209-468-7011



Notice from St. Joseph Health System:
Please note that the information contained in this message may be privileged 
and confidential and protected from disclosure.
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Re: [Sepsis Groups] CMS -Severe Sepsis Septic Shock Management Bundle

[Townsend, Sean, M.D.]

It's here:

https://www.qualitynet.org/dcs/ContentServer?c=Pagepagename=QnetPublic%2FPage%2FQnetTier4cid=1228774725171

Thanks,

Sean R. Townsend, MD
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street #301
San Francisco, CA  94115
towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
415-600-5770 office
415-600-1541 fax

On Apr 2, 2015, at 5:45 AM, 
peggy.siene...@hcahealthcare.commailto:peggy.siene...@hcahealthcare.com 
peggy.siene...@hcahealthcare.commailto:peggy.siene...@hcahealthcare.com 
wrote:

Last look it was not there!!

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Posani, Theresa
Sent: Wednesday, April 01, 2015 7:52 AM
To: Alverson, Verna; Orth, Claudia; 
Sepsisgroups@lists.sepsisgroups.orgmailto:Sepsisgroups@lists.sepsisgroups.org
Subject: [EXTERNAL] Re: [Sepsis Groups] CMS -Severe Sepsis  Septic Shock 
Management Bundle

Ok, so you guys on the East coast what does it say?  New reporting parameters?  
Did they drop the CVP and mixed venous ABG components?

Theresa Posani, MS, RN, ACNS-BC, CCRN
Med/Surg CNS
Sepsis Coordinator
(817) 250-3907 office
(972) 838-7954 cell
theresapos...@texashealth.orgmailto:theresapos...@texashealth.org

image001.jpgA Clinical Nurse Specialist (CNS) is a Masters prepared Advance 
Practice Registered Nurse whose function is to improve outcomes in patient 
care. Functioning in five sub roles including:Expert in Clinical Practice, 
Educator, Leader, Researcher and Consultant, we influence our 3 spheres of 
practice; Patient Care, Nursing and Systems.

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Alverson, Verna
Sent: Thursday, March 26, 2015 9:21 AM
To: Orth, Claudia; 
Sepsisgroups@lists.sepsisgroups.orgmailto:Sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] CMS -Severe Sepsis  Septic Shock Management Bundle

Just received this email below from a colleague in my department.
She received it from 
qualityreportingnotificat...@hsag.commailto:qualityreportingnotificat...@hsag.com
 this morning

Subject: [hiqrimprove-poc-notify] Implementation of Severe Sepsis and Septic 
Shock: Management Bundle Measure (NQF #0500)


The purpose of this email is to notify hospitals participating in the Inpatient 
Quality Reporting (IQR) Program that the Centers for Medicare  Medicaid 
Services (CMS) will require data collection of the Severe Sepsis and Septic 
Shock: Management Bundle measure (NQF #0500) beginning with October 1, 2015 
discharges. This measure was adopted for the Fiscal Year (FY) 2017 payment 
determination in the Calendar Year (CY) 2015 Inpatient Prospective Payment 
System (IPPS) Final Rule.

CMS continues to believe that this is an important area for measurement given 
that mortality rates range from 16-49% and that sepsis is one of the top ten 
most common principal causes for hospitalizations. Further, through 
surveillance of early effective treatment of severe sepsis or septic shock, 
hospitals will not only know where in the sequence of steps to treat severe 
sepsis and septic shock patients, but also begin to decrease mortality related 
to sepsis and the costs associated with inefficient care of severe sepsis and 
septic shock patients. With the implementation of this measure, CMS will be 
able to gauge if care of severe sepsis and septic shock patients is improving.

The Severe Sepsis and Septic Shock measurement information, including the 
Measure Information Form and algorithm, and abstraction guidance will be 
provided in Version 5.0 of the Specifications Manual for National Hospital 
Inpatient Quality Measures which will be posted to QualityNet on April 1, 2015.

Please do not respond directly to this email. For questions related to the 
Severe Sepsis and Septic Shock measure, please use the Hospitals-Inpatient 
Questions  Answers tool at https://cms-ip.custhelp.com.

Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Support 
Contractor

Phone: 866.800.8765, 844.472.4477

3000 Bayport Dr. Ste. 300 | Tampa, FL 33607





This material was prepared by the Inpatient Value, Incentives, and Quality 
Reporting Outreach and Education Support Contractor, under contract with the 
Centers for Medicare  Medicaid Services (CMS), an agency of the U.S. 
Department of Health and Human Services. HHSM-500-2013-13007I, 
FL-IQR-Ch8-03252015-08


IMPORTANT WARNING: This electronic message transmission, and any documents 
accompanying it, contains information from Health Services Advisory Group of 
Florida, Inc. (D/B/A FMQAI), which is intended for the individual or entity to 
whom it is addressed. This e-mail may contain information that is privileged 
and confidential, the disclosure of which is governed by applicable law. 
Disclosure of confidential information is prohibited by Federal regulations (42 
CFR Part 480). If the reader of this e-mail is not the intended recipient, or 
the employee or agent responsible to deliver it 

Re: [Sepsis Groups] CMS -Severe Sepsis Septic Shock Management Bundle

[Townsend, Sean, M.D.]

This is the case and before October you can expect programming from the SSC to 
describe the new 6-hour bundle that no longer makes CVP and scvo2 a requirement.

Sean R. Townsend, MD
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street #301
San Francisco, CA  94115
towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
415-600-5770 office
415-600-1541 fax

On Mar 25, 2015, at 2:00 PM, Orth, Claudia 
cor...@mhc.netmailto:cor...@mhc.net wrote:

Good Afternoon,

I was just informed by a colleague that they were told during a Quantros 
webinar today, which is the software solution we currently use to submit Core 
Measures, that the Severe Sepsis and Septic Shock Management Bundle will be 
required by CMS effective October 1, 2015 discharges and that they are planning 
to release the spec manual on April 1, 2015.

Has anyone else heard about this and what steps are other institutions taking 
to prepare for this? Also, are you planning, if you currently do so, to 
continue submitting data to the SSC database and then also using whatever 
software you currently use to submit the CMS measures?

Any thoughts and feedback would be greatly appreciated! Thank you in advance 
for your time and willingness to share!

Respectfully,
Claudia

Claudia Orth BSN, RN, CCRN-K
Regional Sepsis Coordinator
Munson Medical Center
(231) 935-5692 (Voice)
cor...@mhc.netmailto:cor...@mhc.net

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Re: [Sepsis Groups] Impact of ProCESS study on your protocols

[Townsend, Sean, M.D.]

Agree with all that too.  I just don't think ProCESS helped us define much.  
Think about the absurdity of studying usual care.  Once you publish your 
findings what was usual is contaminated by your conclusions.  Practice changes 
and what you publish changes your practice.  You can study it now, in 5 years, 
in 10 years and come to different conclusions.  It's a great way to stay 
perpetually NIH funded.  The fabulous never ending study of the usual.

Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301x-apple-data-detectors://0/0
San Francisco, CA  94115x-apple-data-detectors://0/0
email towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
office (415) 600-5770tel:(415)%20600-5770
fax (415) 600-1541tel:(415)%20600-1541

On Jul 22, 2014, at 10:48 AM, Kramer, George C. 
gkra...@utmb.edumailto:gkra...@utmb.edu wrote:

one religion is be have the good docs that can perform all of the of detective 
work on the clues and find the culprit and device the right plan to apprehend 
or cure.

another religion is find the good docs, get them to better define their 
interpretation and tools and put it into a clinical guideline with some 
specificity. These tools should incorporate imagination and differential 
thinking  And the tool helps out for those docs that are spread thin with too 
many patient on the unit, or are too young or in the OR and not a bedside.

The tools should even help the good docs.

All the docs will deviate from the guidelines often based on rationale based on 
circumstances, co-morbiidies, etc. But reducing variability of care is better 
care. part of religion 2. And deviations will define better guidelines for the 
special circumstances.

george

but i am a naive physiologist.



George C. Kramer, PhD.
Professor
Director, Resuscitation Research Lab
Dept. of Anesthesiology
UTMB, Galveston

mobile  409-939-3040
Mary 409747-0077









On Jul 22, 2014, at 8:10 AM, Joseph J. Bander 
band...@trinity-health.orgmailto:band...@trinity-health.org wrote:

Amen


Sent from my Verizon Wireless 4G LTE smartphone


 Original message 
From: Townsend, Sean, M.D.
Date:07/22/2014 9:08 AM (GMT-05:00)
To: Kramer, George C.
Cc: Sue Beswick ,Richard Teplick ,
Subject: Re: [Sepsis Groups] Impact of ProCESS study on your protocols

No offense to anyone here, but this type of measurement is ubiquitous in 
medicine.  We measure blood pressure, which tells us what directly again?  We 
measure heart rate, which tells us tamponade or afib or digoxin overdose -- no 
direct correlation -- but plenty of indirect correlation.  We measure train of 
4 -- same.  So no physiologic measurement tells us much about disease directly. 
 We measure elevated RVSP and might have PE or pulmonary hypertension or 
something else.

We are stuck with imagination and differential thinking and that's what makes a 
good doc versus someone reading the meter.  ScvO2 is a clue.  80% or more if 
the time it adds to the picture rather than subtracts info.

It's more like resolution of a photograph. More pixels = more information.  
Maybe you like looking at blurry pictures or limiting your pixels.  The ostrich 
keeps it's head in the ground.  I don't know any moreProCESS people seem 
happy to know less and make decisions anyway.

Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301x-apple-data-detectors://0/0
San Francisco, CA  94115x-apple-data-detectors://0/0
email 
towns...@sutterhealth.orgmailto:towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
office (415) 600-5770tel:(415)%20600-5770
fax (415) 600-1541tel:(415)%20600-1541

On Jul 21, 2014, at 9:33 AM, Kramer, George C. 
gkra...@utmb.edumailto:gkra...@utmb.edumailto:gkra...@utmb.edu wrote:

what about urinary output?

it is the gold standard for burn shock a type of shock with high permeability, 
loss of vascular volume, depressed cardiac contractility, SIRS,

hmm, that sound similar to sepsis.

g


On Jul 18, 2014, at 11:13 AM, Richard Teplick 
tepl...@zeus.bwh.harvard.edumailto:tepl...@zeus.bwh.harvard.edumailto:tepl...@zeus.bwh.harvard.edu
 wrote:

One obvious problem with the initial study (Rivers) is that SvO2 is that  
cannot possibly uniquely reflect adequacy of organ perfusion; at best it 
reflects extraction. Because of the disparity in organ blood flow and 
autoregulatory reserve, low flow to, for example, the kidneys could never be 
detected in the presence of high muscle and skin flow (both of which generally 
occur in septic shock). Moreover, elite aerobic athletes can reduce their PvO2 
to the teens producing SvO2s  0.3. Yet they clearly have adequate muscle and 
skin flow although gut and renal flow may be reduced and may have low SvO2 but 
this cannot be determined from the SvO2 alone. Moreover, giving fluid to 
increase cardiac output may not alter blood flow to vital organs.  My point is 
that we shouldn’t blindly accept

Re: [Sepsis Groups] Fluid Bolus in pts. with weight 200 kg

[Townsend, Sean, M.D.]

I have to say I'm the SSC faculty member who suggested actual body weight.  The 
rational I have heard is that it's not the adipose cell itself absorbing the 
fluid, which I agree doesn't make sense.  Rather it's the extensive network of 
capillary beds that support the adipose tissue - it has to be perfused too even 
if minimally metabolically active.  Thus, consideration has to be given to the 
extra capillary network not carried by non-obese patients.

And I confess to not being sure among the arguments presented here which is 
strongest.

All the more to get some kind of invasive monitoring in this population.

Sean

Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA 94115
email towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Terry Clemmer
Sent: Friday, May 30, 2014 6:50 AM
To: Barnes-Daly, Mary Ann; 'Kelsey K. Solano'; 
'sepsisgroups@lists.sepsisgroups.org'
Subject: Re: [Sepsis Groups] Fluid Bolus in pts. with weight  200 kg

You must consider the type of fluid you are giving. NS volume of distribution 
in only extracellular due the cell wall sodium pump. Most fat is intracellular 
and the saline will not be distributed into the fat cell. That is why we use 
predicted body weight. I agree with George Kramer the best would be Ideal body 
weight but that is not practical in the acute resuscitation scenario. When 
giving free water like D5W then the intracellular distribution needs to be 
taken into account.

Terry P. Clemmer, MD
Director: Critical Care Medicine
LDS Hospital
Professor of Medicine
University of Utah School of Medicine
Salt Lake City, Utan 84143

Work Phone: 801-408-3661
Work Fax: 801-408-1668

From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Barnes-Daly, Mary Ann
Sent: Thursday, May 29, 2014 4:19 PM
To: 'Kelsey K. Solano'; 'sepsisgroups@lists.sepsisgroups.org'
Subject: Re: [Sepsis Groups] Fluid Bolus in pts. with weight  200 kg

Every recommendation that I have seen or heard, most recently from the faculty 
on the SSC, is to go with actual body weight.
Remembering that adipose tissue is highly vascular and contains a large amount 
of water and that the main 2 reasons for the fluid bolus are 1. Vasodilation 
reducing perfusion pressure and more importantly 2. Capillary leaking - and 
with all those miles (literally) of leaky capillaries obese patients have a 
very high propensity for intravascular volume depletion.


From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On 
Behalf Of Kelsey K. Solano
Sent: Wednesday, May 28, 2014 7:05 AM
To: 
sepsisgroups@lists.sepsisgroups.orgmailto:sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] Fluid Bolus in pts. with weight  200 kg

I am wondering whether there are any recommendations regarding fluid 
resuscitation in patients weighing 200 Kg? Our physicians have expressed 
concern about the recommended fluid bolus for patients who are  200 Kg and 
potential for CHF exacerbations. Are there any resources that address this 
concern or any modifications for this patient population? Also, is it always 
recommended to go with 30 ml/kg based on current weight or should we be 
calculating ideal weight when determining bolus volume? Currently we are using 
the patient's actual weight on admission for bolus calculations.  Any 
clarifications regarding the fluid bolus would be greatly appreciated.

Thanks,

Kelsey K. Solano
Sepsis Coordinator
Email: solan...@sjrmc.commailto:solan...@sjrmc.com
Office: 574-335-2438

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Re: [Sepsis Groups] Natl. compliance rates w/ central line placement

[Townsend, Sean, M.D.]

Published rates of cannulation success and complications vary according to the 
anatomic site and operator experience. One review described an overall 
complication rate of 15 percent [1], while an observational cohort study of 385 
consecutive CVC attempts over a six month period found that mechanical 
complications occurred in 33 percent of attempts [2]. Complications included 
failure to place the catheter (22 percent), arterial puncture (5 percent), 
catheter malposition (4 percent), pneumothorax (1 percent), subcutaneous 
hematoma (1 percent), hemothorax (less than 1 percent), and aystolic cardiac 
arrest (less than 1 percent).

[1] McGee DC, Gould MK.  Preventing complications of central venous 
catheterization. N Engl J Med. 2003;348(12):1123.

[2] Eisen LA, Narasimhan M, Berger JS, Mayo PH, Rosen MJ, Schneider RF. 
Mechanical complications of central venous catheters.J Intensive Care Med. 
2006;21(1):40.


Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA  94115
email towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541

From: sepsisgroups-boun...@lists.sepsisgroups.org 
[mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On Behalf Of Orth, Claudia
Sent: Wednesday, April 09, 2014 06:40 PM
Cc: sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] Natl. compliance rates w/ central line placement

I am hoping that someone might be able to educate me on the current national 
compliance rates for central line placement?

Thank you in advance for any assistance.

Claudia
Sepsis Coordinator
Munson Medical Center

Sent from IPhone
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Re: [Sepsis Groups] Natl. compliance rates w/ central line placement

[Townsend, Sean, M.D.]

Oh, you asked for compliance rates...not complication rates...

Compliance with insertion and achieving the metrics are two different things.  
In Levy MM et al. The Surviving Sepsis Campaign: Results of an international 
guideline based performance improvement program targeting severe sepsis. Crit 
Care Med 2010 Vol. 38, No. 2 the compliance rate with CVP goals was 38% and 
ScvO2 was 24% as best performance for hospitals that participated over 8 
quarters of data in the Campaign.

Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA  94115
email towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541

From: Townsend, Sean, M.D.
Sent: Thursday, April 10, 2014 06:29 PM
To: 'Orth, Claudia'
Cc: sepsisgroups@lists.sepsisgroups.org
Subject: RE: [Sepsis Groups] Natl. compliance rates w/ central line placement

Published rates of cannulation success and complications vary according to the 
anatomic site and operator experience. One review described an overall 
complication rate of 15 percent [1], while an observational cohort study of 385 
consecutive CVC attempts over a six month period found that mechanical 
complications occurred in 33 percent of attempts [2]. Complications included 
failure to place the catheter (22 percent), arterial puncture (5 percent), 
catheter malposition (4 percent), pneumothorax (1 percent), subcutaneous 
hematoma (1 percent), hemothorax (less than 1 percent), and aystolic cardiac 
arrest (less than 1 percent).

[1] McGee DC, Gould MK.  Preventing complications of central venous 
catheterization. N Engl J Med. 2003;348(12):1123.

[2] Eisen LA, Narasimhan M, Berger JS, Mayo PH, Rosen MJ, Schneider RF. 
Mechanical complications of central venous catheters.J Intensive Care Med. 
2006;21(1):40.


Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA  94115
email towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541

From: 
sepsisgroups-boun...@lists.sepsisgroups.orgmailto:sepsisgroups-boun...@lists.sepsisgroups.org
 [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On Behalf Of Orth, Claudia
Sent: Wednesday, April 09, 2014 06:40 PM
Cc: 
sepsisgroups@lists.sepsisgroups.orgmailto:sepsisgroups@lists.sepsisgroups.org
Subject: [Sepsis Groups] Natl. compliance rates w/ central line placement

I am hoping that someone might be able to educate me on the current national 
compliance rates for central line placement?

Thank you in advance for any assistance.

Claudia
Sepsis Coordinator
Munson Medical Center

Sent from IPhone
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Re: [Sepsis Groups] PROCESS implications

[Townsend, Sean, M.D.]

Hi Ryan,

Very well reasoned and nicely said.  I'm glad you made these points.  The best 
thing about ProCESS is that we will have a long and open discussion about where 
we stand.

For the sake of pro/con, let me make a rejoinder.  :-)

1.  Jones et al. reflected a trial that did not tell us anything much about 
usual care.  The comparison was head to head EGDT using ScvO2 versus EGDT 
using lactate clearance as a substitute for ScvO2.  Everyone had central lines 
in both arms.  Everyone was resuscitated using CVP as a guide.

2.  Jones et al. and ProCESS reflect care at academic centers.  It may well be 
that the nation's elite centers that have enough interest to sign up 
investigators who care sufficiently to invest years of time into studying 
sepsis, residents and fellows monitoring resuscitation parameters around the 
clock, and well established standards and protocols achieve low mortality rates 
and high compliance rates with SSC guidelines.

3.  Neither Jones nor ProCESS show low compliance with SSC guidelines results 
in great outcomes.  On the contrary, the control arm in ProCESS approached 60% 
compliance with central access, and Jones had 100% compliance with current SSC 
bundles in both arms.

5.  In ProCESS I can't tell you how to be like the control arm because frankly 
we just don't know how care was provided.  A far as we can tell 60% of the 
control patients might have had the same therapy as the intervention.  What 
does this mean?  Nobody can say.

4.  US hospitals just don't look like this care in thousands of hospitals 
across the country.  Compliance with SSC bundles in the US is at best in the 
30-40% range in hospitals that have been actively working on adherence for 2 
years (Levy 2010).  Mortality in that group if community hospitals is in the 
28% range for severe sepsis and septic shock combined (shock is higher).  The 
largest current database if US hospitals that compares mortality of all acute 
care discharges, Medicare and commercial coverage and no coverage combined, is 
the Midas Comparative Database.  This database has 750 US hospitals, roughly 
15% of all hospitals in the country.  As of this month, the P50 shock mortality 
in this swath of hospitals is 32.5%.

 5.  I don't pretend to have all the answers yet.  ProCESS is probably showing 
us that really awesome care short of the SSC bundles, reliably executed is 
pretty darn good.  The public health dilemma and true danger of ProCESS is that 
the huge majority -- thousands of hospitals (there are around 5000 US 
hospitals) -- don't look like ProCESS.

6.  If you can honestly say your own *shock* mortality is 18% -- ask the 
quality department at your system, they know -- and 60% of your patients get 
lines, and you have 24/7 intensivist coverage following these patients, well 
then I guess you look like ProCESS.  The 26 hospitals in my system have none of 
that, each has shock mortality rates greater than 23% and some approaching 34%. 
 One has 24/7 intensivist coverage, central line insertion rates are about 20%.

7.  So, I'm not comfortable saying do whatever you like.  I spend a lot of 
energy visiting hospitals across the country.  For the public health we cannot 
let the message be relax your standards even below where they are now.  I 
continue to say if you want to improve in your current state, aim high, set 
bold targets.  The day you look like ProCESS you can pause and reflect on what 
to do next.

:-)

I think that's the positive message my colleagues and I need to get out there.  
The debate is good to have because it's a chance for us to raise awareness and 
focus people on what they can actually say about their own outcomes thus far.

I really appreciate your intelligent and well made remarks, and I know this 
discussion is far from over!  I've said the best day will come when a neutral 
objective 3rd party can make this statement.  I'm invested as you know.

Sean

Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301x-apple-data-detectors://0/0
San Francisco, CA  94115x-apple-data-detectors://0/0
email towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
office (415) 600-5770tel:(415)%20600-5770
fax (415) 600-1541tel:(415)%20600-1541

On Mar 29, 2014, at 8:38 AM, Ryan Arnold 
ryanarnol...@mac.commailto:ryanarnol...@mac.com wrote:

I will suggest a counter to the observation that the PROCESS trial does not 
represent most US hospitals.

We have 2 US-based studies now with ED-centered randomization and similar 
mortality rates. The smaller scale multi-centered RCT (Jones) and the larger 
scale multi-centered RCT (PROCESS) have near identical overall mortality rates 
to each other (Jones: overall mortality 59/300 = 19.7%; PROCESS: overall 
mortality 259/1341 = 19.3%). Each of these used identical inclusion criteria to 
the original EGDT study and identical inclusion criteria to current SSC 
guidelines.

The other 2 studies mentioned in the 

Re: [Sepsis Groups] National Average for Sepsis Mortality rate

[Townsend, Sean, M.D.]

A difficult question!  You have to ask in terms of sepsis, severe sepsis and 
septic shock.

Then you have to decide what kind of data to use as an estimate.  Discharge 
administrative data sets based on ICD-9 and DRG or some other manual process 
like a trial.

What I can tell you is that in the Midas Comparative database, which has 
administrative data from 750 US hospitals, the p50 for severe sepsis and septic 
shock combined mortality is 26%.

That represents an awful lot of community hospitals (almost 15% of US 
hospitals) and so in some ways is nice data.

This is one if the major reasons that the ProCESS trial does not look like most 
US hospitals -- and the error in of overly relying on it to change your 
standards.  So for example, if you do not have 18% SHOCK ALONE mortality and 
57.6% central line insertion rate, as in the control group of ProCESS, you do 
not look much like ProCESS.  The question is can you afford to alter your 
standards at this moment, or is it sensible to do so when the trial doesn't 
reflect your care?

Sean

Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301x-apple-data-detectors://0/0
San Francisco, CA  94115x-apple-data-detectors://0/0
email towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
office (415) 600-5770tel:(415)%20600-5770
fax (415) 600-1541tel:(415)%20600-1541

On Mar 26, 2014, at 7:08 AM, Ogunrinu, Victoria  ARMC-Administration 
ogunri...@armc.sbcounty.govmailto:ogunri...@armc.sbcounty.gov wrote:

What is the National Average for Sepsis Mortality rate?. Would someone please 
share the source?

Thank you,

Victoria Ogunrinu, RN, CNS, MSN, MPH
Assistant Hospital Administrator - DSRIP
Arrowhead Regional Medical Center
400 N. Pepper Ave. Colton, CA 92324
•(909) 580-6366. Pager: (909) 349-8303
•ogunri...@armc.sbcounty.govmailto:ogunri...@armc.sbcounty.gov
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[Sepsis Groups] proCESS Trial

[Townsend, Sean, M.D.]

Many of you have undoubtedly seen or heard about the results of the proCESS 
trial published in today's NEJM.

The trial enrolled 1341 patients, of whom 439 were randomly assigned to 
protocol-based EGDT, 445 to protocol based standard care, and 456 to usual 
care.  By 60 days, there were 92 deaths in the protocol-based EGDT group 
(21.0%), 8`1 in the protocol based standard-care group (18.2%), and 86 in the 
usual-care group (18.9%) (relative risk with protocol-based therapy vs. usual 
care 1.04 (95% confidence interval [CI], 0.82 to 1.31; P=0,83; relative risk 
with protocol-based EGDT vs. protocol-based standard care, 1.15; 95% CI, 0.88 
to 1.51; P=.31).  There were no significant differences in 90-day mortality, 
1-year mortality, or the need for organ support.

The authors conclude that in a multicenter trial conducted in the tertiary care 
setting, protocol-based resuscitation of patients in whom septic shock was 
diagnosed in the emergency department did not improve outcomes.

While these results are important because the trial is multi-institutional and 
controlled, several issues need to be critically examined in the coming days.  
These results will be better examined by those less invested in the Campaign 
than myself and my colleagues.  However, some issues to consider include:


1.  There is a question of face validity for mortality rates such as 
reported here.  Two accompanying papers in the same issue of the NEJM report 
severe sepsis mortality rates in the 30% range.



2.  Each of these institutions were tertiary care institutions influence 
substantially over the last decade by the work of the Surviving Sepsis 
Campaign.  Stated differently, 'usual care' has been systematically changed by 
the SSC over a decade already in terms of early resuscitation.



3.  In all groups, the total % of enrolled patients that had central lines 
in 6 hours was approximately 60%.  If most institutions on this listserv could 
have 60% central line placement, many of us would be very happy and likely have 
lower mortality rates.



4.  There were 1300 patients excluded from this trial for logistical 
reasons.  Thus, half the patients were excluded.  This extraordinarily high 
rate requires further understanding.



5.  75% of enrolling sites had sepsis protocols and usual care occurred 
in same ED setting as the two protocol-directed arms.


I think we have more to learn about protocolized resuscitation for sepsis.  In 
many ways all 3 arms were quantitative resuscitation strategies.

The results of ARISE and PROMIS should provide us with further understanding 
over time.

Sean

Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA  94115
email towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541

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Re: [Sepsis Groups] Noninvasive EGDT

[Townsend, Sean, M.D.]

Did you happen to know that all patients in that trial received a central line 
and that CVP was optimized using it?  I think therefore we can't call that 
trial non-invasive.

Also, although that trial enrolled 300 patients, the intervention did not 
differ until the level of optimizing ScvO2, i.e. all patients that benefited 
from CVP, a fluid bolus, antibiotics etc. and met targets progressively dropped 
out of the running to actually compare lactate clearance to ScvO2.  Thus, in 
the end, 29 patients got a head to head comparison of lactate clearance to 
ScvO2 optimization.

This would suggest that enrollment in the trial should have been 3000 patients 
in order to test the actual difference in intervention at the power requirement 
of 300.

One can make the argument reasonably that the assertion of non-inferiority is 
underpowered by a factor of 10.

One must also wonder about extraordinarily high lactates.  None were enrolled 
in the trial.  So, if I have a lactate of 9 and clear it by 10% to 8.1 should I 
be comfortable that I have hit my resuscitation targets?  Doesn't make me so 
comfortable.

Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA  94115
email towns...@sutterhealth.orgmailto:towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541

From: sepsisgroups-boun...@lists.sepsisgroups.org 
[mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On Behalf Of Ram Parekh
Sent: Tuesday, April 30, 2013 1:50 PM
To: Vipul Kella
Cc: sepsisgroups@lists.sepsisgroups.org
Subject: Re: [Sepsis Groups] Noninvasive EGDT

We have at our hospital and at most of the GNYHA hospitals in the New York area.

This protocol is based on the non-inferiority study of lactate clearance by 
Jones/Shapiro and was implemented with our current Stop Sepsis collaborative 
which has given ED providers the option of utilizing the 'invasive' or 
'non-invasive protocol' as EGDT options. Thus, the protocol was simultaneously 
implemented in over 50 hospitals at the same time.
On Mon, Apr 29, 2013 at 9:57 AM, Vipul Kella 
vke...@emergencydocs.commailto:vke...@emergencydocs.com wrote:
Has anyone implemented the noninvasive EGDT protocol at their hospital?  What 
was your experience?

--
Vipul Kella, MD FACEP
Medical Emergency Professionals (MEP)

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Re: [Sepsis Groups] Where Does Severe Sepsis Belong?

[Townsend, Sean, M.D.]

Dear Doris,

Questions about strategies to improve practice on the listserv are a good 
thing. Not having a strategy beyond everyone's best judgment is probably not 
the right answer on the exam.

I'm sure you have great judgment, but we all know many colleagues who would 
benefit from some guidance on where to place patients.

Judgment alone hasn't done much to get adherence to best therapies. In the 
world's best example, Intermountain Healthcare in Utah, adherence to bundled 
therapies is 85% or so. Their mortality rate for severe sepsis is less than 
10%. The rest of us can't say either of those things. Their publication is in 
peer review and soon we'll all see clearly the power of their example.

I just wanted to survey the crowd that has demonstrated interest in this 
subject for what they do so I can fix my own problems.

Sean




Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA 94115
email towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541

-Original Message-
From: Doberenz, Doris 
[doris.dober...@imperial.nhs.ukmailto:doris.dober...@imperial.nhs.uk]
Sent: Sunday, March 17, 2013 08:44 AM Pacific Standard Time
To: 'sepsisgroups@lists.sepsisgroups.org'
Subject: Re: [Sepsis Groups] Where Does Severe Sepsis Belong?


Why is so much written about this without much real content? How many more or 
less rhetoric questions with or without answers because our patients and their 
diseases and severity actually vary... OOOPS who'd have thought that!? For 
example 'where severe sepsis belongs' will depend on seeing the patient as a 
clinician in addition to certain quite clear severity criteria in their context 
and conjunction e.g. heart rate, blood pressure, resp rate, urine output, lab 
signs of organ failure, lactate, central venous sats if available), and to 
decide how severe the whole situation is and thus how much monitoring and 
support a specific patient in a specific situation and severity needs. How many 
more mails and how many more pages of guidelines and time and expense of 
development of these guidelines by experts do we need for this and how many not 
always sufficiently evidence based but dictatorial bundles, which then get 
overtaken by the scientific evidence (e.g APC, steroids)??? Back t
 o the shopfloor (and the floor or the ICU according to the real need) and back 
to basics, and back to applying good medicine and good science for each 
individual patient and his or her specific situation rather than being spoonfed 
and dictated bundle criteria from some institute without sufficient robust 
and durable scientific evidence...


Doris Doberenz FRCA FFICM EDAIC EDA
Consultant
Intensive Care Unit and Anaesthetic Department
Charing Cross Hospital
Fulham Palace Rd
London W6 8RF
Tel 020 3311 1234 bleep 5742
Mobile 07855 754 160









-Original Message-
From: sepsisgroups-boun...@lists.sepsisgroups.org 
[mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On Behalf Of Townsend, 
Sean, M.D.
Sent: 15 March 2013 06:32
To: 'sepsisgroups@lists.sepsisgroups.org'
Subject: [Sepsis Groups] Where Does Severe Sepsis Belong?

It's been a long time since I've had to ask this question. I used to think I 
knew the answer.

Here it is: do all patients who meet severe sepsis criteria need to be admitted 
to the ICU ?

Examples:

1. Pneumonia, fever, tachycardia, INR 1.5.
2. Cellulitis, leukocytosis, fever, creatinine 2.0.
3. UTI, leukocytosis, fever, lactate 3.0.

Where do people put these patients in reality? What mind of monitoring do they 
deserve?

By prevailing bundles, each gets lactate checked, blood cultures, broad 
spectrum antibiotics. That's it. Good enough? Good enough for the floor? Need 
the ICU? Why?

Sean


Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA 94115
email towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541
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[Sepsis Groups] Where Does Severe Sepsis Belong?

[Townsend, Sean, M.D.]

It's been a long time since I've had to ask this question. I used to think I 
knew the answer.

Here it is: do all patients who meet severe sepsis criteria need to be admitted 
to the ICU ?

Examples:

1. Pneumonia, fever, tachycardia, INR 1.5.
2. Cellulitis, leukocytosis, fever, creatinine 2.0.
3. UTI, leukocytosis, fever, lactate 3.0.

Where do people put these patients in reality? What mind of monitoring do they 
deserve?

By prevailing bundles, each gets lactate checked, blood cultures, broad 
spectrum antibiotics. That's it. Good enough? Good enough for the floor? Need 
the ICU? Why?

Sean


Sean R. Townsend, M.D.
Vice President of Quality  Safety
California Pacific Medical Center
2330 Clay Street, #301
San Francisco, CA 94115
email towns...@sutterhealth.org
office (415) 600-5770
fax (415) 600-1541
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