Dr. Townsend, I greatly appreciate your clear, concise and reasonable responses to all the CMS Severe Sepsis questions and discussions. Thank you.
Mary Draper RN BSN CCRN Quality Manager-Best Practice Support Quality Management Supervisor Office (925) 674-2045<tel:(925)%20674-2045> Cell (925) 451-8792<tel:(925)%20451-8792> Fax (925) 674-2373<tel:(925)%20674-2373> [email protected]<mailto:[email protected]> On Apr 10, 2015, at 6:07 AM, Townsend, Sean, M.D. <[email protected]<mailto:[email protected]>> wrote: This question will require formal clarification by CMS and the vendors it uses to capture the information. The vendor your hospital system uses to send information to CMS will create a means to capture this information uniformly. Our hospital system for instance uses Midas. This vendor will resolve this question with CMS in a compliant fashion. Typically, if a selected case is indeterminate as to diagnosis by abstraction guidelines at the hospital level, hospitals have freedom to select another chart during the sampling period. This is true for any measure included in the inpatient quality reporting (IQR) data set. Long and short, I wouldn’t worry about this issue with too much of my attention. From: Brown, Sheree [mailto:[email protected]] Sent: Thursday, April 09, 2015 8:44 AM To: '[email protected]<mailto:[email protected]>'; Townsend, Sean, M.D. Cc: [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]> Subject: RE: [Sepsis Groups] CMS Abstraction for Severe Sepsis/Septic Shock PRESENT... Actually, the abstraction guidelines list provider (physician/PA/APNPA) notes as the preferred data source to determine if a patient has severe sepsis. Severe sepsis is considered present if the provider documents any of these specific terms: Inclusion Guidelines for Abstraction: • Severe Sepsis • R/O severe sepsis • Differential diagnosis: severe sepsis • Possible severe sepsis If there is no documentation of any of these terms by the provider, then the record is reviewed to see if patient meets the 3 criteria for severe sepsis (infection + 2 SIRS + 1 organ dysfunction). So as I understand it…if the physician/PA/NP documents ‘severe sepsis’ then the SIRS criteria does not need to be met. Sheree Sheree Brown MSN, RN, CNL Manager, Performance Excellence Phone: 517 788-4800 ext. 4209 Pager: 517 534-0127 Fax: 517 788-4715 [email protected]<allegiancehealth.org> <image001.gif> From: [email protected]<mailto:[email protected]> [mailto:[email protected]] Sent: Thursday, April 09, 2015 10:23 AM To: [email protected]<mailto:[email protected]>; Brown, Sheree; [email protected]<mailto:[email protected]> Cc: [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]> Subject: Re: [Sepsis Groups] CMS Abstraction for Severe Sepsis/Septic Shock PRESENT... I am seeing denials of severe sepsis as a reported diagnosis by third party auditors ( CMS and other auditors) as they feel severe sepsis is not clinically validated as the patient does not have 2 of the sirs criteria, despite having signs of severe sepsis ( organ dysfunction due to infection) This is medically incorrect as one can have severe sepsis without any of the sirs criteria (even though it is uncommon, it does occur based on my experience and as Dr Levy had told me by phone several years ago,) This is also noted in a recent NEJM article ( http://www.nejm.org/doi/full/10.1056/NEJMoa1415236?query=pulmonary ) Therefore, I am concerned that the criteria kindly forwarded by Ms Brown ( see below) would add to the problem if it rules out the diagnosis of severe sepsis based on not having 2 of the 4 sirs criteria. Any thoughts? William E. Haik, M.D., F.C.C.P., C.D.I.P. AHIMA Approved ICD-10-CM/PCS Trainer Office: (850) 863-2110<tel:(850)%20863-2110> Cell: (850) 803-5854<tel:(850)%20803-5854> Fax: (850) 864-4438 <tel:(850)%20864-4438> <tel:(850)%20864-4438> In a message dated 4/8/2015 4:21:14 P.M. Central Daylight Time, [email protected] writes:<tel:(850)%20864-4438> 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 [email protected]<mailto:[email protected]> 415-600-5770 office 415-600-1541 fax On Apr 8, 2015, at 8:11 AM, Brown, Sheree <[email protected]<mailto:[email protected]>> 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 [email protected]<allegiancehealth.org> <image001.gif> From: Sepsisgroups [mailto:[email protected]] On Behalf Of Andrew Markowski Sent: Wednesday, April 08, 2015 12:00 AM To: Ryan Arnold Cc: [email protected]<mailto:[email protected]> 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 214-766-0665<tel:214-766-0665> Sent from my iPhone On Apr 6, 2015, at 10:36 AM, Ryan Arnold <[email protected]<mailto:[email protected]>> 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. <[email protected]<mailto:[email protected]>> 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 [email protected]<mailto:[email protected]> office (415) 600-5770 fax (415) 600-1541 ________________________________ From: Sepsisgroups [[email protected]<mailto:[email protected]>] On Behalf Of Jennifer L Halligan [SJGH] [[email protected]<mailto:[email protected]>] Sent: Thursday, April 02, 2015 8:44 AM To: [email protected]<mailto:[email protected]> 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 <image001.gif>_______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ________________________________ This e-mail message and any attachment(s) is intended only for the individual(s) to whom it is addressed and may contain information that is privileged, confidential or proprietary in nature. Any unauthorized disclosure, copying or distribution of this e-mail or the content of this message is prohibited. 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