We changed triage time to time of onset of hypotension/lactate >4 a while back 
as time zero. It made sense and that is what our state quality improvement 
project had been collecting. I have the same concerns about time 0 in a pt with 
clear septic shock being AFTER fluid administration and BP status is known. 
Time from hypotension to fluid bolus seems like one of the most important parts 
of the bundle. i assume the time after the fluid bolus if lactate > 4 would 
also be considered time 0 regardless of blood pressure?


Daniel Gerard RPh
Critical Care Pharmacist
McLaren Northern Michigan
231-487-4770
FAX: 213-487-4817
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Sent: Friday, May 29, 2015 8:30 AM
To: [email protected]
Subject: Sepsisgroups Digest, Vol 158, Issue 6

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Today's Topics:

   1. Joint Commission Performance Measure Time Zero (Angela Craig)
   2. Re: Joint Commission Performance Measure (Angela Craig)
   3. Re: CMS Guidelines (Brandy Cuevas)


----------------------------------------------------------------------

Message: 1
Date: Thu, 28 May 2015 10:32:10 -0500
From: Angela Craig <[email protected]>
To: "'[email protected]'"
        <[email protected]>,
        "[email protected]"
        <[email protected]>
Subject: [Sepsis Groups] Joint Commission Performance Measure Time
        Zero
Message-ID:
        
<343E31412FC9094487B54371286ADDA01F2B14CB48@D109EXCHMB.crmchealth.hospital>

Content-Type: text/plain; charset="utf-8"

OK so most of us have changed to time of triage for time zero  I would assume.  
I had a meeting with our data abstractor for Sepsis Core Measures yesterday and 
she mentioned time zero would be changing.  She then showed me the manual for 
the data abstractors.

It stated for Septic Shock Present the following:  Criteria

There must be documentation of severe sepsis present AND
Tissue hypoperfusion persists after crystalloid fluid administration evidenced 
by either SBP <90, or MAP<65, or a decrease in SBP by >40points OR Lactate 
level is >4

Soooo My abstractor was under the impression this would be the new time zero 
based on this.

There was a sheet on Severe Sepsis Present as well.  What concerns me is that 
based on documentation is what will que them for time zero.  I am worried that 
there will be delays in care if that is how it will be determined.  What are 
everyone's thoughts?

Am I missing something?  Will everyone just stay with time zero that we feel is 
"clinically correct" and consistent across the country and just let core 
measures monitor something different?  Can someone help me understand this.  I 
really hope I am not reading something correctly or just not understanding.

Thank you in advance - I am soo grateful for this List serve!!!

Angela Craig APN,MS,CCNS
Clinical Nurse Specialist
Intensive Care Unit
Cookeville Regional Medical Center
931-783-5035

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Message: 2
Date: Thu, 28 May 2015 10:22:49 -0500
From: Angela Craig <[email protected]>
To: "'[email protected]'"
        <[email protected]>,
        "[email protected]"
        <[email protected]>
Subject: Re: [Sepsis Groups] Joint Commission Performance Measure
Message-ID:
        
<343E31412FC9094487B54371286ADDA01F2B14CB47@D109EXCHMB.crmchealth.hospital>

Content-Type: text/plain; charset="utf-8"

We just certified and I think the 3 hour bundle compliance is great.  We also 
chose to look at screening compliance.  We have the units on all the floors 
screen a sampling to make sure they are done accurately.  2 other areas we 
chose to look at were time to goal with CVP and SCVO2.  Just a few ideas for 
you.

Angela Craig APN,MS,CCNS
Clinical Nurse Specialist
Intensive Care Unit
Cookeville Regional Medical Center
931-783-5035


From: Sepsisgroups [mailto:[email protected]] On 
Behalf Of [email protected]
Sent: Wednesday, May 27, 2015 2:29 PM
To: [email protected]
Subject: [Sepsis Groups] Joint Commission Performance Measure

Good Afternoon,

I will be recertifying for the second time and curious to see what is "IN" 
right now for the Joint Commission performance measures.  I was leaning towards 
3 hour bundle compliance, lactate clearance but am looking for any other 
suggestions to get me to 4 measures.

Thank you!

Megan Borden, BSN, RN, CEN
Sepsis Coordinator
Memorial Hospital Jacksonville
3625 University Blvd South
Jacksonville, FL 32216
Office: 904-702-6080
Mobile: 904-334-7079



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Message: 3
Date: Thu, 28 May 2015 10:03:11 -0500
From: Brandy Cuevas <[email protected]>
To: "[email protected]"
        <[email protected]>
Cc: "[email protected]"
        <[email protected]>
Subject: Re: [Sepsis Groups] CMS Guidelines
Message-ID:
        <[email protected]>
Content-Type: text/plain; charset="us-ascii"

Hi Debbie,
It is my understanding that a patient with severe sepsis only has to have a 
repeat lactate within 6 hours if initial lactate is elevated.  Only in septic 
shock patients does the patient need the focused exam or two of the other items.

Maybe I am misunderstanding the measure?  My perception is if after the initial 
3 hour requirement (lactate, blood culture, abx, and fluid), if the "repeat 
exam" shows hypotension and the patient is placed on a vasopressor, then at 
that time (which is the re-assessment) they need the focused exam or two of the 
other items.  If they are not hypotensive/on vasopressors, then they are only 
severe sepsis and not septic shock which does not require the additional 
testing?!

If you find out differently, please let me know!  I have attached a sepsis 
guideline sheet that a hospital shared on the listserv that has been helpful to 
me.

Brandy

Brandy Cuevas, BSN, RN
Quality Improvement Coordinator
William Newton Hospital
1300 E. 5th Ave.
Winfield, KS  67156
620-222-6225
[email protected]<mailto:[email protected]>

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From: Sepsisgroups [mailto:[email protected]] On 
Behalf Of [email protected]
Sent: Wednesday, May 27, 2015 2:25 PM
To: [email protected]
Subject: [Sepsis Groups] CMS Guidelines

So, I've read through the new CMS Guidelines and it states that a repeat 
assessment must be completed within 6 hrs with either a focused exam (including 
VS, cardiopulmonary exam, cap refill, peripheral pulse eval and skin exam) or 
any two of the four: CVP, SV02, bedside cardiovascular ultrasound, passive leg 
raise or fluid challenge.

At our hospital, we have the "shift evaluation" and "shift re-evaluation."  If 
the nurse documents the "shift re-evaluation" they are basically saying nothing 
has changed since the last evaluation.  I'm wondering if that will suffice, or 
if they actually have to do another complete head-to-toe assessment.  Any 
thoughts??

Thanks,
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:[email protected]]


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