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 <[email protected]<mailto:[email protected]>> 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. <[email protected]<mailto:[email protected]>> 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 <[email protected]<mailto:[email protected]><mailto:[email protected]>> 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. <[email protected]<mailto:[email protected]><mailto:[email protected]>> 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 <[email protected]<mailto:[email protected]><mailto:[email protected]>> 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:[email protected]] On Behalf Of Townsend, Sean, M.D. Sent: Tuesday, September 29, 2015 8:20 PM To: Jennifer L Halligan [SJGH] Cc: [email protected]<mailto:[email protected]><mailto:[email protected]> 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] <[email protected]<mailto:[email protected]><mailto:[email protected]><mailto:[email protected]>> 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 _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]><mailto:[email protected]><mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]><mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]><mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
