Something that has helped us immensely with more accurately defining our N regardless of great/not-so-great documentation is to look at cultures. If anyone orders a culture, it isn't a reach to say that infection has been suspected whether overtly stated or not. If you look at the labs concomitantly ordered with that 9/22 lactate (or within 6 hrs, at least), is there a blood culture? If so, you should be able to back up your checkmark for "infection" to around your 9/22 times.
Hope this helps! Sam -- Sam Farrell, RN CCRN Intensivist Program Manager West Coast Critical Care Specialists office: 805.988.7004 fax: 805.988.7101 cell: 805.444.3730 wccriticalcare.com *CONFIDENTIALITY NOTICE : This message and any included attachments are intended only for the addressee and may contain confidential information belonging to the sender that is legally protected. Unauthorized forwarding, printing, copying, distribution, or use of such information is strictly prohibited and may be unlawful. If you are not the addressee, please promptly delete this message and notify the sender of the delivery error by e-mail. Thank you.* On Sun, Oct 18, 2015 at 7:35 AM, Townsend, Sean, M.D. < [email protected]> wrote: > 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 <[email protected]> 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 =2.1 organ dys > 9-22 @ 2255 HR = 111 SIR > 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 > [email protected] > > > ************* > _______________________________________________ > Sepsisgroups mailing list > [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 >
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