I agree that I am learning so much and finding answers to my questions. Things 
that make me go "HMMMMMM"

Anita Siscoe-Hapshie

Anita Siscoe-Hapshie, RN, MSN, CCRN
Sepsis Coordinator
[email protected]<mailto:[email protected]>
Citrus Memorial Hospital
502 W. Highlands Blvd.
Inverness, FL 34452
Office 352.560.6214
Fax 352.726.9119

    Nurses are true
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From: Sepsisgroups [mailto:[email protected]] On 
Behalf Of PAMELA J. ANDERSON
Sent: Tuesday, March 22, 2016 1:42 PM
To: Belfi, Karen <[email protected]>; Clement, Joseph (DPH) 
<[email protected]>; [email protected]
Subject: [EXTERNAL] Re: [Sepsis Groups] [EXTERNAL] Re: Severe Sepsis with 
Initial Lactate <4, repeat 3hrs later >4-?Shock or not

Thanks for taking the time to locate this for us - so it appears that for the 
sake of compliance for abstraction, we would answer "No" to septic shock 
present if based only on the repeat lactate, but for the sake of our patients, 
we should still give the fluid bolus.
Can I just say how much I appreciate this group! Don't know what we'd do 
without each other!
Pam

Pamela Anderson, BSN, RN
Clinical Data Abstractor
Interim Sepsis Coordinator
Loyola University Health System
Center for Clinical Excellence
Maguire Center | Bldg 105-3909 | Maywood, IL 60153
(O) 708-216-5544 | (F) 708-216-7867 | (E) 
[email protected]<mailto:[email protected]>

NOTE:  The information contained in this message may be privileged and 
confidential and protected from disclosure.  If the reader of this message is 
not the intended recipient, or an employee or agent responsible for delivering 
this message to the intended recipient, you are hereby notified that any 
dissemination, distribution or copying of this communication is strictly 
prohibited.  If you believe you have received this communication in error, 
please notify us immediately by replying to the message and deleting it from 
your computer.  Thank you.  Loyola University Health System

From: Belfi, Karen [mailto:[email protected]]
Sent: Tuesday, March 22, 2016 12:27 PM
To: PAMELA J. ANDERSON; Clement, Joseph (DPH); 
[email protected]<mailto:[email protected]>
Subject: RE: [EXTERNAL] Re: [Sepsis Groups] Severe Sepsis with Initial Lactate 
<4, repeat 3hrs later >4-?Shock or not

This was addressed in the CMS Q&A, from the Oct 26 webinar. We are to abstract 
the Initial Lactate for shock criteria, not any repeat levels.


Question 182: How would an abstractor proceed if a patient's initial lactate 
level was <2.0 but the repeat lactate level was >4.0? At the time of the repeat 
lactate level returning within 6 hours at a level greater than 4.0 (in the 
absence of hypotension <90), is the 30 cc/kg fluid bolus required or is the 30 
cc/kg fluid bolus only required on the initial lactate level if it is greater 
than 4.0?
Answer 182: For purposes of the SEP-1 measure, the initial lactate level result 
value is what is used. Assuming the patient does not have hypotension, if the 
initial lactate level result is < 4 the patient does not have septic shock. If 
it is ≥4 the patient does have septic shock. The measure does not require 
abstraction of the repeat lactate result level, only the time the repeat 
lactate was drawn. Clinically this would still represent septic shock and the 
patient should be treated accordingly.


Question 209: Shouldn't repeat lactate >4 be the definition of shock, not the 
initial, similar to how shock is not diagnosed until after fluid bolus 
administration?
Answer 209: While clinically a repeated or subsequent lactate ≥4 could signify 
the presence of septic shock, initial lactate is used for purposes of the 
measure to reduce the complexity in determining the presence of severe sepsis 
and septic shock. Please note, for purposes of the measure the initial lactate 
is not necessarily always going to be the first lactate drawn. The first bullet 
point in the Initial Lactate Level Collection data element's Notes for 
Abstraction states, "If there are multiple lactate levels, only abstract the 
level drawn closest to the time of presentation of severe sepsis. That lactate 
level is the initial lactate level for purposes of this data element."


Question 211: Septic Shock Present: On slide 26 it was added that the lactate 
level greater than 4 is related to the initial lactate. So if the repeat 
lactate to be done for the 6 hour window for severe sepsis is greater than 4 
but the initial was only 2.1, does this qualify as septic shock of no 
hypotension is present?
Answer 211: For purposes of the measure, the repeat lactate level is not 
collected and not taken into consideration. The measure only looks at whether 
or not a repeat lactate was drawn and the time it was drawn. If the initial 
lactate is < 4 and the patient does not have persistent hypotension, the 
patient does not have septic shock for purposes of the measure.



Karen Belfi, RN, MSN
Quality Outcomes Coordinator
Lankenau Medical Center
484-476-8092
Pager: 5240
[cid:25FFED76-F7F0-4047-910F-0D7077ED1E1E]

From: Sepsisgroups [mailto:[email protected]] On 
Behalf Of PAMELA J. ANDERSON
Sent: Friday, March 18, 2016 7:56 AM
To: Clement, Joseph (DPH); 
[email protected]<mailto:[email protected]>
Subject: [EXTERNAL] Re: [Sepsis Groups] Severe Sepsis with Initial Lactate <4, 
repeat 3hrs later >4-?Shock or not

That's what I would do, too - but because the v5.0b updated the spec to include 
mention of "initial lactate >=4", I'm confused - I've got a QNet pending that 
addresses this issue & I'll post it when I get a response.
Thanks!
Pam

Pamela Anderson, BSN, RN
Clinical Data Abstractor
Interim Sepsis Coordinator
Loyola University Health System
Center for Clinical Excellence
Maguire Center | Bldg 105-3909 | Maywood, IL 60153
(O) 708-216-5544 | (F) 708-216-7867 | (E) 
[email protected]<mailto:[email protected]>

NOTE:  The information contained in this message may be privileged and 
confidential and protected from disclosure.  If the reader of this message is 
not the intended recipient, or an employee or agent responsible for delivering 
this message to the intended recipient, you are hereby notified that any 
dissemination, distribution or copying of this communication is strictly 
prohibited.  If you believe you have received this communication in error, 
please notify us immediately by replying to the message and deleting it from 
your computer.  Thank you.  Loyola University Health System

From: Clement, Joseph (DPH) [mailto:[email protected]]
Sent: Thursday, March 17, 2016 4:09 PM
To: PAMELA J. ANDERSON; 
[email protected]<mailto:[email protected]>
Subject: Re: [Sepsis Groups] Severe Sepsis with Initial Lactate <4, repeat 3hrs 
later >4-?Shock or not


I would answer Yes to the septic shock question - as long as the shock 
date/time is within 6 hours of the severe sepsis time, it would count.



If anybody believes otherwise I'd love to hear as that's how we've done it.


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

________________________________
From: Sepsisgroups 
<[email protected]<mailto:[email protected]>>
 on behalf of PAMELA J. ANDERSON <[email protected]<mailto:[email protected]>>
Sent: Thursday, March 10, 2016 6:19 AM
To: 
[email protected]<mailto:[email protected]>;
 [email protected]<mailto:[email protected]>
Subject: [Sepsis Groups] Severe Sepsis with Initial Lactate <4, repeat 3hrs 
later >4-?Shock or not



v5.0b Specs indicate septic shock presentation date and time is determined by 
persistent hypotension... OR tissue perfusion present as evidenced by INITIAL 
lactate >=4.

Severe sepsis was present @ 09:12, with the initial lactate of 3.6. The repeat 
done @ 12:01 was 6.7 (30cc/kg was given).

Because there was no documentation of "septic shock", and the patient was not 
hypotensive at the end of the bolus, based on the verbiage from the specs, I 
would answer, "NO" to the question of whether Septic Shock was present.
Any thoughts?
Thanks-
Pam

Pamela Anderson, BSN, RN
Clinical Data Abstractor
Sepsis Coordinator
Loyola University Health System
Center for Clinical Excellence
2160 S. First Avenue | Bldg 105-3915 | Maywood, IL 60153
(O) 708-216-5544 | (F) 708-216-7867 | (E) 
[email protected]<mailto:[email protected]>



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