There is a new specification in the v5.2 manual starting with 1/1/17 discharges
(now available on Quality Net) that addresses this exact issue –
“Data Element Name: Blood Culture Collection Acceptable Delay” – Definition:
Documentation supporting there was an acceptable delay in the collection of a
blood culture.
Suggested Data Collection Question: Is there documentation supporting an
acceptable delay in collecting a blood culture?
Allowable Values:
There is documentation supporting an acceptable delay
in the collection of a blood culture.
There is no documentation supporting an acceptable
delay in the collection of a blood culture.
Notes for Abstraction:
Only the following situations demonstrate an acceptable
delay, resulting in the blood culture being drawn after an IV antibiotic was
administered. o Surgical patients who receive a pre-op prophylactic IV
antibiotic and within 24 hours of that antibiotic dose develop severe sepsis
then have a blood culture drawn.
o Within 24 hours prior to severe sepsis presentation,
IV antibiotics were started in the hospital for an infection before severe
sepsis was identified as present or suspected and a blood culture was drawn
after the initial IV antibiotic dose.
o Within 24 hours prior to severe sepsis presentation
IV antibiotics were started prior to arrival to the hospital and a blood
culture was drawn after arrival to the hospital.
o There is physician/APN/PA documentation indicating
the IV antibiotic was started before the blood culture was drawn because
waiting for the blood culture to be drawn would have resulted in a delay of 45
minutes or more in starting the IV antibiotic.
If there is documentation supporting an acceptable
delay in the collection of a blood culture, choose Value “1.”
If there is no documentation supporting an acceptable
delay in the collection of a blood culture, choose Value “2.”
There are also some other “tweaks” to some of the other measures that will
affect the Sep 1 abstractions – and this coming on the first day of v5.1 !!! ☺
Pam
Pamela Anderson, BSN, RN
Clinical Data Abstractor
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)
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From: Sepsisgroups [mailto:[email protected]] On
Behalf Of Coolidge, Diane
Sent: Thursday, June 30, 2016 8:39 AM
To: 'Charity Love'; Greg Stanford; Veronica Tarala
Cc: [email protected]
Subject: Re: [Sepsis Groups] Sepsisgroups Digest, Vol 209, Issue 1
I actually had a very similar scenario; attached is the response I received
from CMS. Hope this helps.
Diane
Diane Coolidge RN
Quality Review Specialist
Community Hospital Division, Quality Assurance
Phone: 262-257-3419 Fax: 262-257-2620
E-mail: [email protected]<mailto:[email protected]>
Froedtert & The Medical College of Wisconsin
Community Memorial Hospital
W180 N8085 Town Hall Road
Menomonee Falls, WI 53051
froedtert<http://www.froedterthealth.org/>.com
This document is a confidential peer review document that records the
investigations, proceedings and evaluations of Froedtert Hospital and Medical
College of Wisconsin for the purpose of reviewing or evaluating the quality of
health care and services provided by Froedtert Hospital and Medical College of
Wisconsin. Medical College of Wisconsin Medical Staff
This document may not be disclosed or released except as specifically provided
in Section 146.38(3) of the Wisconsin Statutes. The unauthorized disclosure or
release of this document or the information contained in this document may
result in civil liability pursuant to Section 146.38(4) of the Wisconsin
Statutes
From: Sepsisgroups [mailto:[email protected]] On
Behalf Of Charity Love
Sent: Tuesday, June 28, 2016 11:49 AM
To: Greg Stanford; Veronica Tarala
Cc:
[email protected]<mailto:[email protected]>
Subject: Re: [Sepsis Groups] Sepsisgroups Digest, Vol 209, Issue 1
Would like an opinion on a specific case. I have a patient that came in
through the ED and only fit criteria for sepsis, not severe in the ED and blood
cultures were not taken prior to IV ABX administration. This patient later
became hypotensive on the floor, thus fitting the criteria for severe sepsis
since two SIRS were present at this time. Since blood cultures were not
originally taken prior to ABX administration would this still be a fallout even
if at the time the ABX were given the patient did not yet meet severe sepsis
criteria? If blood cultures are taken once we have the presentation of severe
sepsis would this fit the measure even if it would be after the first dose of
ABX was already given?
Would appreciate anyone’s input on this matter.
Thanks,
Charity Love, RN, CCRN
Sepsis Coordinator
Mount Sinai Medical Center-Infection Control
Office: (305) 674-2121 X54926
Pager: (305) 212-4041
Cell: (305) 785-4214
From: Sepsisgroups [mailto:[email protected]] On
Behalf Of Greg Stanford
Sent: Saturday, June 25, 2016 2:20 PM
To: Veronica Tarala
Cc:
[email protected]<mailto:[email protected]>
Subject: Re: [Sepsis Groups] Sepsisgroups Digest, Vol 209, Issue 1
Here you go.
On Jun 25, 2016, at 12:06 PM, Veronica Tarala
<[email protected]<mailto:[email protected]>> wrote:
Does anyone have access to an article that has the latest definition of sepsis?
On Jun 23, 2016, at 6:47 PM, Greg Stanford
<[email protected]<mailto:[email protected]>> wrote:
No. Coding should not be using a differential diagnosis. It depends on how it
is worded. “Probable”, for example, will get coded. “Possible” will not. I
have ED docs who will put everything but the kitchen sink into the differential
because they think that will justify a higher level of billing. They
frequently have a template with a huge list of differentials. And it does not
meet criteria for source of infection.
Greg Stanford, MD
Medical Director
Clinical Documentation Improvement and Outcomes
1840 Amherst Street | Winchester, Va 22601
Phone: (540) 596 4999 Cell: 540 664 5736 |
|[email protected]<mailto:[email protected]>
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I would like to understand how my peers are abstracting a particular issue. I
have a question for the group…
If you have a patient in the EC and the physician lists as part of the
differential diagnoses a UTI or PNA. Then the physician documents as his final
EC diagnosis respiratory failure, COPD with exacerbation. Then let’s say the
patient does have the clinical signs to support severe sepsis. (temp 102, Pulse
124, Respiratory failure documented and placed on vent).
Do you count the differential diagnoses of UTI and PNA as a source of infection
in this scenario?
Thanks,
Debra
Debra M. Cox, BSN, RN
STTI Member
Corporate Quality Specialist | Quality Services
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O: 864-560-2694 | c: 864-327-5731 | f: 864-560-7365
e: [email protected]<mailto:[email protected]>| w:
SpartanburgRegional.com<http://www.spartanburgregional.com/>
"You never change things by fighting the existing reality. To change something,
build a new model that makes the existing model obsolete." ~R.
Buckminster Fuller
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