Following the guidelines, we don’t need physician documentation that the patient has severe sepsis. We need the 3 criteria of infection, 2 SIRS, and organ dysfunction. While the criteria we need to use for the measure isn’t without its faults, it’s what we have to work with currently. IN Q&As, we’ve been told to use the organ dysfunction unless there’s physician/APN/PA documentation that the lab is related to a different condition. Here are a couple examples:
Question 215: How will we tell if labs are related to chronic organ dysfunction? Are we to assume? Answer 215: If there is documentation indicating the abnormal lab is due to or may be due to a chronic condition or medication that is acceptable. The measure also provides two examples that are acceptable, creatinine >2 for a patient with end stage renal disease, and an INR > 1.5 for a patient on Warfarin. Question 315: On slide 34 it says not to include evidence of organ dysfunction that is considered chronic. Is the documentation of ESRD in the patient's history enough or does the physician need to specifically link the two in his/her documentation? Answer 315: An association does not need to be documented for Creatinine >2 for a patient with end stage renal disease, and INR >1.5 for a patient on Warfarin, because those are included in the Severe Sepsis Present. For other conditions and medications, there should be documentation indicating the association. Karen Belfi, RN, MSN Quality Outcomes Coordinator Lankenau Medical Center 484-476-8092 Pager: 5240 [cid:[email protected]] From: Sepsisgroups [mailto:[email protected]] On Behalf Of Dena Videtic Sent: Tuesday, July 05, 2016 8:13 AM To: Murray, Sandra; '[email protected]' Subject: [EXTERNAL] Re: [Sepsis Groups] Sepsis Question on organ dysfunction Sandra, This is a good question. From an abstraction point of view, I would look for physician documentation that the patient has Severe Sepsis because as nurses, it is not in our scope of practice to diagnose patients. The bilirubin could be elevated due to a biliary obstruction. An interesting article was published in April about the subjectivity of sepsis diagnosis even among physicians. If you’re interested it is called: ‘Diagnosing Sepsis is Subjective and Highly Variable: A Survey of Intensivists Using Case Vignettes” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822273/ Dena Videtic RN BSN Quality Indicators Doctors Hospital Coral Gables, FL 786-308-3315 From: Sepsisgroups [mailto:[email protected]] On Behalf Of Murray, Sandra Sent: Thursday, June 30, 2016 2:26 PM To: [email protected]<mailto:[email protected]> Subject: [Sepsis Groups] Sepsis Question on organ dysfunction Would you count a t.bili of 9.3 as organ dysfunction if patient comes in with abdominal pain, meets the SIRS criteria and the CT shows pt to have acute cholecystitis? Sandra Murray, RN, BSN | Heart Failure & Sepsis Program Coordinator Performance Improvement-Patient Safety and Risk T 817.848.4963 | M 682.367.3032 [email protected]<mailto:[email protected]> [cid:[email protected]] Follow us on Social Media This document was generated by, or was prepared by or at the direction or request of a medical committee, medical peer review committee, nursing peer review committee, and/or patient safety committee, including a joint committee, of Texas Health Resources and its member hospitals as defined under Texas Health & Safety Code Sec. 161.031, et seq., Texas Occ. Code Secs. 151.001, et seq., 160.001, et seq. and 303.001, et seq., and is used for committee purposes, specifically, quality assurance and assessment and the evaluation of patient safety and medical and healthcare services at the Hospital. This document and the information contained within it are considered confidential, privileged and not subject to court subpoena pursuant to the above-cited statutes and 42 U.S.C. Sec. 11101, et seq. The information contained in this message and any attachments is intended only for the use of the individual or entity to which it is addressed, and may contain information that is PRIVILEGED, CONFIDENTIAL, and exempt from disclosure under applicable law. If you are not the intended recipient, you are prohibited from copying, distributing, or using the information. Please contact the sender immediately by return e-mail and delete the original message from your system. ________________________________ This message originates from Baptist Health South Florida (BHSF). It contains information that may be confidential or privileged and is intended only for the individuals or entity named above. It is prohibited for anyone else to disclose, copy, distribute or use the contents of this message. This message may not be copied or distributed without this disclaimer. All personal messages express views solely of the sender, which are not to be attributed to BHSF. If you received this message in error, please notify us immediately at [email protected]<mailto:[email protected]>. BHSF scanned this email for viruses, vandals and malicious content
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