Good Morning! Our EMR will change the color of the value to red if it falls below the "norms" - making it easier to spot.
There are a couple of ways to avoid the inappropriate presence of Severe Sepsis based on criteria - First, per the Sep-1 Add'l notes for abstraction (v5.1), "If there is physician/APN/PA documentation or nursing documentation indicating a low blood pressure reading is invalid, erroneous, or questionable, disregard that reading when determining the presence of initial hypotension"; and, per the Specifications Manual for National Hospital Inpatient Quality Measures, version 5.2a - Additional Notes for Abstraction for the Sepsis (SEP-1 Measure) Version 5.2a - Updated: November 2016: "Initial Hypotension": For physician/APN/PA documentation indicating a SBP <90 mmHg or MAP <65 mmHg is normal for the patient, is due to a chronic condition, is due to an acute condition that is not an infection, or is due to a medication, the following apply: -The documentation must also include either the blood pressure value or reference to the low blood pressure under consideration. If the value or reference to the value is not included in the documentation, inferences should not be made that the documentation pertains to the abnormal value. -The documentation should be prior to or within 24 hours following the time the value was recorded or reported. -If there is physician/APN/PA documentation indicating the patient does not have hypotension and it is referencing a specific time period in which there was one or more low blood pressure recorded, the low blood pressure value(s) should not be used. The documentation must be within 24 hours following the low blood pressure value(s)." This would require the RN or MD to actually be aware of the significance of a low MAP & the need to closely review patient's vital signs to "catch" the low map(s). In addition, if it is discovered within the 6 hour window, have the MD/APN/PA document within 6 hours of TOP that the patient does not have Severe Sepsis & you are good to go. Hope this helps! Pam Pamela Anderson, BSN, RN Clinical Data Abstractor Loyola University Health System Center for Clinical Excellence 2160 S. First Avenue | Bldg 105-3908 | Maywood, IL 60153 (O) 708-216-5228 | (F) 708-216-7867 | (E) [email protected]<mailto:[email protected]> CONFIDENTIALITY NOTICE** This email communication and any attachments may contain confidential and privileged PHI for the use of the designated recipients named above. Distribution, reproduction or any other use of this transmission by any party other than the intended recipient is prohibited. If you have received this communication in error, please notify the sender immediately. From: Sepsisgroups [mailto:[email protected]] On Behalf Of Nelson, Kathy Sent: Friday, April 07, 2017 2:43 PM To: [email protected] Subject: [External] [Sepsis Groups] One low MAP can trigger Severe Sepsis presentation Question posed by our physician leadership: Is anyone else having a problem with their CMS bundles when it comes to a low MAP. Our EMR captures every vital sign and if the auto-calculated MAP falls only momentarily to 64, it will trigger our data abstractors to establish a diagnosis of hypotension and put the patient into the severe sepsis category without necessarily having any of the other organ dysfunction criteria for the diagnosis. This results in a fall out on the bundle and makes us non-compliant from CMS data collection purposes. Has anyone else had a similar EMR issue and if so, how did you deal with it? Thanks! Kathy Nelson, MBA, CPHQ, RHIA Public Data Manager Advocate Health Care Center for Health Information Services (CHIS) 3075 Highland Parkway, Suite 600 Downers Grove, IL 60515 P: 630- 929-6782 (Internal: 55-6782) [email protected]<mailto:[email protected]> This e-mail, and any attachments thereto, is intended only for use by the addressee(s) named herein and may contain legally privileged and/or confidential information. If you are not the intended recipient of this e-mail (or the person responsible for delivering this document to the intended recipient), you are hereby notified that any dissemination, distribution, printing or copying of this e-mail, and any attachments thereto, is strictly prohibited. If you have received this e-mail in error, please respond to the individual sending the message and permanently delete the original and any copy of any e-mail and any printout thereof. Confidentiality Notice: This e-mail, including any attachments is the property of Trinity Health and is intended for the sole use of the intended recipient(s). It may contain information that is privileged and confidential. Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please delete this message, and reply to the sender regarding the error in a separate email.
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