It appears that CMS is prescriptive on what is allowed as exclusion criteria 
for fluids.  Patients can refuse fluids but from what I can conclude from the 
measure this must be clearly documented by the provider.  We have missed this 
measure repeatedly for not giving the 30ml/kg even if there is provider 
documentation to the "why not".  I do acknowledge from the literature that in 
hypotensive septic patients we are treating the patients shock not their 
co-morbidity. I do support an exception in the measure if the provider 
documents "fluid overload" secondary to the fluid bolus (with other data: drop 
in SPO2, ECHO, dynamic fluid responsive measurements)....but CMS is not there 
yet.  

Jeanie Bollinger MSN,RN, ACCNS-AG, CCRN-K
Clinical Nurse Specialist
Acute Medicine
Mission Health
509 Biltmore Avenue
Asheville, NC 28801

Office: 828-213-7171
Cell: 828-400-1194

-----Original Message-----
From: Sepsisgroups [mailto:[email protected]] On 
Behalf Of [email protected]
Sent: Monday, September 17, 2018 1:39 PM
To: [email protected]
Subject: [EXTERNAL] Sepsisgroups Digest, Vol 305, Issue 1

Send Sepsisgroups mailing list submissions to
        [email protected]

To subscribe or unsubscribe via the World Wide Web, visit
        http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org

or, via email, send a message with subject or body 'help' to
        [email protected]

You can reach the person managing the list at
        [email protected]

When replying, please edit your Subject line so it is more specific than "Re: 
Contents of Sepsisgroups digest..."


Today's Topics:

   1. Re: Sepsisgroups Digest, Vol 304, Issue 2 (Carlson, Brenda L)
   2. Bolus infusions (Jeanie Bollinger)


----------------------------------------------------------------------

Message: 1
Date: Thu, 13 Sep 2018 14:39:27 +0000
From: "Carlson, Brenda L" <[email protected]>
To: "'[email protected]'"
        <[email protected]>
Subject: Re: [Sepsis Groups] Sepsisgroups Digest, Vol 304, Issue 2
Message-ID:
        <aa41639db69c4bc2b5384201df38e...@exmbxpdc08.urmc-sh.rochester.edu>
Content-Type: text/plain; charset="us-ascii"

Perhaps CMS would have accepted this as an appropriate exclusion if the 
provider had included wording such as "CHF with pulmonary edema and concerns 
for fluid overload" or "ESRD on HD with anasarca and concerns for fluid 
overload". The provider didn't clearly state why there was a concern for fluid 
overload. 

Brenda L. Carlson MS, BSN, RN
Assistant Quality Officer
Office of Clinical Practice Evaluation
University of Rochester Medical Center
265 Crittenden Blvd., Saunders Research Building, 3.205
585-273-4721
This message may contain information which is confidential and privileged. 
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message in error, please advise sender by reply email, and delete the message. 
Thank you! 




-----Original Message-----
From: Sepsisgroups [mailto:[email protected]] On 
Behalf Of [email protected]
Sent: Wednesday, September 12, 2018 4:06 PM
To: [email protected]
Subject: Sepsisgroups Digest, Vol 304, Issue 2

Send Sepsisgroups mailing list submissions to
        [email protected]

To subscribe or unsubscribe via the World Wide Web, visit
        
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or, via email, send a message with subject or body 'help' to
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When replying, please edit your Subject line so it is more specific than "Re: 
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Today's Topics:

   1. 30mL/Kg Bolus Exemptions (Culver, Danette)
   2. Re: Blood cultures false positive (Vickie Robertson)


----------------------------------------------------------------------

Message: 1
Date: Wed, 12 Sep 2018 13:35:59 -0400
From: "Culver, Danette" <[email protected]>
To: "[email protected]"
        <[email protected]>
Subject: [Sepsis Groups] 30mL/Kg Bolus Exemptions
Message-ID:
        <6fe413f8a5447e4498be19afc648a354015120393...@nhc0902.nhc.network.local>
        
Content-Type: text/plain; charset="us-ascii"

All,

We recently queried CMS for accepting the following documentation as refusal to 
30ml/kg bolus and they stated it did not meet the criteria. Can anyone provide 
a rationale as to why this documentation doesn't suffice? My providers prefer 
taking a more positive approach that is more inclusive of the patient, not the 
negative tone of 'patient refuses.' Any advice is greatly appreciated as well.

The following was documented by one of my MDs - "Patient meets criteria for 
30ml/kg bolus, there is concern for fluid overload and cardiogenic shock. The 
plan was discussed with patient and patient's daughter who agreed to modified 
plan of care to include gentle hydration and vasopressors, not a 30ml/kg bolus."

Thanks so much,
Danette

Danette Culver, MSN, APRN, ACNS-BC, CCRN-K, RN-BC Clinical Nurse Specialist, 
Sepsis Coordinator Norton Healthcare, Louisville KY
O: 502.629.4058
C: 812.881.0080

A Clinical Nurse Specialist (CNS) is a Master's prepared Advance Practice Nurse 
whose function is to improve outcomes in patient care. The CNS is a clinical 
practice expert, an educator, a researcher, and a consultant who influences the 
three spheres of practice: patient care, nursing, and systems. - National 
Association of Clinical Nurse Specialists

______________________________________________________________________
This message is confidential, intended only for the named recipient(s) and may 
contain information that is privileged or exempt from disclosure under 
applicable law. Any patient health information must be delivered immediately to 
intended recipient(s). If you are not the intended recipient(s), you are 
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 >

------------------------------

Message: 2
Date: Mon, 10 Sep 2018 22:34:53 +0000
From: Vickie Robertson <[email protected]>
To: jenny clarke <[email protected]>
Cc: "[email protected]"
        <[email protected]>
Subject: Re: [Sepsis Groups] Blood cultures false positive
Message-ID:
        <[email protected]>
Content-Type: text/plain; charset="iso-8859-1"

We had the same issue at a hospital I previously worked for, especially in the 
ED where we were responsible for drawing our own labs.  We found the following 
contributed to the contaminated specimen:
        1.  Cultures were being drawn from the IV site which caused them to 
often be contaminated.  (Site cleansed with Chloraprep thoroughly before 
anything 
                else was set up allowing for the proper drying time between 
cleansing and sticking)
        2.   Nurses would draw both sets from the same site (in serviced on 2 
sets  = 2 sites unless extremely hard stick then only 1 set was obtained)
        3.  When doing blood cultures, the bottles were often uncapped and left 
sitting at the bedside while finishing setting up to drawn them.
                This left them exposed in the room (corrected by when uncapped 
an alcohol prep was placed over the cap until ready to place the blood)
        
Every month on the BULLETIN BOARD in our breakroom, were the names of all 
nurses along with their contamination percentage, if we had X amount of 
contaminates we had to do an in service with 15 of our Co-workers reviewing the 
proper way to draw a blood culture.


Have a Blessed Day. Philippians 4:13 (NKJV)1 "?I can do all things through 
Christ who strengthens me."
Thank you.

Vickie Robertson, RN, Case Manager
Unity Health | Harris Medical Center
1205 McLain St. | Newport, AR 72112
?P (870) 512-3224 | F (870) 523-0395
https://urldefense.proofpoint.com/v2/url?u=http-3A__www.Unity-2DHealth.org&d=DwICAg&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=FQX0EdGt2z5AU0WET6IGnDY7hW-OH5oVWIrKTppItnPTAfNZCRPOOCAWFJtHw_aG&m=7329wV9Z4IOW17kRPGK2wreBn9maXVs3QX8R3uLOo4U&s=B5wLuN-geZL2hNfSg3E-pDx0Lr_yOHfMCcCtpIC1eSc&e=
?


?
Disclaimer:? This electronic message may contain information that is 
Proprietary, Confidential, or Legally privileged or protected.? It is intended 
only for the individual(s) and entity named in the message.? If you are not an 
intended recipient of this message, please notify the sender immediately and 
delete the material from your computer.? Do not deliver, distribute or copy 
this message and do not disclose its contents or take any action in reliance on 
the information it contains.
?



-----Original Message-----
From: Sepsisgroups [mailto:[email protected]] On 
Behalf Of jenny clarke
Sent: Friday, September 7, 2018 1:10 PM
To: Angela Craig <[email protected]>
Cc: [email protected]
Subject: Re: [Sepsis Groups] Blood cultures false positive

That is a great idea. Thanks 

Sent from my iPhone

> On Sep 7, 2018, at 1:02 PM, Angela Craig <[email protected]> wrote:
> 
> We are working on this exact issue at our hospital.  We are about to go to a 
> process where we will post all names and contamination rates and celebrate 
> those who do well and those who have a 3% or greater contamination rate will 
> have to go to a blood culture refresher class.  Hope that helps.  
> 
> 
> 
> Angela Craig APN,MS,CCNS
> ICU Clinical Nurse Specialist
> 1 Medical Center Boulevard, Cookeville, TN 38501
> Phone: 931-783-5035 Fax: 931-783-5039 [email protected] | 
> crmchealth.org |Facebook | Twitter Cookeville Regional Medical Center:
> Building Healthier Communities
> 
> -----Original Message-----
> From: Sepsisgroups
> [mailto:[email protected]] On Behalf Of 
> Bankert, Eve
> Sent: Wednesday, September 05, 2018 11:39 AM
> To: jenny clarke; [email protected]
> Subject: Re: [Sepsis Groups] Blood cultures false positive
> 
> *** WARNING: This is an EXTERNAL EMAIL that originated outside of 
> CRMC's Email System. Do not click any links or open any attachments 
> unless you trust the sender and know the content is safe. ***
> 
> 
> I would recommend extensive education/training for all personnel collecting 
> blood cultures.  As the microbiology supervisor in a community hospital in NY 
> that had a 10% contamination rate, we used a multidisciplinary approach and 
> brought the rate down to 2% in a year's time.
> 
> -----Original Message-----
> From: Sepsisgroups
> [mailto:[email protected]] On Behalf Of 
> jenny clarke
> Sent: Tuesday, September 04, 2018 12:42 PM
> To: [email protected]
> Subject: [Sepsis Groups] Blood cultures false positive
> 
> Anyone have any help to curb this issue? I have even tried to make it 
> sterile process and still running into issues.  Thanks ahead
> 
> Sent from my iPhone
> _______________________________________________
> Sepsisgroups mailing list
> [email protected]
> https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups
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> KTppItnPTAfNZCRPOOCAWFJtHw_aG&m=7329wV9Z4IOW17kRPGK2wreBn9maXVs3QX8R3u
> LOo4U&s=8bos_quxtQkMZ3DJRkqqWwrubHz5nfRzumfGjKTjtBw&e=
> rg _______________________________________________
> Sepsisgroups mailing list
> [email protected]
> https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups
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> KTppItnPTAfNZCRPOOCAWFJtHw_aG&m=7329wV9Z4IOW17kRPGK2wreBn9maXVs3QX8R3u
> LOo4U&s=8bos_quxtQkMZ3DJRkqqWwrubHz5nfRzumfGjKTjtBw&e=
> rg
> 
> This email message has been delivered safely and archived online by 
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------------------------------

Subject: Digest Footer

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------------------------------

End of Sepsisgroups Digest, Vol 304, Issue 2
********************************************


------------------------------

Message: 2
Date: Fri, 14 Sep 2018 17:46:02 +0000
From: Jeanie Bollinger <[email protected]>
To: "[email protected]"
        <[email protected]>
Subject: [Sepsis Groups] Bolus infusions
Message-ID:
        
<dm5pr04mb02047ee831f1866793158cbd82...@dm5pr04mb0204.namprd04.prod.outlook.com>
        
Content-Type: text/plain; charset="us-ascii"

Danette I have had some of the same questions.  As the Clinical Nurse 
Specialist on our sepsis team, I review every CMS OFI.  If we fall out on 
fluids, I then look through my CNS lens as a clinical expert to determine from 
a broad perspective if the patient received the appropriate care.  If there is 
any grey at all, these cases are then sent to one of our sepsis team MDs for 
review.  We then all learn from any opportunities and this is shared with our 
teams. 

 I remember some time ago Dr. Townsend confirming that we (our teams) should 
focus on improvement for our septic population and not alter appropriate care 
in order to meet the CMS measure. We had a recent fallout because we did not 
meet the 30 ml/kg but during fluid resuscitation.  I reviewed this patient in 
depth.  The patient's SPO2 dropped and the patient subsequently developed 
pulmonary edema.  It would not have been appropriate to continue to volume 
resuscitate this patient who developed respiratory distress and pulmonary 
edema.  Subsequent echo demonstrated right ventricular overload with 
ventricular septum on the LV wall.  Appropriate care was done but we missed the 
measure.  

This measure is a challenge as it represents a small sample of our large septic 
population.  I am fortunate to have advanced analytics to help our team analyze 
the data of our entire population and so we can focus on PDSA cycles.  Yes our 
sepsis dashboard is dependent on provider coding the patient appropriately, but 
we have made and sustained our improvements.  We always have opportunities for 
improvement. Sepsis is definitely a marathon and not a sprint.  

Jeanie Bollinger MSN,RN, ACCNS-AG, CCRN-K Clinical Nurse Specialist Acute 
Medicine Mission Health
509 Biltmore Avenue
Asheville, NC 28801

Office: 828-213-7171
Cell: 828-400-1194

-----Original Message-----
From: Sepsisgroups [mailto:[email protected]] On 
Behalf Of [email protected]
Sent: Wednesday, September 12, 2018 4:06 PM
To: [email protected]
Subject: [EXTERNAL] Sepsisgroups Digest, Vol 304, Issue 2

Send Sepsisgroups mailing list submissions to
        [email protected]

To subscribe or unsubscribe via the World Wide Web, visit
        http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org

or, via email, send a message with subject or body 'help' to
        [email protected]

You can reach the person managing the list at
        [email protected]

When replying, please edit your Subject line so it is more specific than "Re: 
Contents of Sepsisgroups digest..."


Today's Topics:

   1. 30mL/Kg Bolus Exemptions (Culver, Danette)
   2. Re: Blood cultures false positive (Vickie Robertson)


----------------------------------------------------------------------

Message: 1
Date: Wed, 12 Sep 2018 13:35:59 -0400
From: "Culver, Danette" <[email protected]>
To: "[email protected]"
        <[email protected]>
Subject: [Sepsis Groups] 30mL/Kg Bolus Exemptions
Message-ID:
        <6fe413f8a5447e4498be19afc648a354015120393...@nhc0902.nhc.network.local>
        
Content-Type: text/plain; charset="us-ascii"

All,

We recently queried CMS for accepting the following documentation as refusal to 
30ml/kg bolus and they stated it did not meet the criteria. Can anyone provide 
a rationale as to why this documentation doesn't suffice? My providers prefer 
taking a more positive approach that is more inclusive of the patient, not the 
negative tone of 'patient refuses.' Any advice is greatly appreciated as well.

The following was documented by one of my MDs - "Patient meets criteria for 
30ml/kg bolus, there is concern for fluid overload and cardiogenic shock. The 
plan was discussed with patient and patient's daughter who agreed to modified 
plan of care to include gentle hydration and vasopressors, not a 30ml/kg bolus."

Thanks so much,
Danette

Danette Culver, MSN, APRN, ACNS-BC, CCRN-K, RN-BC Clinical Nurse Specialist, 
Sepsis Coordinator Norton Healthcare, Louisville KY
O: 502.629.4058
C: 812.881.0080

A Clinical Nurse Specialist (CNS) is a Master's prepared Advance Practice Nurse 
whose function is to improve outcomes in patient care. The CNS is a clinical 
practice expert, an educator, a researcher, and a consultant who influences the 
three spheres of practice: patient care, nursing, and systems. - National 
Association of Clinical Nurse Specialists

______________________________________________________________________
This message is confidential, intended only for the named recipient(s) and may 
contain information that is privileged or exempt from disclosure under 
applicable law. Any patient health information must be delivered immediately to 
intended recipient(s). If you are not the intended recipient(s), you are 
notified that the dissemination, distribution or copying of this message is 
strictly prohibited. If you receive this message in error, or are not the named 
recipient(s), please notify the sender at either the e-mail address or 
telephone number above and discard this e-mail. Thank you.
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------------------------------

Message: 2
Date: Mon, 10 Sep 2018 22:34:53 +0000
From: Vickie Robertson <[email protected]>
To: jenny clarke <[email protected]>
Cc: "[email protected]"
        <[email protected]>
Subject: Re: [Sepsis Groups] Blood cultures false positive
Message-ID:
        <[email protected]>
Content-Type: text/plain; charset="iso-8859-1"

We had the same issue at a hospital I previously worked for, especially in the 
ED where we were responsible for drawing our own labs.  We found the following 
contributed to the contaminated specimen:
        1.  Cultures were being drawn from the IV site which caused them to 
often be contaminated.  (Site cleansed with Chloraprep thoroughly before 
anything 
                else was set up allowing for the proper drying time between 
cleansing and sticking)
        2.   Nurses would draw both sets from the same site (in serviced on 2 
sets  = 2 sites unless extremely hard stick then only 1 set was obtained)
        3.  When doing blood cultures, the bottles were often uncapped and left 
sitting at the bedside while finishing setting up to drawn them.
                This left them exposed in the room (corrected by when uncapped 
an alcohol prep was placed over the cap until ready to place the blood)
        
Every month on the BULLETIN BOARD in our breakroom, were the names of all 
nurses along with their contamination percentage, if we had X amount of 
contaminates we had to do an in service with 15 of our Co-workers reviewing the 
proper way to draw a blood culture.


Have a Blessed Day. Philippians 4:13 (NKJV)1 "?I can do all things through 
Christ who strengthens me."
Thank you.

Vickie Robertson, RN, Case Manager
Unity Health | Harris Medical Center
1205 McLain St. | Newport, AR 72112
?P (870) 512-3224 | F (870) 523-0395
www.Unity-Health.org
?


?
Disclaimer:? This electronic message may contain information that is 
Proprietary, Confidential, or Legally privileged or protected.? It is intended 
only for the individual(s) and entity named in the message.? If you are not an 
intended recipient of this message, please notify the sender immediately and 
delete the material from your computer.? Do not deliver, distribute or copy 
this message and do not disclose its contents or take any action in reliance on 
the information it contains.
?



-----Original Message-----
From: Sepsisgroups [mailto:[email protected]] On 
Behalf Of jenny clarke
Sent: Friday, September 7, 2018 1:10 PM
To: Angela Craig <[email protected]>
Cc: [email protected]
Subject: Re: [Sepsis Groups] Blood cultures false positive

That is a great idea. Thanks 

Sent from my iPhone

> On Sep 7, 2018, at 1:02 PM, Angela Craig <[email protected]> wrote:
> 
> We are working on this exact issue at our hospital.  We are about to go to a 
> process where we will post all names and contamination rates and celebrate 
> those who do well and those who have a 3% or greater contamination rate will 
> have to go to a blood culture refresher class.  Hope that helps.  
> 
> 
> 
> Angela Craig APN,MS,CCNS
> ICU Clinical Nurse Specialist
> 1 Medical Center Boulevard, Cookeville, TN 38501
> Phone: 931-783-5035 Fax: 931-783-5039 [email protected] | 
> crmchealth.org |Facebook | Twitter Cookeville Regional Medical Center:
> Building Healthier Communities
> 
> -----Original Message-----
> From: Sepsisgroups
> [mailto:[email protected]] On Behalf Of 
> Bankert, Eve
> Sent: Wednesday, September 05, 2018 11:39 AM
> To: jenny clarke; [email protected]
> Subject: Re: [Sepsis Groups] Blood cultures false positive
> 
> *** WARNING: This is an EXTERNAL EMAIL that originated outside of 
> CRMC's Email System. Do not click any links or open any attachments 
> unless you trust the sender and know the content is safe. ***
> 
> 
> I would recommend extensive education/training for all personnel collecting 
> blood cultures.  As the microbiology supervisor in a community hospital in NY 
> that had a 10% contamination rate, we used a multidisciplinary approach and 
> brought the rate down to 2% in a year's time.
> 
> -----Original Message-----
> From: Sepsisgroups
> [mailto:[email protected]] On Behalf Of 
> jenny clarke
> Sent: Tuesday, September 04, 2018 12:42 PM
> To: [email protected]
> Subject: [Sepsis Groups] Blood cultures false positive
> 
> Anyone have any help to curb this issue? I have even tried to make it 
> sterile process and still running into issues.  Thanks ahead
> 
> Sent from my iPhone
> _______________________________________________
> Sepsisgroups mailing list
> [email protected]
> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.o
> rg _______________________________________________
> Sepsisgroups mailing list
> [email protected]
> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.o
> rg
> 
> This email message has been delivered safely and archived online by 
> Mimecast.  For more information please visit http://www.mimecast.com
> 
_______________________________________________
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[email protected]
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------------------------------

Subject: Digest Footer

_______________________________________________
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------------------------------

End of Sepsisgroups Digest, Vol 304, Issue 2
********************************************
------------------------------------------------------------------------------
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Subject: Digest Footer

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------------------------------

End of Sepsisgroups Digest, Vol 305, Issue 1
********************************************
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