Leading?
I am trying to design a new sepsis query that is more clear and lends itself to accurate capture of sepsis vs SIRS vs Severe Sepsis vs Shock, etc.
Our old query listed all possible clinical indicators and then provided options without definitions. I would like to provide definitions this time and am wondering if it would be considered ‘leading’ if the clinical indicators were under each definition and checked off under those headings below. For ex:
SIRS: Dysregulated imflammatory response to a NONINFECTIOUS insult. Two of more of the following criteria:
â Temperature >38.3 or < 36
â Heart Rate >90 beats/min I
â Respiratory Rate >20 breaths/min
â WBC > 12,000 or
Our old query listed all possible clinical indicators and then provided options without definitions. I would like to provide definitions this time and am wondering if it would be considered ‘leading’ if the clinical indicators were under each definition and checked off under those headings below. For ex:
SIRS: Dysregulated imflammatory response to a NONINFECTIOUS insult. Two of more of the following criteria:
â Temperature >38.3 or < 36
â Heart Rate >90 beats/min I
â Respiratory Rate >20 breaths/min
â WBC > 12,000 or
Comments
Our system also includes clinical criteria citing consensus definitions for diseases - I feel it important to cite such definitions than can be used to define and document key terms, but always allowing the responding clinician with any/all other options.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
VHA Standard Inpatient Query Form -
Sepsis/Systemic Inflammatory Response Syndrome (SIRS)
FACILITY: {HOSPNAME}
DATE of QUERY:
{TODAY}
Best Regards,
Patricia
Patricia Stein, RN, MAOL, CNOR
Clinical Documentation Specialist
Health Information SWB-2
Scripps Green Hospital
stein.patricia@scrippshealth.org
(office) 858-554-4709
(cell) 760-274-7397
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012
Table 1. Diagnostic Criteria for Sepsis
Infection, documented or suspected, and some of the following:
General variables
Fever (> 38.3°C)
Hypothermia (core temperature < 36°C)
Heart rate > 90/min–1 or more than two sd above the normal value for age
Tachypnea
Altered mental status
Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)
Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence of diabetes
Inflammatory variables
Leukocytosis (WBC count > 12,000 μL–1)
Leukopenia (WBC count < 4000 μL–1)
Normal WBC count with greater than 10% immature forms
Plasma C-reactive protein more than two sd above the normal value
Plasma procalcitonin more than two sd above the normal value
Hemodynamic variables
Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg in adults or less than two sd
below normal for age)
Organ dysfunction variables
Arterial hypoxemia (Pao2/Fio2 < 300)
Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)
Creatinine increase > 0.5 mg/dL or 44.2 μmol/L
Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
Ileus (absent bowel sounds)
Thrombocytopenia (platelet count < 100,000 μL–1)
Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 μmol/L)
Tissue perfusion variables
Hyperlactatemia (> 1 mmol/L)
Decreased capillary refill or mottling
Table 2. Severe Sepsis
Severe sepsis definition = sepsis-induced tissue hypoperfusion or organ dysfunction (any of the
following thought to be due to the infection)
Sepsis-induced hypotension
Lactate above upper limits laboratory normal
Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source
Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection source
Creatinine > 2.0 mg/dL (176.8 μmol/L)
Bilirubin > 2 mg/dL (34.2 μmol/L)
Platelet count < 100,000 μL
Coagulopathy (international normalized ratio > 1.5)
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
Hope that clarifies,
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Karen Maritano, R. N.
Clinical Documentation Specialist
Legacy Health
Portland, Oregon
503-413-7154