Sepsis HELP!!!

Unknown

Hi,

We are experiencing a problem with some of our Docs documenting sepsis or SIRS too much. They document 2/4 (or 3/4 or 4/4 you get the picture) of SIRS criteria met but they are pulling these criteria from different times and sets of vital signs. For example at 8a the temp was 101.8, Hr 89, RR 18/ 12n temp 99.8 HR 99 RR 20/ 4p temp 98.9 hr 92 rr 18/ 8p temp 99.8 hr 90 rr 18....so they are saying that this pt meets SIRS criteria because they have a temp 101.8 and a HR >90.
Sometimes it's within a 24 hour period they are pulling these different criteria. I don't feel this really meets SIRS criteria. What is everyone's take on this.
Should SIRS criteria be present within the same set of vitals? or can it be taken from a certain time period. Does anyone know of documentation of this?

kshumpert

From what I understand, 2/4 SIRS may not be present and yet the patient may be septic. This could be due to age, organ transplant or other immune compromised conditions. I would ask for clarification from the physician and explain why the information is necessary. Not every patient fits in the box.


Kathy Shumpert, RN, BSN

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Pager 765-604-0424
Fax 765-453-8152

When something can be read without effort, great effort has gone into its
writing. ~Enrique Jardiel Poncela

Unknown

My point is that these docs are fitting people into the box that maybe
shouldn't be. We don't feel that these pts are actually septic. I
realize that pts may not meet SIRS criteria and be septic but that's not
the case here. These are pts on the general medical floors that are here
for short stays. The docs back up their diagnosis because the "met
criteria".
I don't know how to get them to look at the whole clinical picture....

Gina Spatafore, RN
Clinical Documentation Integrity Specialist

robert.hodges2

I'd only take it from the same set of vitals, and ideally more than one set. Don't forget that for SIRS they also have to document the underlying condition causing the SIRS. It shouldn't be used as a standalone diagnosis.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
 
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Unknown

Thanks Robert! That is what I was looking for but do you have any evidence-based practice guidelines to defend this position? That is what our docs would be looking for.
I agree, there should be a certain trend of vital signs but I can't find anything stating this.

Gina Spatafore, RN
Clinical Documentation Integrity Specialist

kshumpert

Do you have a medical advisor to speak to? When I question something in a medical record and it involves diagnosing, I involve my medical advisor. This helps me to double check myself to verify that I am correct or gives me a learning moment and many times he will speak to the physician if he feels that the physician is incorrect in the documentation.


Kathy Shumpert, RN, BSN

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Pager 765-604-0424
Fax 765-453-8152

When something can be read without effort, great effort has gone into its
writing.

nseebert

I have the same issue- Sepsis is becoming quite "common". I did take this to my advisor and she actually disagreed- she found one temp in the ED that was elevated and the HR. There was nothing after that with any symptomtology that would indicate sepsis and abx were dc'd. I have a meeting scheduled with her to review lots of literature and Dr. Gold's notes. Seems that the pendulum swings back and force


Peace,
Nancy
Nancy R. Seebert, RN, BS, MA
Clinical Documentation Specialist
Legacy Mt. Hood Medical Center
Phone: 503-674-1820
Pager: 503- 938-1447
Fax: 503-674-1821
Email: nseebert@lhs.org
Our legacy is good health for: Our people, Our patients, Our communities ,Our world

robert.hodges2

Gina,

Here is my reference: http://www.hcpro.com/HOM-229305-5728/Address-these-common-QAs-related-to-SIRS-documentation.html & http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_033812.hcsp?dDocName=bok1_033812.

I can't find a reference there or on the AHIMA site that says the values must come on the same day, especially where vital signs are concerned.

There may be more in the coding clinics referenced by AHIMA, but there is nothing on the CDC site around SIRS. I hate to say this, but it may take a RAC auditor to wake them up.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

NormaB

God bless our ID docs they are consulted on every possible Sepsis case but they are a good resource when I really need to know if a patient has Sepsis or not.

I try to use only my admitting vitals, signs and symptoms. That establishes the "present on admission" status of the diagnosis. Our physician consultant trainer said you shoild at least have an elevated temp and elevated white count in most cases before querying for Sepsis. Dr.Gold said at conference this year it should be at least four clinical indicators.

I also agree that a query for the etiology of the Sepsis should be issued.

As our queries are not part of the medical record I would probably let the physician know that the clinical indicators for Sepsis were not present on admit. And if he still believed the patient to be "septic" we need more documentation to substantiate the diagnosis or perhaps consider another etiology and diagnosis. I call it it a "reverse query".

I think it helps them to know we are not all about getting them to document just anything. That we are actually looking both ways.

Now some clinical indicators may be documented a day or 3 down the road because all tests have to be run and results gathered. I watch again to make sure these were ordered on the day of admission so I can go back to present on admit.

Also the type of antibiotics ordered as well as the patients LOS. If they are discharged in 3 days chances are we are probably not loking at Sepsis.

I think cases like these are best tackled one-on-one with the physician.

N Brunson, RHIA, CCDS

sbeatty

Hi listers,

Do a Google (or whatever) search for the Surviving Sepsis Campaign. This is a group of organizations that are working together to improve treatment and outcomes. I was reading the criteria they updated in 2008 last evening from home. Some of the criteria are assessed for response to fluid resuscitation, and that period was defined as a 6 hour time period. So it appears that the criteria should be met within 6 hours to be considered POA. Just my thoughts-please let me know of other references or opinions. Have a great day!

janrumdavis

I think you have to base it on the whole picture of the patient. Confirm SIRS (fever or hypothermia, tachycardia, tacypnea, leukocytosis or leukopenia), determine if due to trauma or infection, any organ dysfunction, & what antibiotic(s) being given. If it is sepsis or severe sepsis the MD documentation should be linking to infection responsible for the sepsis (i.e. UTI with sepsis, etc). If some fever & tachycardia in just one vital sign session then I would not think sepsis.