sepsis 2

For those working in facilities that are continuing to utilize Sep 2 criteria....

In light of the Surviving Sepsis campaigns agreement with Sepsis 3, How are you justifying not adopting Sepsis3?

Are your CDI's continuing to query for sepsis based on Sepsis2 or only querying for sepsis3?

Are you concerned about potential legal, ethical, compliance issues associated with billing for sepsis in patients that do not meet Sepsis 3?


We adopted sepsis-3 last May. It has gone fairly smoothly. Our docs are using it fairly consistently and we have been querying for clinical indicators when needed. We just had a new physician put in charge of sepsis for our facility and we wants to go BACK to sepsis2. Our sepsis rate dropped in half by adopting sepsis3 (we have always been a high outlier). I am concerned about potential compliance issues but I realize other facilities have probably not adopted so I would be interested in hearing from you how your facility is supporting this decision and how the CDI is functioning in response to sepsis.


thanks!


Katy

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Comments

  • The problem is that Sepsis 2 is what has been given as the guideline for meeting Core measures, but Sepsis 3 is what commercial payers are using.  It is difficult to meet Core measures if you change to Sepsis 3.  Sepsis 2 states septic shock is present if you have severe sepsis and lactic acid greater than 4.  Sepsis 3 states for septic shock you need a patient with hypotension, a  pressor and a lactic acid >2.  It's a real dilemma and a huge financial concern


  • I think we'd all benefit if we can ensure that acute organ dysfunction associated with sepsis is clearly stated and documented.   Caveat is that Sepsis 3 and SOFA does 'not' recognize all organ dysfunctions associated with severe sepsis, nor does it purport to do so.   This does not address the issues raised above whereby  Core Measure Guidelines are not aligned with Sepsis 3 criteria.  I don't see a solution at this time as we have different entities speaking different languages...However, it is pertinent that SSC is now using a revised definition for Sepsis, and that is very important.

    Paul Evans, RHIA, CCDS

  • I really enjoyed to conversation regarding sepsis at the February quarterly conference call. I think we have to not get hung up on SOFA. As stated in that call, this is a tool that assists in supporting the dx of sepsis, but SOFA>2 is not the definition according to sepsis3. The definition is organ dysfunction 2/2 dysregulated host response to infection. So I think providers can support sepsis (according to sep 3) with other organ dysfuntion as long as the documentation of the connection/thought process is clear.

    I think, as always, there is a lot of 'grey' with sepsis but i think even prior to sep3, we all knew that they were MANY patients categorized as sepsis because of a fever and leukocytosis with UTI (or similar) that did not appear to truly be septic in the sense of a life-threatening illness. I guess now that we have been thinking about sepsis according to sep3, I am not sure how to support us (as a facility) in going back to sep2. It seems like the literature is moving in the other direction.


    As for core measures, yes there are differences. I think we have to remember that the core measure is related to 'severe sepsis and septic shock', which does correlate pretty well with the sepsis3 definition. There are some slight variances, but they overlap in the vast majority of cases.   


    We are still considering our options on this and I really appreciate the input.


    Katy Good

  • Exactly Katy...I was hung up on SOFA until I listened to the recording of the quarterly call this morning and then I had an "ah ha" moment and feel better about it. Our Quality folks had a fit last week when I mentioned if the medical staff was discussing moving to Sepsis 3 as an organization. They feel that moving to Sepsis 3 will make them not pass the core measure. I didn't see where it would since the core measure is for severe sepsis and that's basically the Sepsis 3 definition. I do not know all the nuances of the core measure but I don't think it would be a huge issue if the medical staff decided to adopt Sepsis 3. It appears that some MD's are using it and some not....we really need an organizational decision.

    Have you noticed your sepsis denials have gone down after adopting Sepsis 3?

    Jeff

  • I certainly agree that Sepsis 3 does not address all of the organ dysfunction that may assist with confirmation of Sepsis; (see paper I wrote for ACDIS).  However, I am mindful that some rigid 3rd party reviewers will use only the SOFA scores to deny valid cases of sepsis...that is one of my concerns.  Sep -1 criteria has its own set of issues as this abstract measure does not account for MD documentation or coding rules...this issue has become a bit of a Babylon in my view.  Stay tuned??
  • Do most of you have a committee or some means of adopting things like Sepsis 3, etc in their facility?  I don't believe we have that, it is a matter of each doctor deciding when and how to adopt such changes.  
  • Our facility developed a clinical consensus group regarding sepsis with the CMS core measure came out. This was not a CDI driven process, it was something we were able to kind of tag on to.  If there is someone in your organization that is working on the core measure, it is helpful to leverage this existing focus.

    I agree paul... if we didn't have the CMS core measure, sepsis3 would be easy to adopt. The CMS issue really complicates the issue. I agree that 3rd parties may rigidly apply SOFA. I guess those are the ones we have to be prepared to battle. But those numbers will be fairly small. Whereas, if they choose to apply sepsis3 to a facility that is utilizing sepsis2, I would imagine the denials would become quite large. When sep3 came out, I audited sepsis cases and found that >50% at our facility would not meet sep3. Of course we know that auditors will take the strictest view they can and it often feels like we have limited options since we are so clearly not in the power position when it comes to denials.


    And jeff, Yes! I think we made that mistake too. Also because people really like 'rules' so CDI was trying to strictly apply SOFA because this was concrete. We really cant do this, it has to be care by case. I recently attended a meeting where the physicians were then obsessing about needing SOFA documented and inserting a SOFA calculator in our EMR. I really don't think that should be the focus. I think our focus should be:

    1. Do we have organ dysfunction?

    2. Have we 'named' it and tied it to sepsis.

    We have seen a significant reduction in sepsis denials :)

    Katy Good

  • Katy:  I think the strategy stated in steps 1 & 2 are advisable...just my opinion on this very complicated matter.  For those 'thinking' like a coder, this means we should apply code R65.20 or R65.21, when warranted.




    Paul E.

  • it is certainly complicated. If we are adopting sepsis3 effectively, we should have an R-cde on virtually all 'sepsis' encounters. We have been auditing those without an R-code to see if there was evidence of organ dysfunction.
  • I have assisted with some abstracting for core measures and I do see where this can be a problem with core measures.  An abstractor can say the patient has septic shock based on the fact the patient has severe sepsis and an elevated lactic acid>4.  The physician does NOT need to document the diagnosis "Septic Shock". So if a physician treats a patient like they don't have septic shock based on sepsis 3 definition they will fall out with core measures.  It's very difficulty to find a balance with this.  

  • We attempt to reconcile our core measure abstraction to our documented and coded cases of sepsis, and it is impossible to achieve a match.   In the -1 Sepmeasure, the abstractor uses data collection points to indicate if Severe Sepsis is present, and the abstractor does not review the chart documentation or coding.  
  • yes, I have done the same. it is an entirely different process (reminds me of trying to match our coded CAUTIs/VAPS to those determined to be CAUTIS/VAPS by ID and submitted). The abstracting is based on indicators and treatment rather than stated dx. There are definitely variances that cannot be easily overcome. I think what's most important is that we are using evidenced-based tools to diagnose conditions appropriately and we are following 'best practice' guidelines to manage our patients. We will continue to have fall-outs. But I think we also have to remember that EVERYONE is really struggling with this measure.

    What's interesting is that the JAMA article was fairly specific that it was not focused on treatment and not suggesting that patients with SIRS criteria and infection did not require rapid identification and management. Just that... this is not 'sepsis'. Surviving Sepsis is the more clinical guidance article and this was just released in the last month so I think it will be interesting how things proceed in the next months/years.

     

    Katy Good




  • edited May 2018
    As I was searching for information for a sepsis meeting we have this week with our leading providers, I came across this thread.  We are now in the months/years ahead in this conversation and we are being flooded with denials at our facility.  We have been "guided" to follow the CORE definition of sepsis for passage of the measure and are indeed being judged on the SOFA criteria.  Even some of our providers have suggested an adoption or at the least a blending of the two sets of criteria.  And here we are, sepsis game on.
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