Query re: unmet sepsis criteria w a sepsis diagnosis

debra.runkle@evanhospital.com

I am wondering if anyone has a suggestion for writing a query when the physician indicates that the patient has sepsis but the reviewer doesn't believe that the appropriate sepsis criteria are met. i.e. sepsis 2 criteria my be met but the sepsis 3 definition should be applied and therefore sepsis criteria is not met.

evanspx@sutterhealth.org

I think you would find the sample query wording offered in the ACDIS White Paper, Clinical Validation, helpful?  Have you seen this document which you can find by using the search option on this site? 

bawolfy@yahoo.com

We compile all pertinent clinical indicators (both positive and negative) so as to address any potential documentation conflict the payer may try to exploit later.  This includes exam findings of "no acute distress", lack of appropriate treatment (ex. 30ml/kg IVF), and as in the example below, suggestions that the criteria used may be due to something besides the sepsis.  We include a specific list of the SOFA variables and their numerical value (we put any point score next to each variable in parentheses but do not calculate a total SOFA score - as that depends on baselines that we may not know). We include the Sepsis-3 definition and SOFA table at the bottom of the query as well as a reference to Sepsis-2.  We recognize that some docs are not going to buy into Sepsis-3 (often with clear reasoning), and we want to provide options for a meaningful diagnosis, not just one that is perceived as "denial proof".
Also, if a patient has a SOFA score of 2 or greater but is not described as being very sick, is not treated on a sepsis pathway, has conflicting or inconsistent descriptions/documentation  - it is escalated to the manager or PA to assess the need for validation. 

Reason For Query: Sepsis Confirmation - typical clinical criteria are not documented

History: 69yom with COPD admitted with PNA.

Admission Assessment/Plan: “1. Sepsis, secondary to pneumonia: As evidenced by lactic acid of 9. Initial lactic acid of 3. I do suspect that DuoNeb breathing treatments are contributing to some of her lactic acidosis but I do suspect that she has sepsis based upon her fever, white count, tachycardia and respiratory distress.”

Clinical Indicators:

Underlying/localized infection: Pneumonia

Admission VS: Temp 39.6 (103.3)   HR 117   BP 138/66   RR 20

Admission Exam: “mild distress”

Glucose in the absence of diabetes: 140 and 196

WBC: 25,800

Lactic Acid (1/28): 3.0 (4pm); 6.2 (7pm); 9.0 (9pm);

Lactic Acid (1/29): 5.8 (1am); 2.4 (5am); 2.7 (10am)

Procalcitonin: none documented

Pulmonary Consult note (1/29) - Assessment/Plan: “5. Acidosis, Lactic - resolved, likely due to above” (only diagnoses listed above this are Hypoxia, CAP, Asthma, Multiple pulmonary nodules) “as well as nebulizer use in ER.”

Treatment: Antibiotics, 30 ml/kg IVF

 

SOFA Variables (done on admission unless otherwise noted):

P/F ratio (PaO2/ FiO2) ABG (11/28 at 8pm) = 99mmHg / 0.21 FiO2 = 471

Platelet Ct: 120,000 – one point

Total Bilirubin: 0.20

MAP: lowest mean arterial blood pressure: 74 mmHG (11/28 at 5pm)

GCS:  not provided (pt alert and oriented x 3)

Creatinine:  0.8

Urine Output:  1250cc

 

Question: Please provide additional supporting evidence of the documented diagnosis of sepsis.

Please consider *SOFA (sequential organ failure assessment) criteria if appropriate (see reference table below) and if citing Sepsis-2 supporting evidence please clarify what variables are the result of a systemic response to the underlying infection (not easily explained by other causes) and exceed that which would be expected with a localized infection.

•      Sepsis was present on admission, with supporting evidence of ______ (please specify)

•      Sepsis was determined to not exist

•      Unable to provide additional clarity regarding the sepsis

•      Other (please specify) ___________________________

Include Sepsis-3 reference, SOFA table and the footnote below.

1Levy MM, Fink MP, Marshall JC, et al: 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31:1250–1256.

stephaniehaase

In my opinion I think it may be helpful to include PA or UM Director and Sepsis CNS.  I agree clarification is necessary but having a well mapped-out process for clinical validations will secure success.  And may decrease the use of queries for sepsis clinical validations.  

evanspx@sutterhealth.org

Excellent discussion - we, too, review the record for indications of any acute organ dysfunctions that may satisfy Sepsis 3 Criteria (SOFA), and use the presence (or absence) of such dysfunctions in our communications to the clinicians treating the patient.  My caveat is that SOFA does not mention all of the acute organ dysfunctions some believe may be a consequence of severe sepsis, such as Type 2 MI or critical illness myopathy.

evanspx@sutterhealth.org

bawolfy@yahoo.com

Would you have a copy of this template you could share?  I like the concept of citing the SOFA scores within a query for this topic, but I am having some problems trying to build a template that is not exceeding complex or unwieldy?  thank for any help.   Perhaps you would consider donating a copy to the ACDIS forms and tools committee? 

Paul Evans, RHIA, CCDS

debra.runkle@evanhospital.com

Thank you all, I really appreciate your assistance.

bawolfy@yahoo.com

I have attached a word document with the template I used above. There is always need for some customization with validation (based on the issue - criteria not met, conflicting documentation or simply only documented once).  If your hospital has standardized a sepsis definition, consider using that as the threshold for query. 
WIth the question I may include more indication of why the diagnosis is suspect.  For example: "Please provide additional supporting evidence for the diagnosis of sepsis in this patient without documented organ dysfunction."  If this is the first time a physician is seeing a Sepsis Validation query, as the PA, I do try to give them a call and explain the issues.  

evanspx@sutterhealth.org

Thank you!

RPinson@PinsonandTang.com

Good discussion. I'd like to note that the organization needs to find a way to get a Glasgow Coma Scale score on patients who have an infection and altered mental status, and total bilirubin onall patients with an infection.  Make sure the lab reports a PO2/FIO2 ratio (also critical for identifying resp failure) on all ABG's - it's a simple division using already existing fields for PO2 and FIO2.

Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com