Sepsis in updated Interqual Guidelines
I'm not sure how many of your hospitals/insurance companies utilize Interqual (McKesson). I had a discussion with our Casemanagement/UR department yesterday about a case that the insurance is denying authorization admission based on not meeting criteria for the primary diagnosis of Sepsis. Interqual has built qSOFA (=/> 2) into the criteria along with =/> 1 WBC, heart rate, temp or platelet count abnormalities. It feels like they have taken an odd twist of SIRS and q SOFA to validate admission to the hospital. For Critical subset they have Temp, WBC and heart rate as well as some SOFA and additional options (ie calcium <5.0 and ARDS). Our hospital had changed to Sepsis 3 criteria several months ago. Am I missing some kind of update somewhere along the line? Just curious on anyone else's take on this. I realize that CM/UR efforts and definitions differ from CDI, but between CM/UR, CMS quality initiatives and Sepsis 3, it is getting even harder to find a common ground anywhere.
Comments
IE, 1 (or 2 depending on who you ask) SIRS plus some organ dysfunction associated with MODS.
It is important to note that (in my opinion) sepsis should never be diagnosed based exclusively on qSofa or exclusively on 2x Sirs (but there are clinical circumstances which call for exceptions to be made).
What i find disturbing about the payer policy is that if you read the SOFA3 criteria they note a substantial population which had a Plus 2 SOFA score and failed to meet any SIRS criteria yet were later proven to be septic and even had an increased incidence of both organ failure and death.
There is no "one way" to do this and any entity that claims to have found the perfect "one simple answer" has frankly already outed themselves as being incorrect (just by having made that claim).
Interested in what others say.
And unfortunately if you have a "good day" where you treat early, symptoms are abated quickly and the patient responds well to therapy, good medical care which worked to prevent a catastrophic outcome is often rewarded with a denial letter for failure to meet medical necessity.
The implication being physicians are supposed to call Hogwartz and find out which patients are actually going to die according to the divining cap....