Septic Shock

bbogda@morrishospital.org

We have a couple providers that will  diagnose certain patients with severe sepsis with septic shock when they are hypotensive stating that they caught the the cascade early and averted the need for vasopressors.  Or possibly they are considering the patient in shock but there is another reason that they might want avoid pressors due to cardiac condition or whatnot, and give the patient a chance to improve with fluids only, or maybe they are getting other volume expanders like albumin or blood.  I am wondering if anyone has been successful in appealing a denial for septic shock when pressors are not used.
Thanks for any insight.
Betty

ttrombley@ghrrevcycle.com

It sounds like this denial is based on Sepsis 3 criteria which does state that in order to be in septic shock that vasopressors must be administered.  If your facility is not using Sepsis 3 definition, then I would appeal based on whatever clinical criteria you have in the record along with the Sepsis 2 criteria.  This is likely just the beginning for many of us with the Sepsis 3 vs Sepsis 2 definition.  I would like to see what others have experienced or can advise on.  
Thanks,
Tammy

lprescott1

Septic shock is not caught "early in the cascade" in my opinion. Hypotension is not enough to support septic shock. i would agree that the use of other expanders would assist in supporting the diagnosis. But I would want to support the fact the hypotension is not responsive to fluid bolus alone int he documentation.

afrady@blr.com

In younger patients with effective cardiac compensatory mechanisms. A patient in septic shock at the cellular level can respond in the following way.  You have 3 baro-receptors.  Two in each carotid artery and one in the Aorta.  Through the use of the autonomic nervous system a generally healthy patient can respond by increasing the systemic vascular resistance via clamping down on peripheral circulation (although you might observe this with cold clammy extremities).  The autonomic nervous system then stimulates both cardiac rate and contractility (and you would be able to observe this via tachycardia and some patient's might even complain of a "heart pounding).  Such a patient can present normotensive and still be in septic shock.  For this reason i personally have not bought into the Sepsis 3 definition of Septic Shock, save one point.   If you look closely there are more criteria for septic shock in Sepsis 3 than just the use of vasopressor to maintain a MAP >65.

"Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4968574/

Note the "or" in "or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia"  this is especially helpful in identifying patients with positive cardiac compensatory mechanisms that would be otherwise missed using BP alone.

Also keep in mind baseline leveling.  My wife barely 90/50 on a healthy day so a BP of 87/45 may not be especially concerning.  

My BP when not on meds however  can be as high as 170/100 so even at 110/60 (If it were a sudden drop like shock) I may actually be experienceing dizzineess, weakness, syncope and hypoperfusion to my kidney'setc. (at least until my set points get re-leveled and the BP brought down slowly).   I find the setting of a "one size fits all" single value cut off to be easily to apply clinically, yet extremely inaccurate when considering the actual presentations of real patients in the real world. 

As stated above, if your facility does or does not recognize Sepsis 3 that needs to be in an official policy some where.   I will also state that if this is a private payer, the contract should be looked at to see if it allows the payer to select Sep 3 criteria and enforce it on their claims for their insured and if there is any language in the contract that allows the facility to object to the insurance position on enforcing a certain criteria for payment purposes and what the facility can do about it, if anything. 

As Limjoco recently pointed out, the entire reason why we change our criteria (some times more aggressive, some times more conservative) is because we learn more about diseases processes and strive to treat them better.   It is inappropriate for a payer to pigeon hole the hospital into using their "pet critera" given the number of patient presentations and the complexity of each patient's biophysiology which is not a uniform standard which is applicable to "cross the board" metrics in a world where you also have multiple confounding criteria and standards of which no single one has been proven above the rest.

The short easy answer of course to avoid denials is just to do what ever the payer says, but i do not think that is a course of action with a trend line that maintains quality care into the future, i believe it is a course of action that fixes your present problems with a trend line to low quality assembly line cut rate medical practice. 

bbogda@morrishospital.org

Thank you all for your input.  It is greatly appreciated.

lberry@wcch.com

Mr. Frady, 
In response to the sep 3 criteria for septic shock:
"Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia"
You responded
"Note the "or" in "or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia"  this is especially helpful in identifying patients with positive cardiac compensatory mechanisms that would be otherwise missed using BP alone".

This criteria  requires both hypotension with pressors and LA >2 right? So it doesn't allow for those with normal bp or positive compensatory mechanisms.
I'm just struggling to get it all straight before we start educating physicians.