Sepsis-3/SOFA
Hi ladies and gents,
Now that facilities have a bit of time to consider Sepsis-3, I am wondering what adjustments are being made in your CDI program and facility. Our facility did decide (last week) to adopt the Sepsis-3 definition. Education rolled out this week and CDI is expected to use SOFA criteria to query for sepsis. We have also been asked to query for clinical indicators, referencing SOFA criteria in cases where sepsis is documented and the patient does not meet the Sepsis-3 definition. A few questions I have:
1. Are you querying for clinical indicators (reverse-query/anti-query) when patient doesn't meet SOFA?
2. Have you re-designed query templates and what do they look like?
3. Is It appropriate for the CDI to calculate a SOFA score when querying for/against sepsis?
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Now that facilities have a bit of time to consider Sepsis-3, I am wondering what adjustments are being made in your CDI program and facility. Our facility did decide (last week) to adopt the Sepsis-3 definition. Education rolled out this week and CDI is expected to use SOFA criteria to query for sepsis. We have also been asked to query for clinical indicators, referencing SOFA criteria in cases where sepsis is documented and the patient does not meet the Sepsis-3 definition. A few questions I have:
1. Are you querying for clinical indicators (reverse-query/anti-query) when patient doesn't meet SOFA?
2. Have you re-designed query templates and what do they look like?
3. Is It appropriate for the CDI to calculate a SOFA score when querying for/against sepsis?
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Comments
Do you know where your MD advisor is getting the information that this definition 'does not go into effect' until 2018? The JAMA article does not state that (that I have found) and our hospital generally relies on UpToDate to provide our clinical information and it was recently update to Sepsis-3/SOFA as the definition of sepsis. I am wondering if your Advisor is referring to possible CMS not updating their definition until 2018 or something similar?
Thanks for your input.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
I personally believe a limitation w/ SOFA 3 is that it does not reference other acute organ dysfunctions (Type 2 Demand MI, Demand Ischemia, BS elevations, exacerbation of CHF) that may be a consequence of Sepsis.
Personally, I see quite a bit of overlap with both sets of criteria. We 'do' cite numerous clinical factors (using SSC) when we issue any query pertaining to Sepsis, the consequences of Sepsis, or the apparent lack of clinical support when Sepsis is documented.
(If you review the SSC citation of acute organ DYSFUNCTIONS that may be 2/2 Sepsis, there is quite a bit congruence with the SOFA Scores in Sepsis 3 and SSC. I personally do calculate the SOFA scores in my practice, but I do not 'cite' them as SOFA in my query because the SSC query we use has referenced these consequences for quite some time. The SOFA will very often reflect organ dysfunction parallel to SSC (Plts, Cr, Respiration, CV, et al). The query forms we use for SCC includes elements of SOFA, and this has been the case for years.
In my view, it not only appropriate the cite the criteria you have stated is your practice, but mandated by Best Practice...Ultimately, I believe institutions (physicians) should be able to cite, adopt, endorse, the criteria they choose, recognizing Sepsis 3 is part of the ongoing progress on this syndrome that lacks one definition. I believe 3rd parties should honor and respect the definitions chosen by our respective physician Subject Matter Experts, but we have seen is not often the case.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
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We are not making any changes to our queries/CDI program at this time.
Our physicians have not committed to using the new criteria - they are
still in the evaluation process.
Debby
Deborah A Dallen, BSN, RN, CCDS
Supervisor
Clinical Documentation Improvement
Einstein Medical Center
Health Information Management
Phila PA 19141
215-456-8902
dallend@einstein.edu
Best Regards,
Cari Merlina RN, BSN
Clinical Documentation Improvement Specialist
Revenue Cycle
Yampa Valley Medical Center
1024 Central Park Dr
Steamboat Springs, CO 80487
p.970.871.2425
f.970.875.2796
Cari.merlina@yvmc.org
[yvmc]
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
A team of physicians/nurses/infection disease staff was in the end of developing a Care Process Model at our hospital related to sepsis when the sepsis-3 criteria came out. This was in an effort to identify sepsis appropriately and quickly as well as treating in a uniform manner with the Core Measure in mind. Because education was included in the CPM, they opted to transition now rather than use old criteria. So far our docs have been receptive. Our intensivists were already adopting this criteria prior to the CPM group making their decision so they were on board already. The overwhelming consensus of the team was that sepsis is over-diagnoses with SIRS+infection as criteria and that this doesn’t really represent sepsis but often is a completely appropriate response to infection. Our physician that handles medical necessity denials is already seeing denials for sepsis (prior to sepsis-3) because patients met SIRS+infection criteria, were diagnosed with sepsis and admitted as inpatients and discharged a couple days later. This may be an issue that is specific to our facility but this physician believes that the new definition will lead to more accurate identification and management of truly sepsis patients. We will see…
I agree with many of Paul’s concerns but feel a bit more negative about the idea of auditors accepting multiple definitions ;-). I am curious to see if we end up seeing a lot of denials when sepsis is coded based on old criteria. Problem is it could be months or even years before we know….
Though coding and CMS have not yet adopted this definition, I think we can still make this work in the current code set. We should see far less sepsis without ‘severe sepsis’ and we will continue to query for the link between sepsis and organ dysfunction.
Ultimately, this is the definition the hospital is adopting and CDI is following suit….
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Sommer Slavin, RN, MS, MBA
Operations Manager
Utilization Management at Strong Memorial Hospital
Work (585) 276-5265
Pager (585) 275-2222 PIC 3226
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From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, April 28, 2016 11:54 AM
To: Benson Kathleen
Subject: RE: [cdi_talk] Sepsis-3/SOFA
Hmmm…. Are we the only ones???
A team of physicians/nurses/infection disease staff was in the end of developing a Care Process Model at our hospital related to sepsis when the sepsis-3 criteria came out. This was in an effort to identify sepsis appropriately and quickly as well as treating in a uniform manner with the Core Measure in mind. Because education was included in the CPM, they opted to transition now rather than use old criteria. So far our docs have been receptive. Our intensivists were already adopting this criteria prior to the CPM group making their decision so they were on board already. The overwhelming consensus of the team was that sepsis is over-diagnoses with SIRS+infection as criteria and that this doesn’t really represent sepsis but often is a completely appropriate response to infection. Our physician that handles medical necessity denials is already seeing denials for sepsis (prior to sepsis-3) because patients met SIRS+infection criteria, were diagnosed with sepsis and admitted as inpatients and discharged a couple days later. This may be an issue that is specific to our facility but this physician believes that the new definition will lead to more accurate identification and management of truly sepsis patients. We will see…
I agree with many of Paul’s concerns but feel a bit more negative about the idea of auditors accepting multiple definitions ;-). I am curious to see if we end up seeing a lot of denials when sepsis is coded based on old criteria. Problem is it could be months or even years before we know….
Though coding and CMS have not yet adopted this definition, I think we can still make this work in the current code set. We should see far less sepsis without ‘severe sepsis’ and we will continue to query for the link between sepsis and organ dysfunction.
Ultimately, this is the definition the hospital is adopting and CDI is following suit….
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Marty
Temple Health
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, April 28, 2016 12:54 PM
To: Conroy, Martin
Subject: RE: [cdi_talk] Sepsis-3/SOFA
Hmmm…. Are we the only ones???
A team of physicians/nurses/infection disease staff was in the end of developing a Care Process Model at our hospital related to sepsis when the sepsis-3 criteria came out. This was in an effort to identify sepsis appropriately and quickly as well as treating in a uniform manner with the Core Measure in mind. Because education was included in the CPM, they opted to transition now rather than use old criteria. So far our docs have been receptive. Our intensivists were already adopting this criteria prior to the CPM group making their decision so they were on board already. The overwhelming consensus of the team was that sepsis is over-diagnoses with SIRS+infection as criteria and that this doesn’t really represent sepsis but often is a completely appropriate response to infection. Our physician that handles medical necessity denials is already seeing denials for sepsis (prior to sepsis-3) because patients met SIRS+infection criteria, were diagnosed with sepsis and admitted as inpatients and discharged a couple days later. This may be an issue that is specific to our facility but this physician believes that the new definition will lead to more accurate identification and management of truly sepsis patients. We will see…
I agree with many of Paul’s concerns but feel a bit more negative about the idea of auditors accepting multiple definitions ;-). I am curious to see if we end up seeing a lot of denials when sepsis is coded based on old criteria. Problem is it could be months or even years before we know….
Though coding and CMS have not yet adopted this definition, I think we can still make this work in the current code set. We should see far less sepsis without ‘severe sepsis’ and we will continue to query for the link between sepsis and organ dysfunction.
Ultimately, this is the definition the hospital is adopting and CDI is following suit….
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
This is all shifting, and it will be interesting to follow and precisely how this impacts CDI and Coding.
In my view, strict application of ‘only’ SOFA may infer the MD is not free to use their own clinical judgement; also, it is pretty ‘easy’ to grade a score of at “2” using SOFA in a pt w/ infection.
Sepsis is a syndrome w/o validated criterion for diagnostic test, difficult to define; it has been stated to me that some clinicians believe that using ‘only’ SOFA may lead to late identification of Sepsis at the cost of lives as EGDT may be delayed.
Compelling issues and more to follow, certainly.
PE
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
I agree that a physician can you criteria of their choosing. However, we know that an auditor may not agree. That may not be ‘fair’ but we all know this to be true. As I said earlier, we just received our first denial TODAY based on sepsis-3. We will fight it and I assume we will win. The DOS was prior to sepsis-3 being published so in my mind, our case is strong. Patient meets sepsis-2 with tachycardia and leukocytosis with underlying culture+ UTI. Interestingly enough, this was coded to severe sepsis because we also had documented encephalopathy which was tied to the sepsis. However, they have denied this dx as well because the patient had an underlying sz disorder and sz activity was suspected (phenytoin levels were low). Although the MD did acknowledge that the mental status changes may have been multifactorial due to sepsis and sz, they did explicitly document the link to sepsis. This was a 5day LOS.
I understand (and share) the concerns about a delay to care if sepsis identification is delayed. However I do think it’s important to note that sepsis-3 does not imply that patients should not be aggressively treated when symptomology warrants it. SIRS criteria may continue to be valuable as an indicator of severe illness and these patients may continue to require admission. The full clinical picture continues to need to be evaluated. Sepsis-3 clarifies that these patients (SIRS+infection) are not clinically septic though they may have a severe infectious illness. I have not been the one educating MD’s on the criteria (this has been peer-to-peer) however, my understanding is that they are not being told to change their practice in that way. In fact we have a sepsis-alert system in placed that is based off of SIRS criteria and this will continue to be utilized for early identification. Our MD’s are being encouraged to document possible/probable/impending sepsis if they are concerned about sepsis initially in cases where SOFA criteria may not be met and then to specify after study if this was ruled out.
This is a very complicated issue and I am very interested to see how it pans out.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Got it..but, it still often comes down to someone working off site w/o ever seeing the pt disagreeing w/ the clinical judgement of the treating clinician based on ‘their’ use of Sepsis -3 versus SIRS. A good example is your case whereby the MD explicitly stated the encephalopathy is 2/2 Sepsis…this IS Severe Sepsis using any criteria, SIRS OR Sepsis -3.
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The only point where I differ is that SOFA, per my MD experts, ‘can’ indeed lead to lack of early recognition.
Regarding this point:
“Sepsis-3 clarifies that these patients (SIRS+infection) are not clinically septic though they may have a severe infectious illness” – that is debatable and one would have to fully buy into the SOFA philosophy, which does not recognize that patient’s with early sepsis may present w/o acute organ dysfunction. (I’d say Sepsis-3 holds this position, but not sure it clarifies the issue).
Organ ‘dysfunction’ can vary from patient to patient as well as the severity of sepsis; SOFA is confined to ‘only’ 6 body systems. Not being contentious, but I have been particularly passionate about:
1. The Coding of Sepsis and Severe Sepsis
2. Offsite 3rd parties issuing denials to physician subject matter experts based on a different use of application of criteria, particularly when our staff has carefully chosen a set of criteria they deem to be Best for the patient.
PE
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Urine cultures positive for 100,000 CFU of E. Cole and Blood positive for the same.
MD documents Septicemia after confirming validity of cultures.
Per Sepsis 3, this is not Sepsis as no accompanying ‘acute organ dysfunction” – per SCC, this is Sepsis identified and treated prior to any acute organ dysfunction….would a 3rd party deny validity?
PE
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
I think sepsis-3 would suggest that sepsis was prevented in this case as its only sepsis if organ dysfunction was present. The patient was aggressively treated as appropriate and we avoided that negative outcome. We may have had ‘impending’ sepsis, but it didn’t actually happen. I think my point is that sepsis-3 (that I can see) is not suggesting a change in treatment for those patients presenting with SIRS criteria. If fact they specifically state that SIRS criteria may be helpful in identifying infection. They are just not defining these patients a septic, though they might have become septic without treatment.
I don’t feel like I have the education or experience to speak to the clinical validity of the Sepsis-3 criteria, this is the role of our clinicians working with these patients. Whether SOFA is appropriate diagnostic criteria is rather beyond me. One thing I definitely will say though is that I think we all can agree that SIRS+infection definition casts a VERY wide net. I review sepsis every quarter and it’s amazing how many documented cases of ‘sepsis’ I see that DO meet SIRS+infection criteria and have short lengths of stay, admission to the medical unit, do not appear to be critically sick, etc. We have all questioned whether these patients are truly septic from a clinical standpoint. There is the running joke that practically everyone presenting to the ER meets SIRS criteria. Also, lets not forget the reverse situation. There are plenty of patients with infection and resulting organ dysfunction that do not meet SIRS criteria, these were not captured in the old definition.
I appreciate all the discussion and opinions though that everyone has shared. You give me a lot to think about…. ☺
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Q&A ID Number: 162942
New Sepsis/Septic Shock Recommendations from JAMA
Question:
Will there be a suspension of the SEP-1 measures in consideration of the recommendations from the Society of Critical Care Medicine published in the February 2016 issue of JAMA which: Aim to Redefine Definition and Enhance Diagnosis of Sepsis, Septic Shock
A task force of leading sepsis experts is putting forth important, new recommendations for physicians. The group’s recommendations not only advance new definitions for sepsis and septic shock, but also offer clinical guidance to help physicians more quickly identify patients with or at risk of developing sepsis.
Answer:
CMS always welcomes new research and innovative thinking. We realize that hospitals are curious whether the newly proposed sepsis and septic shock definitions published in JAMA will replace the severe sepsis and septic shock definitions specified in the SEP-1 measure. CMS is not making any immediate changes to the current definitions as specified in the SEP-1 measure. However, CMS is reviewing the new information, and will release a more detailed response to the JAMA articles in the near future.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Re: Denial for claims stating that Sepsis 3 criteria not met, my concern is that Sepsis 3 has yet to be universally accepted by several major authoritative bodies represented by physicians subject matter experts. Given that not all fully endorse Sepsis 3, it seems questionable that various 3rd parties will dispute the clinical opinion (and documentation) of physicians that are not wholly convinced that Sepsis 3 trumps SSC, and are now issuing denials based on Sepsis 3.
I personally find the SOFA tables very useful in terms of identifying acute organ dysfunction that may be a consequence of Sepsis. I agree that using both sets of criteria can be very helpful to us as we perform our work and the diagnosis of Severe Sepsis would be difficult to deny in pt with a positive SIRS screening accompanied with SOFA scores of ‘2’ or greater.
The elements of SOFA could be incorporated into a query such as below in order to query for Sepsis.
MD/Provider please clarify:
The clinical significance of the abnormal labs and findings, indicated above, as well as any acute organ dysfunction, if present (Column A and B below)
Severe sepsis is documented. Please document any acute organ dysfunction associated with severe sepsis (Column B below) - Any potential association must be documented explicitly
Sepsis and an associated condition is documented. Please indicate the severity of sepsis (Column A below)
You may answer this Query by marking the checkbox(es) below or using free text at the ( * ) if appropriate.
Provider Query Response:*
Provider Query Response (Using Checkbox Options)
A – Potential Inflammatory Response
SEPSIS
Sepsis w/o associated acute organ dysfunction
Severe sepsis (causing associated acute organ dysfunction – complete Column
SIRS
SIRS due to infectious process with Sepsis
SIRS due to infectious process without Sepsis
SIRS due to non-infectious etiology without acute organ dysfunction
SIRS due to non-infectious etiology with acute organ dysfunction
No Form of Systemic Illness
Bacteremia without sepsis (abnormal lab finding only, does not indicate systemic illness)
Localized infection only, without systemic illness (please specify)*
Not clinically significant
Unable to determine
Other diagnosis (please specify)*
B - Associated Acute Organ Dysfunction(s)
No associated acute organ dysfunction
Lactic acidosis
Shock
Circulatory failure (peripheral)
Hypotension, only, w/o shock
Acute kidney failure / injury
Acute tubular necrosis
Acute renal insufficiency
Azotemia Oliguria Anuria
Acute respiratory failure
Acute respiratory distress syndrome (ARDS)
Hypoxia Hypercarbia
Critical illness myopathy
Critical illness polyneuropathy
Disseminated intravascular coagulopathy (DIC)
Thrombocytopenia Coagulopathy
Encephalopathy Coma Acute delirium
Acute hepatic failure Shock liver
Ileus Jaundice
Acute cardiomyopathy
Acute myocardial infarction (AMI)
Acute heart failure (congestive)
Acute demand ischemia
Acute coronary syndrome
Atrial fibrillation
Diabetic ketoacidosis
Multiple organ dysfunction syndrome (MODS)
Other diagnosis (please specify)*
The purpose of this query is to ensure accurate coding, severity of illness and risk of mortality compilation. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
o Sepsis-3, the core measure (SEP-1) remains the same. Considering SEP-1 is primarily about severe sepsis (end-organ dysfunction per Sepsis-2), I believe it is possible to accomplish both goals.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
The Hospital Inpatient Sepsis core measure, under Severe Sepsis as evidenced by Organ dysfunction defines Acute Respiratory Failure as requiring a new need for invasive or non-invasive mechinical ventilation...i.e. endotracheal/tracheostomy tube or BiPAP. This definition does not correlate to current medical or to the coding guideline definition for acute respiratory failure. Current coding and medical definitions do not require a patient to be on a ventilator or bipap to meet criteria for Acute Respiratory Failure. Are hospitals to follow the Sepsis core measure definition for acute Respiratory Failure, or are hospitals to follow current coding and medical definitions for Acute Respiratory Failure?