Core Measures criteria with Sepsis

Just recently, our CDI department has been asked to work with our Core Measures/Quality Department on efforts to improve our numbers in regards to Sepsis core measures criteria/issues. CDI is being asked to query the attending MD for Sepsis clinical validity due to the core measure criteria/issues did not meet (ex. IVFs not given according to the core measure criteria for Sepsis in ED with patients dx with Sepsis or the primary MD is stating Sepsis (but, after further review of the chart per Chief Medical Officer thinks the patient is not Septic, or failure to draw labs according to the core measure protocol).

Our CDI department is questioning is this good ethical principal to query due to core measures deficiency vs clinical validity/documentation issue with Sepsis... Especially if the attending MD think the patient is Septic, but core measures were not met.

Just wondering on other CDIs take on core measure improvement efforts...


  • I am a member on our Core Measures Sepsis Team.  As a CDI, I review cases that the team felt should not have been coded to Sepsis.  If, after my review, I also feel they should not be coded to Sepsis, I then send to Coding Manager for review.  I also share my findings with the CDI team for future education regarding clinical indicators of Sepsis, etc.

    As a CDI, I don't feel I could assist in core measures being documented since these are time sensitive issues (i.e. abx given within a certain timeframe, lactate drawn in a certain timeframe, etc).  CDI's goal is clinical validation of diagnosis documented by MD, not making sure labs, treatment, etc are ordered correctly and timely.  Our Sepsis team encourages the use of Sepsis order sets to assist in correct IVF, abx, etc, being ordered in a timely fashion and meeting core measures.  If any area is not met, the physician that ordered (or did not order) treatment/labs/etc, is sent a letter explaining how their actions did not meet core measures for their case.

    Hope this helps.

    Kate Sammons, RN, BS, CCDS, ACM

  • Thanks for your input-Kate Sammons
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