Leading?

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
I am trying to design a new sepsis query that is more clear and lends itself to accurate capture of sepsis vs SIRS vs Severe Sepsis vs Shock, etc.

Our old query listed all possible clinical indicators and then provided options without definitions. I would like to provide definitions this time and am wondering if it would be considered ‘leading’ if the clinical indicators were under each definition and checked off under those headings below. For ex:

SIRS: Dysregulated imflammatory response to a NONINFECTIOUS insult. Two of more of the following criteria:
 Temperature >38.3 or < 36
 Heart Rate >90 beats/min I
 Respiratory Rate >20 breaths/min
 WBC > 12,000 or

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Because you are using the most recent definitions cited in 2012 "Surviving Sepsis" and providing options to agree, disagree, state o/w, and so forth, in my opinion, this is compliant and not leading.

    Our system also includes clinical criteria citing consensus definitions for diseases - I feel it important to cite such definitions than can be used to define and document key terms, but always allowing the responding clinician with any/all other options.



    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
  • robert.hodges2robert.hodges2
    Date:













    VHA Standard Inpatient Query Form -
    Sepsis/Systemic Inflammatory Response Syndrome (SIRS)

     

    FACILITY: {HOSPNAME}

    DATE of QUERY:
    {TODAY}

  • stein.patriciastein.patricia
    edited May 2016
    My only suggestion is to spell out the acronym SIRS. It is a dysregulated inflammatory response. However, when an acronym is used, it is nice to spell it out. Otherwise, I agree with Paul's comments.

    Best Regards,
    Patricia

    Patricia Stein, RN, MAOL, CNOR
    Clinical Documentation Specialist
    Health Information SWB-2
    Scripps Green Hospital
    stein.patricia@scrippshealth.org
    (office) 858-554-4709
    (cell) 760-274-7397
  • kmaritankmaritan
    edited May 2016
    Paul & Katy, your assistance is needed. Using Google has brought up the 58 pg document 2012Surviving Sepsis. It seems all I find in the article is info on sepsis, severe sepsis and septic shock. I tried finding new SIRS definition in article but can't find it. Please let us know your source, where all the new definitions are. Thanks.
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Hi - please see pgs 585 and 586 (tables) - note use of word "some" of the following:

    Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012


    Table 1. Diagnostic Criteria for Sepsis
    Infection, documented or suspected, and some of the following:
    General variables
    Fever (> 38.3°C)
    Hypothermia (core temperature < 36°C)
    Heart rate > 90/min–1 or more than two sd above the normal value for age
    Tachypnea
    Altered mental status
    Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)
    Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence of diabetes
    Inflammatory variables
    Leukocytosis (WBC count > 12,000 μL–1)
    Leukopenia (WBC count < 4000 μL–1)
    Normal WBC count with greater than 10% immature forms
    Plasma C-reactive protein more than two sd above the normal value
    Plasma procalcitonin more than two sd above the normal value
    Hemodynamic variables
    Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg in adults or less than two sd
    below normal for age)
    Organ dysfunction variables
    Arterial hypoxemia (Pao2/Fio2 < 300)
    Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)
    Creatinine increase > 0.5 mg/dL or 44.2 μmol/L
    Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
    Ileus (absent bowel sounds)
    Thrombocytopenia (platelet count < 100,000 μL–1)
    Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 μmol/L)
    Tissue perfusion variables
    Hyperlactatemia (> 1 mmol/L)
    Decreased capillary refill or mottling

    Table 2. Severe Sepsis
    Severe sepsis definition = sepsis-induced tissue hypoperfusion or organ dysfunction (any of the
    following thought to be due to the infection)
    Sepsis-induced hypotension
    Lactate above upper limits laboratory normal
    Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
    Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source
    Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection source
    Creatinine > 2.0 mg/dL (176.8 μmol/L)
    Bilirubin > 2 mg/dL (34.2 μmol/L)
    Platelet count < 100,000 μL
    Coagulopathy (international normalized ratio > 1.5)

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    SIRS, used in context of infection, is coded as Sepsis in ICD-9. Our use of the wording SIRS may have lead to some confusion - in this context, we were referring to SIRS WITH infection - accepted in the coding world as Sepsis.



    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
  • kmaritankmaritan
    edited May 2016
    Thanks, have all this, but looking for info on the most recent definition of SIRS, as stated "dysregulated inflammatory response" per Katy's initial email. So does this officially change SIRS from "systemic inflammatory response syndrome"? Curious as I have not seen the term 'dysregulated' used with SIRS before.
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    No. the abbreviation still means the same thing. SIRS=systemic inflammatory response syndrome. I was trying to further define it and that is the definition I got from UpToDate.

    Hope that clarifies,

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • kmaritankmaritan
    edited May 2016
    Thanks Katy and Paul for all the added info I requested. Katy, I saw the Up to Date article just now and now it all makes sense. Thanks again. Looks like I forgot to "sign" my previous emails.


    Karen Maritano, R. N.
    Clinical Documentation Specialist
    Legacy Health
    Portland, Oregon
    503-413-7154
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