In the data collection tool we utilized we asked if there was a working
diagnosis of Severe Sepsis or Septic shock at the time of admission for ED
Admit? Y/N
If No, then was Severe Sepsis or Septic shock a working diagnosis during
hospitalization? Y/N –Collecting this date and time.
Our hospital sepsis team was composed of ED, Infection Specialist and Critical
Care Intensivist – they would discuss the cases that seemed questionable and
determine what was the most appropriate course for patient. There were times
when it was thought no they are specific such as in the patient with dementia
who presents with slight change in MS (based upon family input) or patients
with chronic disease such as COPD or CHF.
Any cases that were placed on the Sepsis bundle orders in less than 24 hours of
ED admission were sent for ED Peer review to determine if there was a miss or
delay. In addition, in house cases that appeared to be a miss were sent for
review by the Infection Specialist on our team.
From: Ron Elkin [mailto:[email protected]]
Sent: Wednesday, February 06, 2013 7:15 PM
To: Crittenden, Andrea L
Cc: Hunter, Patricia; Taylor, Barbara A; Ron Daniels;
[email protected]
Subject: Re: [Sepsis Groups] Time Zero
I believe SSC defines Time Zero as "triage time" for ED patients and "time of
diagnosis" for patients elsewhere in the hospital.
In support of ED triage time, one would argue that it is a simple, easily
determined time in all hospitals and avoids the inevitable endless,debate about
the accuracy of time of diagnosis. The counter-argument has been that this
definition will not account for and will unduly penalize those confronting
patients with true delays in development of the syndrome after arrival in ED.
The clarity of triage time has prevailed as the standard. The expectation is
that both iatrogenic and true delays in diagnosis will haunt us all and the
closer we can push initiation of treatment to the indisputable time of triage,
the better the outcome expected at each center.
From a quality improvement perspective, however, it seems unreasonable to
expect caregivers to act appropriately before arriving at a working diagnosis
of severe sepsis or septic shock. For this reason, our center chose to examine
two questions, each with different implications for improving performance:
1) Did the working diagnosis trigger appropriate and timely therapy? If not,
specific protocol, personnel, and systems issues must be examined and corrected.
2) Was the working diagnosis timely,or was it delayed due to
nurse/physician/systems error? If delayed, distinctly different issues must be
examined. A delayed diagnosis may fall into 3 categories:
i) Potential delay - example: someone with SIRS and a potential source
of infection with delayed testing for later-documented organ dysfunction.
ii) Real delay - example: organ dysfunction was timely documented but
not recognized as severe sepsis.
iii) Both i and ii.
.
I can't recall literature addressing this, but we estimate delay in diagnosis
in roughly 20% of our patients due to error. The analysis has helped us better
categorize and address our problems.
On a different note, it is well established that about 15% of patients with
severe sepsis or septic shock lack 2 or more signs of SIRS. These are largely
elderly and/or immunosuppressed patients. SIRS remains an important screening
tool, but when absent, severe sepsis must still be considered a potential cause
of unexplained organ dysfunction - in apparent contradiction of consensus
definitions.
My $0.02
Ron Elkin MD
California Pacific Medical Center
San Francisco, CA
:
On Wed, Feb 6, 2013 at 12:34 PM, Crittenden, Andrea L
<[email protected]<mailto:[email protected]>>
wrote:
We use ICD-9 codes Severe Sepsis 995.92 or Septic Shock 785.52.
Andrea Crittenden, RN
Quality Improvement Specialist
Providence St. Peter Hospital- Olympia, WA
360-486-6465<tel:360-486-6465>
From:
[email protected]<mailto:[email protected]>
[mailto:[email protected]<mailto:[email protected]>]
On Behalf Of Hunter, Patricia
Sent: Wednesday, February 06, 2013 9:33 AM
To: Taylor, Barbara A; Ron Daniels
Cc:
[email protected]<mailto:[email protected]>
Subject: Re: [Sepsis Groups] Time Zero
Our Hospital currently performs Sepsis audits on ED and IP. We are relying on
clinical personnel to capture sepsis patients for the audit. There is much
discussion about moving the audit to more retroactive and pulling those
patients with codes specific to Sepsis. Is anyone doing auditing relying on
coding solely?
If so, what ICD9 Codes are you using to pull data?
Thanks,
Pat
Patricia Hunter, RN
Clinical Data Analyst
Performance Excellence
Mercy Medical Center - Des Moines, Iowa
515-643-2206<tel:515-643-2206>
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