To my knowledge there is no national standard. That being said the inclusion/exclusion criteria I developed for the Integrated Nurse Leadership Program (through UCSF), has become the default standards in CA since numerous regulatory agencies and hospital associates use it.
It follows what was described below, meaning for the ICD-9 data, which is where mortality is derived, the only exclusion is pediatrics below or equal to age 18 years old. For clinical data, from where we obtain process data, we have more exclusion criteria, such as DNR/Comfort care within 48 hours of admission, transfer of a pt already in severe sepsis/septic shock, no peds, no OB. This might not be a comprehensive list as I am going from memory but these are the bigger items. Julie Kliger, MPA, BSN, RN Founder and Principal The Altos Group, LLC www.thealtosgroup.com 510.551.3330 (c) From: [email protected] [mailto:[email protected]] On Behalf Of [email protected] Sent: Friday, February 01, 2013 3:32 PM To: [email protected]; [email protected]; [email protected] Subject: Re: [Sepsis Groups] Mortality exclsuions for Sepsis (United States) nationally The only exclusion we use is comfort care or patient refusal; certainly not DNR or palliative care. Peggy Rice, RN, BSN, MBA Assistant Chief Nursing Officer Good Samaritan Hospital 2425 Samaritan Drive San Jose, CA 95124 (408) 559-2329 (office) (408) 438-0986 (cell) (408) 559-2620 (fax) [email protected]<mailto:[email protected]> From: [email protected]<mailto:[email protected]> [mailto:[email protected]] On Behalf Of Coleman, Cynthia Sent: Friday, February 01, 2013 6:50 AM To: 'Miller, Kevin - SFMH'; [email protected]<mailto:[email protected]> Subject: Re: [Sepsis Groups] Mortality exclsuions for Sepsis (United States) nationally CAMC currently reports mortality 2 ways, a raw rate and a scrubbed rate. The rates are gathered from ICD-9 codes for severe sepsis and septic shock. The raw rate includes all patients seen with these 2 ICD-9 codes at CAMC. The scrubbed rate excludes all transfers from outlying facilities, and patients with palliative/comfort care orders within 24 hours of admission. Cynthia Coleman, RN, BSN, MBA, CCRN Charleston Area Medical Center Nurse Manager - STICU, 5 South Trauma, Trauma Surgery Clinic Office - 304-388-3410 Pager - 304-330-3410 From: [email protected]<mailto:[email protected]> [mailto:[email protected]] On Behalf Of Miller, Kevin - SFMH Sent: Thursday, January 31, 2013 3:56 PM To: [email protected]<mailto:[email protected]> Subject: [Sepsis Groups] Mortality exclsuions for Sepsis (United States) nationally I have not been able to obtain a list of nationally accepted exclusions for mortality from sepsis. Can anyone provide information if there is a nationally accepted list of exclusion criteria for sepsis mortality (e.g. Palliative care within 6 hours of admission, Burn patients, etc)? Thank you, [cid:[email protected]] "Procrastination is the thief of time" Kevin P. Miller, RN, BSN Manager, Risk Management Saint Francis Memorial Hospital Phone: (415) 353-6296 Fax: (415) 353-6177 Right Fax: (415) 591-6364 [email protected]<mailto:[email protected]> [cid:[email protected]] Confidentiality Notice: This message and any attachments are for the sole use of the intended recipient(s) and may contain information that is legally privileged and/or confidential. This message may also contain confidential health information. If you are not the intended recipient or a person responsible for delivering this message to an intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you are not the intended recipient or a person responsible for delivering this message to an intended recipient, please contact the sender immediately by reply email and destroy all copies of the original message. Confidential health information is protected by state and federal law, including but not limited to, the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and related regulations. Confidentiality Note: The information contained in this message may be privileged and confidential. If this e-mail contains protected health information, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited, except as permitted by law. If you have received this communication in error, please notify the sender immediately by replying to this message and deleting it from your computer. Thank you.
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