HI All, I agree with Sean and yes, this is probably THE most confusing aspect of the CMS bundles. It goes against what we have been doing for years when looking at fluid compliance. Typically is the past, we have always monitored fluid compliance for any patient who was hypotensive with severe sepsis. With the CMS measure, essentially we are looking at just the shock patients and asking did they get the 30 mL/kg of fluids? They are not interested in if they had severe sepsis with hypotension - did they get the right amount of fluids.
I struggled with this for some time! It finally clicked when I looked at it from the above perspective. Hope this helps some. Brenda ☺ Brenda Downs MSN, APRN, ACNS-BC Cell: 480-720-6102 Program Director Clinical Performance Improvement -----Original Message----- From: Sepsisgroups [mailto:[email protected]] On Behalf Of Townsend, Sean, M.D. Sent: Friday, October 09, 2015 3:13 PM To: Myran, Robin Cc: [email protected] Subject: Re: [Sepsis Groups] Clock and Fluids Here's why the reasoning is not circular for every case. It had me stuck for a while too, so I know this will help. You have to remember there are 3 ways to get to the time of presentation with septic shock: 1) the patient has lactate > 4 at a certain time; 2) a timed provider note says so; 3) the patient presents with initial hypotension, they receive 30 ml/kg of crystalloid, and after the full amount of fluid is infused there is recurrent hypotension at a specific time -- that time of recurrent hypotension is the presentation time. You see scenario three and say: "30 cc/kg is required to be administered within the first 3 hours of presentation of septic shock …however… Septic shock isn’t determined until 30 cc/kg is administered and the patient remains hypotensive." But actually that reasoning applies to the first two cases. In the first two cases, and especially the lactate case, the septic shock presentation time is probably before the fluid is administered. Once lactate returns at 4 that triggers the bolus. In the instance of persistent hypotension (case 3) as the way to start the clock, all the 30 ml/kg of fluid has to go in first before I can even look to see if hypotension is recurrent. Then, if present that time is the shock clock start time. Because all that fluid went in before you look for that start time, you are permitted to use the preceding 3 hours to count toward the delivery of the 30 ml/kg. Thus, it's not circular, it's just that you can't define a start time until that much fluid has gone in. So, your choice to start the clock after 20 ml/kg goes in and count the rest afterwards will not meet the measure for case 3. You must infuse the full 30 ml/kg first. To be more specific, when you say "Guided by the fact that the 30 cc/kg is never mentioned in the CMS algorithm until *after* septic shock is determined to be present, we..." you are incorrect. In case #3 above its just the opposite -- septic shock start time is never determined until after the 30ml/kg is infused (and it can be "within 3 hours" because credit is assigned for fluid given 3 hours antecedent to the start time). Sean On Oct 9, 2015, at 1:22 PM, Myran, Robin <[email protected]<mailto:[email protected]>> wrote: Dr. Townsend – First of all, thank you again for your patience with all of our questions and for taking the time to share your expertise. Your conversation below covers the part of the SEP-1 measure that has bothered me from the very beginning: 30 cc/kg is required to be administered within the first 3 hours of presentation of septic shock …however… Septic shock isn’t determined until 30 cc/kg is administered and the patient remains hypotensive. To me, this is circular reasoning. Guided by the fact that the 30 cc/kg is never mentioned in the CMS algorithm until *after* septic shock is determined to be present, we interpret it as follows: Patient comes in hypotensive, we give a fluid bolus (undefined by CMS, but for our protocol usually 20 cc/kg). If they don’t respond to that initial bolus, then they are determined to be in “septic shock” and we make sure they get a total of 30 cc/kg by the 3rd hour and that we meet the 6 hour goals. Your thoughts? Robin Myran, MSN, RN, PCCN Sepsis Coordinator Hoag Memorial Hospital Presbyterian One Hoag Drive Newport Beach, CA 92658 Office: (949) 764-4588 Fax: (949) 764-5387 Cell: (949) 300-9137 [email protected]<mailto:[email protected]> From: Sepsisgroups [mailto:[email protected]] On Behalf Of Townsend, Sean, M.D. Sent: Tuesday, October 06, 2015 12:34 PM To: 'Cynthia Wells'; Nelson, Kathy Cc: [email protected]<mailto:[email protected]> Subject: Re: [Sepsis Groups] Clock and Fluids This question initially brought by Cynthia and now carried forward by Kathy has been eye opening and I am working to see how we may rectify the apparent dilemma. What I can say in the meantime is a) In the scenario below, and for the present set of specifications, the physician documented shock time would stand, unfortunately as the shock clock start time. (And that late documentation is probably not helpful either, putting earlier performed elements at being at risk of outside abstraction time limits.) b) While as individuals involved with abstraction of charts (or just voracious readers of dense measure material) you have caught a problem which is not obvious to providers – that if the full infusion of fluids has not occurred a shock clock start time cannot be determined (unless the LIP documents shock). It appears that patient would only qualify for severe sepsis start time and not the rest of the measure requirements in the present set of specifications. I would ask you to keep in mind though that clinicians are very unlikely to understand this and while it is being remedied, that ignorance is probably a good thing. In other words, a provider will know only that they are supposed to give 30 ml/kg of fluids, it is extraordinarily unlikely they will be aware that a “glitch” in the measure specification could permit them to willfully under-resuscitate a patient and pass the measure (for severe sepsis and never reach shock). My guess is that SEP-1 will still perform as intended – to get providers cognizant of giving the right amount of fluids. The inner workings of the measurement will remain blind to many of them allowing an opportunity to resolve this issue. c) There is a solution to this … we will figure out a way to remedy it. It will come in a future specification and can’t take effect likely for many months to come. Sean R. Townsend, M.D. Vice President of Quality & Safety California Pacific Medical Center 2330 Clay Street, #301 San Francisco, CA 94115 email [email protected]<mailto:[email protected]> office (415) 600-5770 fax (415) 600-1541 From: Sepsisgroups [mailto:[email protected]] On Behalf Of Cynthia Wells Sent: Monday, October 05, 2015 4:29 PM To: Nelson, Kathy Cc: [email protected]<mailto:[email protected]> Subject: Re: [Sepsis Groups] Clock and Fluids I agree as well with the comments below. It is odd that if the patient doesn't have lactate >4 and no documentation of septic shock in the case where didn't order enough fluids the case would be excluded from 6 hour instead of outlier. The fluids and antibiotics are the major components of saving lives. Cindy Wells Sent from my iPhone On Oct 5, 2015, at 7:04 PM, Nelson, Kathy <[email protected]<mailto:[email protected]>> wrote: My understanding of the measure definition and guidelines brings me to similar answers to these questions: Questions: 1. The patient develops severe sepsis at 0300 and BP drops to 80/40 at 0600. 30ml/kg was given and completed at 0730. BP 60/40 at 0830. Is the presentation time 0830? YES (my thoughts: agree, YES, based on the septic shock criterion that there is persistent hypotension in the one hour following fluid administration) 2. If the presentation time is 0830, then we have already completed the 3 hour bundle prior to presentation and have until 1430 to complete the 6 hour bundle, correct? YES (my thoughts: agree, YES, ASSUMING you took an initial Lactate, obtained a blood culture, administered antibiotics in the 3 hours following severe sepsis presentation time) 3. What would presentation time be if the patient did not receive the full 30ml/kg? BP 80/40 0600, received 20ml/kg at 0730 and Levophed gtt was initiated at 0830 for BP 60/40. MD documents septic shock at 1500. Is the presentation time 0830 with the hypotension following fluids or 1500 when the MD documents septic shock since the full amount of fluids were not received to determine if the patient truly had persistent hypotension? MYUNDERSTANDING IS THAT BECAUSE 30 ML/KG WERE NOT GIVEN, YOU CANNOT USE PERSISITANT HYPOTENSION AS A CRITERIA AND SO DOCUMENTATION OF SEPTIC SHOCK WOULD BE REQUIRED. SO IN THIS INSTANCE, 1500 WOULD BE YOUR START TIME. (my thoughts: Please see QNET Q&A 150527-000044, which states: · If the physician places an order for the total volume it must be equivalent to at least 30 mL/kg. · The Crystalloid Fluid Administration data elements are looking for the correct volume being ordered and the date and time it is started. Whether or not the correct volume was given is not part of these data elements · The Persistent Hypotension data element however does require the full volume of 30 mL/kg be given. So, I agree that you would not be able to use the persistent hypotension criterion for determining septic shock time and would need to use the time the physician documented Septic Shock UNLESS the patient had a Lactate >4 (the alternative definition for shock) 4. The patient develops severe sepsis at 0300. Lactic acid 5.0 at 0600 (not hypotensive). 30ml/kg is completed at 0830. Is the presentation time 0600 or 0830? SHOCK START TIME WOULD BE 0600. (my thoughts: agree, patient meets criteria for shock at 0600 based upon the criteria = severe sepsis + Lactate >4). Kathy Nelson Manager, Public Data Center for Health Information Services Advocate Health Care 3075 Highland Parkway, Downers Grove, IL 60515 630.929.6782 (internal: 55-6782) [email protected]<mailto:[email protected]> -----Original Message----- From: Sepsisgroups [mailto:[email protected]] On Behalf Of Clement, Joseph (DPH) Sent: Friday, October 02, 2015 12:44 PM To: Osburn, Jennifer R. Cc: [email protected]<mailto:[email protected]> Subject: Re: [Sepsis Groups] Clock and Fluids Jennifer - I'm going to test out my knowledge and tell you what I feel pretty sure is correct but I'm eager to hear from others if I am wrong: Questions: 1. The patient develops severe sepsis at 0300 and BP drops to 80/40 at 0600. 30ml/kg was given and completed at 0730. BP 60/40 at 0830. Is the presentation time 0830? YES 2. If the presentation time is 0830, then we have already completed the 3 hour bundle prior to presentation and have until 1430 to complete the 6 hour bundle, correct? YES 3. What would presentation time be if the patient did not receive the full 30ml/kg? BP 80/40 0600, received 20ml/kg at 0730 and Levophed gtt was initiated at 0830 for BP 60/40. MD documents septic shock at 1500. Is the presentation time 0830 with the hypotension following fluids or 1500 when the MD documents septic shock since the full amount of fluids were not received to determine if the patient truly had persistent hypotension? MYUNDERSTANDING IS THAT BECAUSE 30 ML/KG WERE NOT GIVEN, YOU CANNOT USE PERSISITANT HYPOTENSION AS A CRITERIA AND SO DOCUMENTATION OF SEPTIC SHOCK WOULD BE REQUIRED. SO IN THIS INSTANCE, 1500 WOULD BE YOUR START TIME. 4. The patient develops severe sepsis at 0300. Lactic acid 5.0 at 0600 (not hypotensive). 30ml/kg is completed at 0830. Is the presentation time 0600 or 0830? SHOCK START TIME WOULD BE 0600. Joe Joseph Clement, MS, RN, CCNS Clinical Nurse Specialist San Francisco General Hospital ph: 415206-6174 pg: 415 327-0220 ________________________________________ From: Sepsisgroups <[email protected]<mailto:[email protected]>> on behalf of Osburn, Jennifer R. <[email protected]<mailto:[email protected]>> Sent: Tuesday, September 29, 2015 7:46 AM To: 'Townsend, Sean, M.D.' Cc: [email protected]<mailto:[email protected]> Subject: Re: [Sepsis Groups] Clock and Fluids I guess I am still confused on the shock clock. I was under the impression from the specification manual that we used the point at which the patient became hypotensive and/or lactic acid >4 as the septic shock presentation time. Questions: 1. The patient develops severe sepsis at 0300 and BP drops to 80/40 at 0600. 30ml/kg was given and completed at 0730. BP 60/40 at 0830. Is the presentation time 0830? 2. If the presentation time is 0830, then we have already completed the 3 hour bundle prior to presentation and have until 1430 to complete the 6 hour bundle, correct? 3. What would presentation time be if the patient did not receive the full 30ml/kg? BP 80/40 0600, received 20ml/kg at 0730 and Levophed gtt was initiated at 0830 for BP 60/40. MD documents septic shock at 1500. Is the presentation time 0830 with the hypotension following fluids or 1500 when the MD documents septic shock since the full amount of fluids were not received to determine if the patient truly had persistent hypotension? 4. The patient develops severe sepsis at 0300. Lactic acid 5.0 at 0600 (not hypotensive). 30ml/kg is completed at 0830. Is the presentation time 0600 or 0830? Thanks Jennifer Osburn, RN, BSN Quality and Accreditation St. Mary's Medical Center [email protected]<mailto:[email protected]> -----Original Message----- From: Sepsisgroups [mailto:[email protected]] On Behalf Of Townsend, Sean, M.D. Sent: Friday, September 25, 2015 12:12 PM To: Parker, Erin Cc: [email protected]<mailto:[email protected]> Subject: Re: [Sepsis Groups] Clock and Fluids In your scenario the shock clock starts at 14:00. No "second" bolus is required (but you may want to give more fluids). SSC supports the CMS measure for US hospitals. We have not removed all references to triage time and other changes as we have yet to clear these changes with our European counterparts, but it's in the works. On Sep 25, 2015, at 10:04 AM, Parker, Erin <[email protected]<mailto:[email protected]<mailto:[email protected]%3cmailto:[email protected]>>> wrote: Just when I think I have a handle on the shock clock, I still don’t think I completely understand. Question: For a pt with severe sepsis with hypotension: EX: hypotension at 1200 given 30ml/kg, fluids completed at 1300, MAP at 1400 was 55, is 1400 when shock clock starts, and do you complete another 30ml/kg bolus? Question: SSC stills has triage time for clock to being if in ED, is this correct? Erin K. Parker RN, BSN, ACM | Infection Control Genesys Regional Medical Center | One Genesys Parkway | Grand Blanc, MI 48439 Phone: 810.606.5093| Fax: 810-606-5495 | [email protected]<mailto:[email protected]<mailto:[email protected]%3cmailto:[email protected]>> | www.genesys.org<http://www.genesys.org/<http://www.genesys.org%3chttp:/www.genesys.org/>> This e-mail, and any attachments thereto, is intended only for use by the addressee(s) named herein and may contain legally privileged and/or confidential information. 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