Do people know if a "vital sign review" needs to include the actual listing of 
each of the vital signs?  If the MD/NP/PA says "vital signs were reviewed" is 
that sufficient?  The solution below to automatically pull all the VS in seems 
a good one.  It is likely not possible with our system so I'm trying to think 
about alternatives.

thank you,

Joseph Clement, MS, RN, CCNS
Clinical Nurse Specialist
San Francisco General Hospital
ph: 415206-6174
pg: 415 327-0220

________________________________________
From: Sepsisgroups <[email protected]> on behalf of 
Townsend, Sean, M.D. <[email protected]>
Sent: Tuesday, October 13, 2015 9:02 AM
To: Cynthia Wells; Nelson, Kathy
Cc: [email protected]
Subject: Re: [Sepsis Groups] Clock and Fluids

I wish to advise the group we have devised a fix for this problem that will be 
released in version 5.1 of the specs.  This version is effective for discharges 
7/2016.  I will not detail the matter here, but it provides an earlier 
verification of 30ml/kg delivered in the algorithm.  If that is failed, the 
measure is failed so one may not pass with under-resuscitating a patient.

On Oct 8, 2015, at 3:37 PM, Townsend, Sean, M.D. 
<[email protected]<mailto:[email protected]>> wrote:

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/>>




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