Determining by physician documentation only is problematic because physicians document severe sepsis as one of the possible diagnoses. That is why we doubled the number of severe sepsis patients causing increased denominator and therefore decreased mortality when in reality the number of deaths has not been changed after certain point.
Other issue related to this is monitoring 6 hour bundle compliance with patients who do not have severe sepsis. That is why there is no relationship between 6 hour bundle compliance and mortality. If we want to monitor improvement by data collection, it should be accurate so that we can come up with action plan to improve our practice. At this point I believe our effort should focus on education for early recognition and providing a tool (I.e., protocol) for management. Sent from my iPad > On Jan 31, 2016, at 2:27 PM, "[email protected]" > <[email protected]> wrote: > > Send Sepsisgroups mailing list submissions to > [email protected] > > To subscribe or unsubscribe via the World Wide Web, visit > > https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups.org_listinfo.cgi_sepsisgroups-2Dsepsisgroups.org&d=AwICAg&c=PUnqOsCos0lYmbMtBbnNaXdHYubkuj3DpsbI90l9Eks&r=DABW1vPiprcyFbs5E3jbx_50WF6U5caTHUzeMSxN2vA&m=BotBk1Kqw7x_iBYpkPBfWoWO7gc736NnZUymt18ND3M&s=B6-hgrXkwsKP7tTetY40HkAPtRRvoZAW9qSEvYafQxk&e= > > or, via email, send a message with subject or body 'help' to > [email protected] > > You can reach the person managing the list at > [email protected] > > When replying, please edit your Subject line so it is more specific > than "Re: Contents of Sepsisgroups digest..." > > > Today's Topics: > > 1. Re: Septic Shock Presentation Time (Vovan, Andre) > 2. Re: Bundle compliance rates (Ann D. Alway) > 3. Re: Septic Shock Presentation Time (Belfi, Karen) > > > ---------------------------------------------------------------------- > > Message: 1 > Date: Sat, 30 Jan 2016 16:01:29 +0000 > From: "Vovan, Andre" <[email protected]> > To: "[email protected]" <[email protected]>, > "[email protected]" <[email protected]>, > "[email protected]" <[email protected]>, > "[email protected]" > <[email protected]> > Cc: "[email protected]" > <[email protected]> > Subject: Re: [Sepsis Groups] Septic Shock Presentation Time > Message-ID: > > <eaae988fed3144dc.2-16c1b2e3-9718-4119-b320-ae8e52c56...@mail.outlook.com> > > Content-Type: text/plain; charset="windows-1252" > > This is even more confusing. You have one answer that say physician > documentation is enough even with all the criteria is not present. Then you > have an answer that if no fluid is given with clinical septic shock, sep1 > does not recognize septic shock unless fluid bolus is given. > > Not sure why there is this distinction for the measure. If the patient is > hypertensive, we want to get the clinical team to give fluid and get the > resuscitation completed. If there is no fluid given and the measure then > counts the patient only as severe sepsis and allow the 6 hr measure to be > skipped and not recognize the clinical shock then this is counter to what his > been shown to work. > It seems to me that if hospitals design their sepsis protocol to meet the cms > measure, put care would suffer in this instance. > > Sent from Outlook > Mobile<https://urldefense.proofpoint.com/v2/url?u=https-3A__aka.ms_blhgte&d=AwICAg&c=PUnqOsCos0lYmbMtBbnNaXdHYubkuj3DpsbI90l9Eks&r=DABW1vPiprcyFbs5E3jbx_50WF6U5caTHUzeMSxN2vA&m=BotBk1Kqw7x_iBYpkPBfWoWO7gc736NnZUymt18ND3M&s=tB6_X2LCKmtzx2rRbajJ2B1uIyA9fsq0Zqy5EP8gWZ4&e= > > > > > > On Thu, Jan 28, 2016 at 12:39 PM -0800, "Mary Draper" > <[email protected]<mailto:[email protected]>> wrote: > > Thanks Dr. Townsend. > > Mary Draper RN BSN > Coordinator Quality Improvement > Peer Review Support CV/CT > Quality Management JMH > Office (925) 674-2045 > Cell (925) 451-8792 > Fax (925) 674-2373 > [email protected] > > ?O, let us always have a mountain within our soul, with a peak so high that > we never quite reach the top? > For then we will always strive for greater things and will not be content > with merely climbing hills.? Ardath Rodale > > > > -----Original Message----- > From: Sepsisgroups [mailto:[email protected]] On > Behalf Of Townsend, Sean, M.D. > Sent: Tuesday, January 26, 2016 7:53 PM > To: Belfi, Karen > Cc: [email protected] > Subject: Re: [Sepsis Groups] Septic Shock Presentation Time > > I have to retract my comment. I think 10:47 is accurate. > > On Jan 26, 2016, at 7:41 PM, Townsend, Sean, M.D. <[email protected]> > wrote: > > I don't see criteria met at 10:47. MD say so is not enough. > > On Jan 25, 2016, at 1:02 PM, Belfi, Karen > <[email protected]<mailto:[email protected]>> wrote: > > 10:47 would be septic shock time. It?s the earliest time criteria is met. > > Karen Belfi, RN, MSN > Quality Outcomes Coordinator > Lankenau Medical Center > 484-476-8092 > Pager: 5240 > <image001.png> > > From: Sepsisgroups [mailto:[email protected]] On > Behalf Of [email protected]<mailto:[email protected]> > Sent: Wednesday, January 20, 2016 9:15 PM > To: > [email protected]<mailto:[email protected]> > Subject: [Sepsis Groups] Septic Shock Presentation Time > > Clinical criteria for severe sepsis is met at 1002. Crystalloid bolus > completed at 1247. SBP=79 @ 1300. SBP=87 @1330. > Initial lactic acid =4.0 resulted at 1126. > ED physician note started at 1047 containing documentation of possible septic > shock. > Would septic shock presentation time be 1047, 1126 or 1300? > > Karen King, RN MSN > Quality Management Core Measures Specialist, Lead Lakeview Regional Medical > Center > 95 Judge Tanner Boulevard > Covington, LA 70433 > Office: (985) 867-4467 > Cell: (985) 788-0585 > Fax: (985) 867-4263 > Email: [email protected]<mailto:[email protected]> > > This email and any files transmitted with it may contain privileged or > confidential information and may be read or used only by the intended > recipient. If you are not the intended recipient of the email or any of its > attachments, please be advised that you have received this email in error and > that any use, dissemination, distribution, forwarding, printing, or copying > of this email or any attached files is strictly prohibited. If you have > received this email in error, please immediately purge it and all attachments > and notify the sender by reply email or contact the sender at the number > listed. > > > > _______________________________________________ > Sepsisgroups mailing list > [email protected]<mailto:[email protected]> > https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups.org_listinfo.cgi_sepsisgroups-2Dsepsisgroups.org&d=AwICAg&c=PUnqOsCos0lYmbMtBbnNaXdHYubkuj3DpsbI90l9Eks&r=DABW1vPiprcyFbs5E3jbx_50WF6U5caTHUzeMSxN2vA&m=BotBk1Kqw7x_iBYpkPBfWoWO7gc736NnZUymt18ND3M&s=B6-hgrXkwsKP7tTetY40HkAPtRRvoZAW9qSEvYafQxk&e= > _______________________________________________ > Sepsisgroups mailing list > [email protected] > https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups.org_listinfo.cgi_sepsisgroups-2Dsepsisgroups.org&d=AwICAg&c=PUnqOsCos0lYmbMtBbnNaXdHYubkuj3DpsbI90l9Eks&r=DABW1vPiprcyFbs5E3jbx_50WF6U5caTHUzeMSxN2vA&m=BotBk1Kqw7x_iBYpkPBfWoWO7gc736NnZUymt18ND3M&s=B6-hgrXkwsKP7tTetY40HkAPtRRvoZAW9qSEvYafQxk&e= > _______________________________________________ > Sepsisgroups mailing list > [email protected] > https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups.org_listinfo.cgi_sepsisgroups-2Dsepsisgroups.org&d=AwICAg&c=PUnqOsCos0lYmbMtBbnNaXdHYubkuj3DpsbI90l9Eks&r=DABW1vPiprcyFbs5E3jbx_50WF6U5caTHUzeMSxN2vA&m=BotBk1Kqw7x_iBYpkPBfWoWO7gc736NnZUymt18ND3M&s=B6-hgrXkwsKP7tTetY40HkAPtRRvoZAW9qSEvYafQxk&e= > _______________________________________________ > Sepsisgroups mailing list > [email protected] > https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups.org_listinfo.cgi_sepsisgroups-2Dsepsisgroups.org&d=AwICAg&c=PUnqOsCos0lYmbMtBbnNaXdHYubkuj3DpsbI90l9Eks&r=DABW1vPiprcyFbs5E3jbx_50WF6U5caTHUzeMSxN2vA&m=BotBk1Kqw7x_iBYpkPBfWoWO7gc736NnZUymt18ND3M&s=B6-hgrXkwsKP7tTetY40HkAPtRRvoZAW9qSEvYafQxk&e= > > Please note that the information contained in this message and any files > transmitted with it are privileged and confidential and are > protected from disclosure under the law, including the Health Insurance > Portability and Accountability Act (HIPAA). If the reader of this > message is not the intended recipient, or an employee or agent > responsible for delivering this message to the intended recipient, you > are hereby notified that any dissemination, distribution or copying of > this communication is strictly prohibited and may subject you to > criminal or civil penalties. If you have received this communication in > error, please notify the sender by replying to the message and delete > the material from any computer. > > Thank you, > > Hoag Memorial Hospital Presbyterian and its Affiliates > > -------------- next part -------------- > An HTML attachment was scrubbed... > URL: > <https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups.org_pipermail_sepsisgroups-2Dsepsisgroups.org_attachments_20160130_75d5c5cf_attachment-2D0001.htm&d=AwICAg&c=PUnqOsCos0lYmbMtBbnNaXdHYubkuj3DpsbI90l9Eks&r=DABW1vPiprcyFbs5E3jbx_50WF6U5caTHUzeMSxN2vA&m=BotBk1Kqw7x_iBYpkPBfWoWO7gc736NnZUymt18ND3M&s=NSPAyubfH9P6D6Nqbx8bmH1cCekbLhxtMOCWogqiY2g&e= > > > > ------------------------------ > > Message: 2 > Date: Thu, 28 Jan 2016 12:46:50 -0800 > From: "Ann D. Alway" <[email protected]> > To: "'Nielsenshultz, Yara'" <[email protected]>, > "[email protected]" > <[email protected]> > Subject: Re: [Sepsis Groups] Bundle compliance rates > Message-ID: > <172bfe2afb71364b9fe2513ddbfc1395900eb14...@shexchmb1v.phhservices.org> > > Content-Type: text/plain; charset="us-ascii" > > 40% compliance here at a 400 bed Community hospital in the Northwest. > > -----Original Message----- > From: Sepsisgroups [mailto:[email protected]] On > Behalf Of Nielsenshultz, Yara > Sent: Thursday, January 28, 2016 11:14 AM > To: [email protected] > Subject: Re: [Sepsis Groups] Bundle compliance rates > > Back in October, Dr. Townsend stated he expected a bundle compliance rate of > 30-50% (see below). Does this estimate seem congruent with your experience > with this measure? We're seeing a wide range in compliance rates at our > various locations. > > Thank you, > > YARA NIELSENSHULTZ, RN, BSN, MS > Clinical Quality Manager > EmCare, North Division > Direct: (215) 442-5122 > [email protected] > www.EmCare.com > > > -----Original Message----- > From: Sepsisgroups [mailto:[email protected]] On > Behalf Of Townsend, Sean, M.D. > Sent: Saturday, October 03, 2015 1:29 AM > To: Brown, Sheree > Cc: [email protected] > Subject: Re: [Sepsis Groups] Bundle compliance rates > > I expect that compliance will be very low, 30% at best for most facilities. > Some facilities will be 15-20%. This I also will reach 50% by 6-12 months > experience with this metric, but getting there will not be easy. > > Remember, however, CMS will report performance as a benchmark with deciles of > performance. If 30% is the best anyone can do, that will be P90. That said, > changes will be sharp -- P50 may be 27%. > > All metrics accomplish one thing -- they focus facilities on improving the > metric. This will create conversations, meetings, collaborations, arguments, > disagreements, settlements, etc. And it's all good -- it means people will > improve. Probably with pain as well as pleasure in accomplishment. > > This is a tough measure. Very very tough. But if you focus your energies on > the patient and trying to work with it, it will pay off. > > The first SSC paper I think is most illustrative. Compliance went from low > 30's to mid 30's on an all or nothing basis, but mortality dropped 7%. So, > small gains with this measure result in tangible benefits. It just doesn't > "feel" good while it's happening. > > See: > > Levy MM, Dellinger RP, Townsend SR et al, The Surviving Sepsis Campaign: > results of an international guideline-based performance improvement program > targeting severe sepsis, Crit Care Med. 2010 Feb;38(2):367-74. doi: > 10.1097/CCM.0b013e3181cb0cdc. > > > > > On Oct 2, 2015, at 12:50 PM, Brown, Sheree > <[email protected]<mailto:[email protected]>> > wrote: > > Does anyone know if CMS has established an expected minimal rate of > compliance with the Sep-1 measure? Or if not, is there is a reported > compliance rate with the SSC 3 hr and 6 hr bundles? > > Thanks, > Sheree > > Sheree Brown MSN, RN, CNL > Manager, Performance Excellence > Phone: 517 205-4209 ext. 4209 > Pager: 517 534-0127 > Fax: 517 788-4715 > [email protected]<allegiancehealth.org> > [cid:[email protected]] > > _______________________________________________ > Sepsisgroups mailing list > [email protected]<mailto:[email protected]> > https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups.org_listinfo.cgi_sepsisgroups-2Dsepsisgroups.org&d=AwICAg&c=PUnqOsCos0lYmbMtBbnNaXdHYubkuj3DpsbI90l9Eks&r=DABW1vPiprcyFbs5E3jbx_50WF6U5caTHUzeMSxN2vA&m=BotBk1Kqw7x_iBYpkPBfWoWO7gc736NnZUymt18ND3M&s=B6-hgrXkwsKP7tTetY40HkAPtRRvoZAW9qSEvYafQxk&e= > _______________________________________________ > Sepsisgroups mailing list > [email protected] > https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups.org_listinfo.cgi_sepsisgroups-2Dsepsisgroups.org&d=AwICAg&c=PUnqOsCos0lYmbMtBbnNaXdHYubkuj3DpsbI90l9Eks&r=DABW1vPiprcyFbs5E3jbx_50WF6U5caTHUzeMSxN2vA&m=BotBk1Kqw7x_iBYpkPBfWoWO7gc736NnZUymt18ND3M&s=B6-hgrXkwsKP7tTetY40HkAPtRRvoZAW9qSEvYafQxk&e= > > ********************************************************************** > Confidentiality Notice: The information contained in this email and any > attachments > may be legally privileged and confidential. If you are not an intended > recipient, you > are hereby notified that any dissemination, distribution, or copying of this > email is > strictly prohibited. If you have received this email in error, please notify > the > sender and permanently delete the email and any attachments immediately. You > should > not retain, copy, or use this email or any attachment for any purpose; nor > disclose > all or any part of the contents to any other person. > > > ------------------------------ > > Message: 3 > Date: Fri, 29 Jan 2016 06:16:20 -0500 > From: "Belfi, Karen" <[email protected]> > To: "[email protected]" > <[email protected]>, "[email protected]" > <[email protected]>, "[email protected]" > <[email protected]> > Cc: "[email protected]" > <[email protected]> > Subject: Re: [Sepsis Groups] Septic Shock Presentation Time > Message-ID: > <[email protected]> > Content-Type: text/plain; charset="utf-8" > > This is contradictory to everything they stated in both the power point and > the Q&A. > > From the Q&A: > Question 61: If lactate is >4 and no crystalloid fluids are administered, do > you answer ?Yes? or ?No? for Septic Shock present? > Answer 61: The Septic Shock Present data element's Notes for Abstraction > indicates that if crystalloid fluids were not administered after the > presentation date and time of severe sepsis, to choose Value "2 (No)." > > Question 145: If initial lactate is >4, but no crystalloid fluids are given > during the 6 hours after severe sepsis, do we answer "No" to septic shock? > Answer 145: Not necessarily. You would select "No" for Septic Shock Present > if no crystalloid fluids were given at all after presentation of severe > sepsis. There is no time frame after severe sepsis presentation associated > with this. If fluids were not given within 6 hours following presentation of > severe sepsis but were given after 6 hours, then you would select "Yes." This > is an all-or-none point for crystalloid fluids. > > Question 172: If the patient has severe sepsis and an initial lactate of 4.5 > but does not receive any crystalloid fluids, would it still be "No" to Septic > Shock Present due to not having any crystalloids given? > Answer 172: Correct. > > This was from the transcript of the CMS presentation on October 26 (page 27): > Now please note, in the septic shock present data element, there is a bullet > point in the note for abstraction indicating that if crystalloid fluids were > not administered after severe sepsis presentation date and time, that you > would select allowable value 2 for septic shock present, which is equivalent > to No. For purposes of SEP-1 measure, at this point in time, regardless of > how septic shock is identified, if no crystalloid fluids were given after > severe sepsis presentation, you will select allowable value 2, which is No, > for septic shock present. > > Karen Belfi, RN, MSN > Quality Outcomes Coordinator > Lankenau Medical Center > 484-476-8092 > Pager: 5240 > > > > -----Original Message----- > From: [email protected] > [mailto:[email protected]] > Sent: Thursday, January 28, 2016 4:04 PM > To: [email protected]; [email protected]; Belfi, Karen > Cc: [email protected] > Subject: RE: [Sepsis Groups] Septic Shock Presentation Time > > I sent the question regarding fluids and septic shock presentation to CMS and > this is the response I received in November: > > Gena, > There are three ways to determine if Septic Shock is present. > 1. Severe Sepsis present AND Hypotension persists in the hour after > crystalloid fluid administration 2. Severe Sepsis present AND Initial > Lactate level >= 4mmol/L 3. Physician documentation of septic shock > > For #2 - Crystalloid fluid administration is not required to determine > whether the patient has septic shock if using the presence of severe sepsis > and the lactate level to determine. > > > Thanks, > Gena Henriques, MSN, RN > Quality Review Coordinator - Sepsis > Tulane Medical Center > 1415 Tulane Ave. > New Orleans, LA 70112 > Phone: 504-988-3195 > > Think Sepsis: Save A Life > This email and any files transmitted with it may contain PRIVILEGED or > CONFIDENTIAL information and may be read or used only by the intended > recipient. If you are not the intended recipient of the email or any of its > attachments, please be advised that you have received this email in error and > that any use, dissemination, distribution, forwarding, printing, or copying > of this email or any attached files is strictly prohibited. If you have > received this email in error, please immediately purge it and all attachments > and notify the sender by reply email or contact the sender at the number > listed. > > > > > -----Original Message----- > From: Sepsisgroups [mailto:[email protected]] On > Behalf Of Cobb, Amy L. > Sent: Thursday, January 28, 2016 5:45 AM > To: Townsend, Sean, M.D.; Belfi, Karen > Cc: [email protected] > Subject: [EXTERNAL] Re: [Sepsis Groups] Septic Shock Presentation Time > > Has something changed in the Spec Manual since the v5.0b came out? This is > copied and pasted from the manual: > > *If criteria for Septic Shock are not met, but there is physician/APN/PA > documentation of Septic Shock, choose Value ?1.? > > Allowable Values: > 1 (Yes) There is documentation of Septic Shock > 2 (No) There is no documentation of Septic Shock, or unable to determine > > Dr. Townsend, can you clarify this if physician documentation is not enough > and let us know if this was changed/updated? > > Thank you > > > Amy Cobb RN, BSN > Sepsis Coordinator > Research Outcomes > Morton Plant Hospital > MS #73 > 300 Pinellas St. > Clearwater, FL 33756 > 727-298-6953 (Desk) > 727-462-3638 (Fax) > [email protected] > > -----Original Message----- > From: Sepsisgroups [mailto:[email protected]] On > Behalf Of Townsend, Sean, M.D. > Sent: Monday, January 25, 2016 4:12 PM > To: Belfi, Karen > Cc: [email protected] > Subject: Re: [Sepsis Groups] Septic Shock Presentation Time > > I don't see criteria met at 10:47. MD say so is not enough. > > > > On Jan 25, 2016, at 1:02 PM, Belfi, Karen > <[email protected]<mailto:[email protected]>> wrote: > > > > 10:47 would be septic shock time. It?s the earliest time criteria is met. > > > > Karen Belfi, RN, MSN > > Quality Outcomes Coordinator > > Lankenau Medical Center > > 484-476-8092 > > Pager: 5240 > > <image001.png> > > > > From: Sepsisgroups [mailto:[email protected]] On > Behalf Of [email protected]<mailto:[email protected]> > > Sent: Wednesday, January 20, 2016 9:15 PM > > To: > [email protected]<mailto:[email protected]> > > Subject: [Sepsis Groups] Septic Shock Presentation Time > > > > Clinical criteria for severe sepsis is met at 1002. Crystalloid bolus > completed at 1247. SBP=79 @ 1300. SBP=87 @1330. > > Initial lactic acid =4.0 resulted at 1126. > > ED physician note started at 1047 containing documentation of possible septic > shock. > > Would septic shock presentation time be 1047, 1126 or 1300? > > > > Karen King, RN MSN > > Quality Management Core Measures Specialist, Lead > > Lakeview Regional Medical Center > > 95 Judge Tanner Boulevard > > Covington, LA 70433 > > Office: (985) 867-4467 > > Cell: (985) 788-0585 > > Fax: (985) 867-4263 > > Email: [email protected]<mailto:[email protected]> > > > > This email and any files transmitted with it may contain privileged or > confidential information and may be read or used only by the intended > recipient. If you are not the intended recipient of the email or any of its > attachments, please be advised that you have received this email in error and > that any use, dissemination, distribution, forwarding, printing, or copying > of this email or any attached files is strictly prohibited. If you have > received this email in error, please immediately purge it and all attachments > and notify the sender by reply email or contact the sender at the number > listed. > > > > > > > > _______________________________________________ > > Sepsisgroups mailing list > > [email protected]<mailto:[email protected]> > > https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups.org_listinfo.cgi_sepsisgroups-2Dsepsisgroups.org&d=CwIGaQ&c=MS-5dKql6qjhmD6zBX8NdQ&r=KQhQAyB28wX0ryHeUUrvHwtJt_LBhCc_ENWLFE_5OQM&m=MIOxJC-J0Hl7V8zraHmRvAJqUnUQxV84ioAAkoOtpPQ&s=PE9haHZiSt0lsaWrtXo79byWSukDpnw1Pcj-cZckiGI&e= > > _______________________________________________ > Sepsisgroups mailing list > [email protected] > https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups.org_listinfo.cgi_sepsisgroups-2Dsepsisgroups.org&d=CwIGaQ&c=MS-5dKql6qjhmD6zBX8NdQ&r=KQhQAyB28wX0ryHeUUrvHwtJt_LBhCc_ENWLFE_5OQM&m=MIOxJC-J0Hl7V8zraHmRvAJqUnUQxV84ioAAkoOtpPQ&s=PE9haHZiSt0lsaWrtXo79byWSukDpnw1Pcj-cZckiGI&e= > > ---------------------------------------------------------------------- > Confidential: This electronic message and all contents contain information > from BayCare Health System which may be privileged, confidential or otherwise > protected from disclosure. The information is intended to be for the > addressee only. If you are not the addressee, any disclosure, copy, > distribution or use of the contents of this message is prohibited. If you > have received this electronic message in error, please notify the sender and > destroy the original message and all copies. > _______________________________________________ > Sepsisgroups mailing list > [email protected] > https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups.org_listinfo.cgi_sepsisgroups-2Dsepsisgroups.org&d=AwICAg&c=PUnqOsCos0lYmbMtBbnNaXdHYubkuj3DpsbI90l9Eks&r=DABW1vPiprcyFbs5E3jbx_50WF6U5caTHUzeMSxN2vA&m=BotBk1Kqw7x_iBYpkPBfWoWO7gc736NnZUymt18ND3M&s=B6-hgrXkwsKP7tTetY40HkAPtRRvoZAW9qSEvYafQxk&e= > > ------------------------------ > > Subject: Digest Footer > > _______________________________________________ > Sepsisgroups mailing list > [email protected] > https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups.org_listinfo.cgi_sepsisgroups-2Dsepsisgroups.org&d=AwICAg&c=PUnqOsCos0lYmbMtBbnNaXdHYubkuj3DpsbI90l9Eks&r=DABW1vPiprcyFbs5E3jbx_50WF6U5caTHUzeMSxN2vA&m=BotBk1Kqw7x_iBYpkPBfWoWO7gc736NnZUymt18ND3M&s=B6-hgrXkwsKP7tTetY40HkAPtRRvoZAW9qSEvYafQxk&e= > > > ------------------------------ > > End of Sepsisgroups Digest, Vol 189, Issue 12 > ********************************************* ---------------------------------------------------------------------- NOTICE: This email may contain PRIVILEGED and CONFIDENTIAL information and is intended only for the use of the specific individual(s) to which it is addressed. It may contain Protected Health Information that is privileged and confidential. Protected Health Information may be used or disclosed in accordance with law and you may be subject to penalties under law for improper use or further disclosure of the Protected Health Information in this email. If you are not an intended recipient of this email, you are hereby notified that any unauthorized use, dissemination or copying of this email or the information contained in it or attached to it is strictly prohibited. If you have received this email in error, please delete it and immediately notify the person named above by reply email. Thank you. _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
