You would use the elevated bilirubin as organ dysfunction in the absence of physician documentation specifying it is related to a chronic/other condition or medication. Below are some questions/answers that I've sent to qualitynet related to this issue that may help clarify further.
Response Noel Albritton via Email 06/07/2016 11:38 AM Hi Angella, Thanks for the question. In order to disregard the elevated creatinine results, the medical record must consider the elevated creatinine is due to a chronic condition or medication. Given the documentation provided, it does not appear the medical record considers the creatinine is elevated due to a chronic condition or medication. Therefore, it is acceptable to abstract the elevated creatinine as evidence of organ dysfunction. Hope this helps! Question: Customer Angella Lott via CSS Web 06/07/2016 08:02 AM MD documents in nephrology consult "AKI: nonoliguric. Improving with IVF. Pre-renal azotemia from Diarrhea, Flu & poor intake. Unknown baseline creat." Within the body of the consult, the patient's creatinine results are noted as 4/2 on 4/23 1225 and 3.7 oon 4/24 0113. Based on this documentation, should we disregard the creatinine results in assigning organ dysfunction criteria? Response Rhonda Carmi via Email 05/04/2016 03:29 PM Good afternoon Angella, There are only 2 specific situations that are spelled out in the specifications manual that represent organ dysfunction that is due to a chronic condition. These are the only 2 that are allowed at this time without physician documentation stating the lab results are directly related to something else. Those two scenarios are: * Patient with End Stage Renal Disease, with Creatinine >2 * Patient on Warfarin with INR>1.5 Anything else requires physician documentation connecting the results to another condition. Question: Customer Angella Lott via CSS Web 05/04/2016 12:16 PM In the H&P, the MD lists final diagnosis, which includes "ESRD - on HD M-W-F". In the body of the H&P, the MD references all lab results obtained since arrival, which includes a creatinine of 4.5. Is this sufficient to disregard the creatinine for organ dysfunction criteria? Or does the MD have to specifically document 'Creatinine elevated due to ESRD'? Response Noel Albritton via Email 04/13/2016 10:38 AM Hi Angella, Thanks for the question. Since Acute Respiratory Failure is considered due to chronic obstructive pulmonary disease, it should not be included as evidence of organ dysfunction. Hope this helps! Question: Customer Angella Lott via CSS Web 04/11/2016 02:45 PM In the discharge summary, MD documents "DIAGNOSES: At this time, 1. Acute respiratory failure due to chronic obstructive pulmonary disease exacerbation present on admission." Also documented in H&P: # Also, shortness of breath and hypercarbic respiratory failure, as per above, also due to acute on chronic systolic and diastolic CHF with exacerbation of COPD - Admit to intermediate care - Initially on Bipap in ED" Is this sufficient to disregard the Bipap as 'Organ Dysfunction' in assigning clinical criteria for Severe Sepsis? Response Joan Roberson via Email 02/24/2016 12:51 PM Thank you for your question. Do not include evidence of organ dysfunction that is considered to be due to a chronic condition or medication (e.g., Creatinine >2 for a patient with end stage renal disease, INR > 1.5 for a patient on Warfarin). Based on the documentation provided, if the patient has hepatic mets then an abnormal bilirubin should not be used as a sign of organ dysfunction. Hope this helps. Question: Customer Angella Lott via CSS Web 11/23/2015 08:07 AM Patient admitted 10/17 - 11/4. Total Bilirubin on admission 0.7, and 1.2 day after admission. On 10/25, elevated to 5.5. MD Documented "T bili/D bili elevated, 5.5/4.4, suspect d/t hepatic mets. CT abd/pelvis 10/17 w several extremely large hepatic metastases." Should this result be disregarded in identifying organ dysfunction due to underlying condition? Best Regards, Angella Lott, LPN CE/CV Data Analyst Team Leader Sentara Healthcare E-mail: [email protected]<mailto:[email protected]> Office: 757-388-2463 -----Original Message----- From: Sepsisgroups [mailto:[email protected]] On Behalf Of [email protected] Sent: Thursday, July 07, 2016 9:17 AM To: [email protected] Subject: Sepsisgroups Digest, Vol 212, Issue 5 Send Sepsisgroups mailing list submissions to [email protected]<mailto:[email protected]> To subscribe or unsubscribe via the World Wide Web, visit http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org or, via email, send a message with subject or body 'help' to [email protected]<mailto:[email protected]> You can reach the person managing the list at [email protected]<mailto:[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: [EXTERNAL] RE: Sepsis Question on organ dysfunction (Belfi, Karen) 2. Re: Sepsis Question on organ dysfunction (Dena Videtic) ---------------------------------------------------------------------- Message: 1 Date: Wed, 6 Jul 2016 15:49:27 -0400 From: "Belfi, Karen" <[email protected]<mailto:[email protected]>> To: Dena Videtic <[email protected]<mailto:[email protected]>> Cc: "Murray, Sandra" <[email protected]<mailto:[email protected]>>, "[email protected]<mailto:[email protected]>" <[email protected]<mailto:[email protected]>> Subject: Re: [Sepsis Groups] [EXTERNAL] RE: Sepsis Question on organ dysfunction Message-ID: <[email protected]<mailto:[email protected]>> Content-Type: text/plain; charset="utf-8" Yes but the guidelines don't tell us to see if the elevated bili is due to liver failure. The presence of an elevated bili is enough to say yes for organ dysfunction for the purposes of the measure. Karen Belfi, RN, MSN Quality Outcomes Coordinator Lankenau Medical Center On Jul 6, 2016, at 12:42 PM, Dena Videtic <[email protected]<mailto:[email protected]<mailto:[email protected]<mailto:[email protected]>>> wrote: Yes but in this case the total bilirubin does not necessarily indicate liver failure. Total bilirubin can be elevated due to gallstones and biliary obstruction. I would continue to look for documentation of organ dysfunction or Severe Sepsis. Dena Dena Videtic RN BSN Quality Indicators Doctors Hospital 786-308-3315 From: Belfi, Karen [mailto:[email protected]]<mailto:[mailto:[email protected]]> Sent: Wednesday, July 06, 2016 10:28 AM To: Dena Videtic <[email protected]<mailto:[email protected]<mailto:[email protected]<mailto:[email protected]>>>; Murray, Sandra <[email protected]<mailto:[email protected]<mailto:[email protected]<mailto:[email protected]>>>; '[email protected]<mailto:[email protected]>' <[email protected]<mailto:[email protected]<mailto:[email protected]<mailto:[email protected]>>> Subject: RE: Sepsis Question on organ dysfunction Following the guidelines, we don?t need physician documentation that the patient has severe sepsis. We need the 3 criteria of infection, 2 SIRS, and organ dysfunction. While the criteria we need to use for the measure isn?t without its faults, it?s what we have to work with currently. IN Q&As, we?ve been told to use the organ dysfunction unless there?s physician/APN/PA documentation that the lab is related to a different condition. Here are a couple examples: Question 215: How will we tell if labs are related to chronic organ dysfunction? Are we to assume? Answer 215: If there is documentation indicating the abnormal lab is due to or may be due to a chronic condition or medication that is acceptable. The measure also provides two examples that are acceptable, creatinine >2 for a patient with end stage renal disease, and an INR > 1.5 for a patient on Warfarin. Question 315: On slide 34 it says not to include evidence of organ dysfunction that is considered chronic. Is the documentation of ESRD in the patient's history enough or does the physician need to specifically link the two in his/her documentation? Answer 315: An association does not need to be documented for Creatinine >2 for a patient with end stage renal disease, and INR >1.5 for a patient on Warfarin, because those are included in the Severe Sepsis Present. For other conditions and medications, there should be documentation indicating the association. Karen Belfi, RN, MSN Quality Outcomes Coordinator Lankenau Medical Center 484-476-8092 Pager: 5240 <image001.png> From: Sepsisgroups [mailto:[email protected]]<mailto:[mailto:[email protected]]> On Behalf Of Dena Videtic Sent: Tuesday, July 05, 2016 8:13 AM To: Murray, Sandra; '[email protected]<mailto:[email protected]>' Subject: [EXTERNAL] Re: [Sepsis Groups] Sepsis Question on organ dysfunction Sandra, This is a good question. From an abstraction point of view, I would look for physician documentation that the patient has Severe Sepsis because as nurses, it is not in our scope of practice to diagnose patients. The bilirubin could be elevated due to a biliary obstruction. An interesting article was published in April about the subjectivity of sepsis diagnosis even among physicians. If you?re interested it is called: ?Diagnosing Sepsis is Subjective and Highly Variable: A Survey of Intensivists Using Case Vignettes? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822273/ Dena Videtic RN BSN Quality Indicators Doctors Hospital Coral Gables, FL 786-308-3315 From: Sepsisgroups [mailto:[email protected]]<mailto:[mailto:[email protected]]> On Behalf Of Murray, Sandra Sent: Thursday, June 30, 2016 2:26 PM To: [email protected]<mailto:[email protected]<mailto:[email protected]<mailto:[email protected]>> Subject: [Sepsis Groups] Sepsis Question on organ dysfunction Would you count a t.bili of 9.3 as organ dysfunction if patient comes in with abdominal pain, meets the SIRS criteria and the CT shows pt to have acute cholecystitis? Sandra Murray, RN, BSN | Heart Failure & Sepsis Program Coordinator Performance Improvement-Patient Safety and Risk T 817.848.4963 | M 682.367.3032 [email protected]<mailto:[email protected]<mailto:[email protected]<mailto:[email protected]>> <image002.png> Follow us on Social Media This document was generated by, or was prepared by or at the direction or request of a medical committee, medical peer review committee, nursing peer review committee, and/or patient safety committee, including a joint committee, of Texas Health Resources and its member hospitals as defined under Texas Health & Safety Code Sec. 161.031, et seq., Texas Occ. Code Secs. 151.001, et seq., 160.001, et seq. and 303.001, et seq., and is used for committee purposes, specifically, quality assurance and assessment and the evaluation of patient safety and medical and healthcare services at the Hospital. This document and the information contained within it are considered confidential, privileged and not subject to court subpoena pursuant to the above-cited statutes and 42 U.S.C. Sec. 11101, et seq. The information contained in this message and any attachments is intended only for the use of the individual or entity to which it is addressed, and may contain information that is PRIVILEGED, CONFIDENTIAL, and exempt from disclosure under applicable law. If you are not the intended recipient, you are prohibited from copying, distributing, or using the information. Please contact the sender immediately by return e-mail and delete the original message from your system. ________________________________ This message originates from Baptist Health South Florida (BHSF). It contains information that may be confidential or privileged and is intended only for the individuals or entity named above. It is prohibited for anyone else to disclose, copy, distribute or use the contents of this message. This message may not be copied or distributed without this disclaimer. All personal messages express views solely of the sender, which are not to be attributed to BHSF. If you received this message in error, please notify us immediately at [email protected]<mailto:[email protected]<mailto:[email protected]<mailto:[email protected]>>. BHSF scanned this email for viruses, vandals and malicious content ________________________________ This message originates from Baptist Health South Florida (BHSF). It contains information that may be confidential or privileged and is intended only for the individuals or entity named above. It is prohibited for anyone else to disclose, copy, distribute or use the contents of this message. This message may not be copied or distributed without this disclaimer. All personal messages express views solely of the sender, which are not to be attributed to BHSF. If you received this message in error, please notify us immediately at [email protected]<mailto:[email protected]<mailto:[email protected]<mailto:[email protected]>>. BHSF scanned this email for viruses, vandals and malicious content ------------------------------ Message: 2 Date: Wed, 6 Jul 2016 16:42:24 +0000 From: Dena Videtic <[email protected]<mailto:[email protected]>> To: "Belfi, Karen" <[email protected]<mailto:[email protected]>>, "Murray, Sandra" <[email protected]<mailto:[email protected]>>, "'[email protected]'" <[email protected]<mailto:[email protected]>> Subject: Re: [Sepsis Groups] Sepsis Question on organ dysfunction Message-ID: <a0854b2bb1a04c4fb7bf7eb7bfc6400f0190a32...@ddmsxmbx6.ad.bhssf.org<mailto:a0854b2bb1a04c4fb7bf7eb7bfc6400f0190a32...@ddmsxmbx6.ad.bhssf.org>> Content-Type: text/plain; charset="utf-8" Yes but in this case the total bilirubin does not necessarily indicate liver failure. Total bilirubin can be elevated due to gallstones and biliary obstruction. I would continue to look for documentation of organ dysfunction or Severe Sepsis. Dena Dena Videtic RN BSN Quality Indicators Doctors Hospital 786-308-3315 From: Belfi, Karen [mailto:[email protected]]<mailto:[mailto:[email protected]]> Sent: Wednesday, July 06, 2016 10:28 AM To: Dena Videtic <[email protected]<mailto:[email protected]>>; Murray, Sandra <[email protected]<mailto:[email protected]>>; '[email protected]' <[email protected]<mailto:[email protected]>> Subject: RE: Sepsis Question on organ dysfunction Following the guidelines, we don?t need physician documentation that the patient has severe sepsis. We need the 3 criteria of infection, 2 SIRS, and organ dysfunction. While the criteria we need to use for the measure isn?t without its faults, it?s what we have to work with currently. IN Q&As, we?ve been told to use the organ dysfunction unless there?s physician/APN/PA documentation that the lab is related to a different condition. Here are a couple examples: Question 215: How will we tell if labs are related to chronic organ dysfunction? Are we to assume? Answer 215: If there is documentation indicating the abnormal lab is due to or may be due to a chronic condition or medication that is acceptable. The measure also provides two examples that are acceptable, creatinine >2 for a patient with end stage renal disease, and an INR > 1.5 for a patient on Warfarin. Question 315: On slide 34 it says not to include evidence of organ dysfunction that is considered chronic. Is the documentation of ESRD in the patient's history enough or does the physician need to specifically link the two in his/her documentation? Answer 315: An association does not need to be documented for Creatinine >2 for a patient with end stage renal disease, and INR >1.5 for a patient on Warfarin, because those are included in the Severe Sepsis Present. For other conditions and medications, there should be documentation indicating the association. Karen Belfi, RN, MSN Quality Outcomes Coordinator Lankenau Medical Center 484-476-8092 Pager: 5240 [cid:25FFED76-F7F0-4047-910F-0D7077ED1E1E] From: Sepsisgroups [mailto:[email protected]]<mailto:[mailto:[email protected]]> On Behalf Of Dena Videtic Sent: Tuesday, July 05, 2016 8:13 AM To: Murray, Sandra; '[email protected]' Subject: [EXTERNAL] Re: [Sepsis Groups] Sepsis Question on organ dysfunction Sandra, This is a good question. From an abstraction point of view, I would look for physician documentation that the patient has Severe Sepsis because as nurses, it is not in our scope of practice to diagnose patients. The bilirubin could be elevated due to a biliary obstruction. An interesting article was published in April about the subjectivity of sepsis diagnosis even among physicians. If you?re interested it is called: ?Diagnosing Sepsis is Subjective and Highly Variable: A Survey of Intensivists Using Case Vignettes? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822273/ Dena Videtic RN BSN Quality Indicators Doctors Hospital Coral Gables, FL 786-308-3315 From: Sepsisgroups [mailto:[email protected]]<mailto:[mailto:[email protected]]> On Behalf Of Murray, Sandra Sent: Thursday, June 30, 2016 2:26 PM To: [email protected]<mailto:[email protected]<mailto:[email protected]<mailto:[email protected]>> Subject: [Sepsis Groups] Sepsis Question on organ dysfunction Would you count a t.bili of 9.3 as organ dysfunction if patient comes in with abdominal pain, meets the SIRS criteria and the CT shows pt to have acute cholecystitis? Sandra Murray, RN, BSN | Heart Failure & Sepsis Program Coordinator Performance Improvement-Patient Safety and Risk T 817.848.4963 | M 682.367.3032 [email protected]<mailto:[email protected]<mailto:[email protected]<mailto:[email protected]>> [cid:[email protected]]<mailto:[cid:[email protected]]> Follow us on Social Media This document was generated by, or was prepared by or at the direction or request of a medical committee, medical peer review committee, nursing peer review committee, and/or patient safety committee, including a joint committee, of Texas Health Resources and its member hospitals as defined under Texas Health & Safety Code Sec. 161.031, et seq., Texas Occ. Code Secs. 151.001, et seq., 160.001, et seq. and 303.001, et seq., and is used for committee purposes, specifically, quality assurance and assessment and the evaluation of patient safety and medical and healthcare services at the Hospital. This document and the information contained within it are considered confidential, privileged and not subject to court subpoena pursuant to the above-cited statutes and 42 U.S.C. Sec. 11101, et seq. The information contained in this message and any attachments is intended only for the use of the individual or entity to which it is addressed, and may contain information that is PRIVILEGED, CONFIDENTIAL, and exempt from disclosure under applicable law. If you are not the intended recipient, you are prohibited from copying, distributing, or using the information. Please contact the sender immediately by return e-mail and delete the original message from your system. ________________________________ This message originates from Baptist Health South Florida (BHSF). It contains information that may be confidential or privileged and is intended only for the individuals or entity named above. It is prohibited for anyone else to disclose, copy, distribute or use the contents of this message. This message may not be copied or distributed without this disclaimer. All personal messages express views solely of the sender, which are not to be attributed to BHSF. If you received this message in error, please notify us immediately at [email protected]<mailto:[email protected]<mailto:[email protected]<mailto:[email protected]>>. BHSF scanned this email for viruses, vandals and malicious content -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.sepsisgroups.org/pipermail/sepsisgroups-sepsisgroups.org/attachments/20160706/530e33c9/attachment.htm> -------------- next part -------------- A non-text attachment was scrubbed... Name: image001.png Type: image/png Size: 40233 bytes Desc: image001.png URL: <http://lists.sepsisgroups.org/pipermail/sepsisgroups-sepsisgroups.org/attachments/20160706/530e33c9/attachment.png> -------------- next part -------------- A non-text attachment was scrubbed... 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