This is the answer from QNet. I don't know what Quest is Subject Organ dysfunction Discussion Thread Response Via Email (Char Teed) 07/07/2016 11:06 AM Sandra, Considering the guidelines: If an abnormal lab value (e.g. elevated creatinine) is considered due to a chronic condition or medication, the relation should be supported within the medical record. If a relation between the abnormal lab value and a chronic condition or medication is not identified within the medical record, the abnormal lab value can be considered evidence of organ dysfunction in relation to severe sepsis. This type of documentation will most likely be physician/APN/PA but is not limited to physician/APN/PA documentation. There is no limitation on where the documentation is located, but it must be in the current medical record.
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] 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. -----Original Message----- From: Belfi, Karen [mailto:[email protected]] Sent: Thursday, July 07, 2016 4:04 PM To: Dena Videtic Cc: Greg Stanford; Murray, Sandra; [email protected] Subject: Re: [EXTERNAL] RE: [EXTERNAL] Re: [Sepsis Groups] Sepsis Question on organ dysfunction I wasn't referring to the cholecystitis as infection. According to the guidelines, an elevated bilirubin is a sign of organ dysfunction. They don't tell you to read further. Send it in to Quest to confirm. Karen Belfi, RN, MSN Quality Outcomes Coordinator Lankenau Medical Center On Jul 7, 2016, at 2:12 PM, Dena Videtic <[email protected]<mailto:[email protected]>> wrote: Karen, I disagree and would continue to look for documentation that it is in fact organ dysfunction related to sepsis. Cholecystitis is not necessarily an infection and an elevated bilirubin is not necessarily organ dysfunction. Dena Dena Videtic RN BSN Quality Indicators Doctors Hospital 786-308-3315 From: Belfi, Karen [mailto:[email protected]] Sent: Thursday, July 07, 2016 9:26 AM To: Greg Stanford <[email protected]<mailto:[email protected]>>; Dena Videtic <[email protected]<mailto:[email protected]>> Cc: Murray, Sandra <[email protected]<mailto:[email protected]>>; [email protected]<mailto:[email protected]> Subject: RE: [EXTERNAL] Re: [Sepsis Groups] Sepsis Question on organ dysfunction If we are reviewing concurrently that would be helpful. However, if we are retroactively abstracting a chart, we can only go by documentation in the chart. The specification manual is clear that if there is no documentation the organ dysfunction isn’t documented as related to a different condition, we are to use it as organ dysfunction criterion. It may not always make sense clinically, but we need to follow the guidelines. 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 Greg Stanford Sent: Wednesday, July 06, 2016 9:40 PM To: Dena Videtic Cc: Murray, Sandra; [email protected]<mailto:[email protected]> Subject: [EXTERNAL] Re: [Sepsis Groups] Sepsis Question on organ dysfunction I agree with Dena. Cholecystitis doesn’t generally give you a bili that high, and I would think of obstruction and cholangitis. Without that, sepsis would be next on my list. but I would query the doctor to better understand his/her clinical impression. Greg Stanford, MD Medical Director Clinical Documentation Improvement and Outcomes 1840 Amherst Street | Winchester, Va 22601 Phone: (540) 596 4999 Cell: 540 664 5736 | |[email protected]<mailto:[email protected]> CONFIDENTIALITY NOTICE: This e-mail is confidential, may be legally privileged, and for the intended recipient only. Access, disclosure, copying, forwarding and distribution by any means is strictly prohibited. If received in error, do not read but delete and e-mail confirmation to the sender. On Jul 5, 2016, at 8:12 AM, Dena Videtic <[email protected]<mailto:[email protected]>> wrote: 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” https://urldefense.proofpoint.com/v2/url?u=http-3A__www.ncbi.nlm.nih.gov_pmc_articles_PMC4822273_&d=DQIGaQ&c=tAAbe3VWSXg4_eMSItYKuRlnp5vCb2OrQZQHnRXk_fc&r=YmGf8IzG_BSHAsWPCc-bClR3kFWXmHZEEr52gBMw9tY&m=xhtY51Df4dNMMj35sZsBFoA_lQ_ml9QnXzobBE-HI40&s=HDFQjIK1m-hv7Nc3kvCUTz6OZC79iupbntn7kovTWiU&e= Dena Videtic RN BSN Quality Indicators Doctors Hospital Coral Gables, FL 786-308-3315 From: Sepsisgroups [mailto:[email protected]] On Behalf Of Murray, Sandra Sent: Thursday, June 30, 2016 2:26 PM To: [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]> <image001.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. 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