You read my mind as well. If there is an audit tool, I would also be interested.
Thank you, Holly Holly Heyer, RN, BSN | Quality Specialist, Quality Department Beaumont Hospital - Taylor 10000 Telegraph Road | Taylor | MI | 48180 P: 313-295-5040 [email protected]<mailto:[email protected]> [cid:[email protected]] [cid:[email protected]]<https://www.facebook.com/BeaumontHospitals> [cid:[email protected]] <https://twitter.com/BeaumontHealth> [cid:[email protected]] <http://blog.beaumont.edu/> [cid:[email protected]] <https://instagram.com/beaumonthealth/> [cid:[email protected]] <https://www.linkedin.com/company/beaumont-health> [cid:[email protected]] <https://www.pinterest.com/beaumonthealth/> [cid:[email protected]] <https://www.youtube.com/channel/UCgNOQP5BvrzQJ_vhRo7VN1Q> From: Sepsisgroups [mailto:[email protected]] On Behalf Of Cooper, Pat Sent: Thursday, January 12, 2017 10:23 AM To: [email protected] Subject: Re: [Sepsis Groups] Mortality Rate Measurement We are looking at improving our process for reviewing sepsis mortality cases. Does anyone have an audit tool they would be willing to share? From: Sepsisgroups [mailto:[email protected]] On Behalf Of Clement, Joseph (DPH) Sent: Thursday, December 22, 2016 1:08 PM To: [email protected]<mailto:[email protected]> Subject: [EXTERNAL] [Sepsis Groups] Mortality Rate Measurement Hello, I'm curious about the various methods other hospitals are using to track their sepsis mortality rate. I am aware of several possibilities: 1. Using administrative data only: measuring the hospital mortality rate among patients who have one of several several sepsis-related ICD-10 codes. If you use this: a. which codes? We use the list of codes that CMS samples from for SEP-1. b. Do you require the code to be in only the Primary Diagnosis, or any of the diagnoses? c. Do you "scrub" this list to remove any patients based on any other criteria? For example, comfort care patients 2. Measuring mortality rate among those cases that were manually reviewed for the presence of severe sepsis and/or were evaluated for the bundle? 3. For hospitals who participate in the University Health Systems Collaborative, the Sepsis Mortality Index is available which provides some risk adjustment (Observed/Expected). 4. In the ICD-9 era, we used to use the Dombrowski Method, in which the mortality rate is measured among the population defined by those with either one of 3 sepsis codes, or both an infection code and an organ dysfunction code. I'm not aware of a methodology to recreate this using ICD-10 codes. Others??? Our experience: We historically used the Dombrowski Method for internal and external reporting - and post ICD-10 conversion we switched to #1 above (using the code list from SEP-1, in any position, with no scrubbing). The difference has been striking - as with this method, the month-to-month variation of our measured mortality rate is extremely high, changing 50-100% between months. This obviously makes trend identification more difficult. So I'm curious what others are doing and how they're thinking about it. We also follow the Sepsis Mortality Index, which helps with benchmarking. Appreciate any thoughts or advice. Sincerely, joe Joseph Clement, MS, RN, CCNS Clinical Nurse Specialist San Francisco General Hospital ph: 628 206-6174 pg: 415 327-0220 office: H5841 ________________________________ The information contained in this e-mail may be privileged and/or confidential, and protected from disclosure, and no waiver of any attorney-client, work product, or other privilege is intended. If you are the intended recipient, further disclosures are prohibited without proper authorization. If you are not the intended recipient (or have received this e-mail in error) please notify the sender immediately and destroy this e-mail. Any unauthorized copying, disclosure or distribution of the material in this e-mail is strictly forbidden and possibly a violation of federal or state law and regulations. The sender and Baylor Scott & White Health, and its affiliated entities, hereby expressly reserve all privileges and confidentiality that might otherwise be waived as a result of an erroneous or misdirected e-mail transmission. No employee or agent is authorized to conclude any binding agreement on behalf of Baylor Scott & White Health, or any affiliated entity, by e-mail without express written confirmation by the CEO, the Senior Vice President of Supply Chain Services or other duly authorized representative of Baylor Scott & White Health.
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