Mary Ann, Not sure if I followed your clarification.
If Severe sepsis criteria are not met, BUT there is MD documentation of "Severe Sepsis", then you choose "1" for severe sepsis present. Same for Septic shock: even if the criteria are not met, BUT there is MD documentation of "Septic Shock", then you also choose "1" for severe sepsis and septic shock present. Isn't that correct?? Courtney Merwin BS, RRT Clinical Quality Analyst East Jefferson General Hospital 4200 Houma Blvd. Metairie, LA 70006 504-503-5968 [email protected]<mailto:[email protected]> From: Sepsisgroups [mailto:[email protected]] On Behalf Of Barnes-Daly, Mary Ann Sent: Saturday, January 14, 2017 12:24 PM To: Crowley Amy; [email protected] Subject: Re: [Sepsis Groups] [**External**] Question for core measure Yes Amy, you are correct - that means if what IS documented does not meet criteria, or if: 1. Nothing is documented - not done 2. Done but not documented - not done All = fallout Thanks, MARY ANN BARNES-DALY MS RN CCRN DC | Clinical Performance Improvement Consultant Quality & Clinical Effectiveness Team | Office of Patient Experience Sutter Health -2200 River Plaza Drive, Sacramento, CA 95833 Mobile 916.200.5604| [email protected]<mailto:[email protected]> "You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete." ~R. Buckminster Fuller From: Sepsisgroups [mailto:[email protected]] On Behalf Of Crowley Amy Sent: Thursday, January 12, 2017 2:26 PM To: [email protected]<mailto:[email protected]> Subject: [**External**] [Sepsis Groups] Question for core measure WARNING: This email originated outside of the Sutter Health email system! DO NOT CLICK links if the sender is unknown and never provide your User ID or Password. I just abstracted a pt with this exact scenario. The wording below of "if criteria is not documented" confuses me. What if the criteria is not met AT ALL? Not documented or met? Is that not the same thing? The criteria being met within 6 hours is the ENTIRE premise for being able to say that the pt had severe sepsis, EVEN IF the provider documents septic shock when the pt doesn't really have it... Maybe I'm not thinking straight or I'm not getting something, but it doesn't make sense to me.. Thoughts? I am highlighting with green. I do not want to have to say yes to pt's such as these when the severe sepsis criteria was never met during the entire pt stay. The only thing they had was a source that grew out from an infected dialysis catheter. The pt was never on any pressors or had any organ dysfunction. Severe Sepsis Present Documentation of the presence of severe sepsis. Was severe sepsis present? Allowable Values 1 (Yes) Severe Sepsis was present. 2 (No) Severe Sepsis was not present, or Unable to Determine. One of the rules for abstraction: "If criteria for severe sepsis are not documented and there is not physician/APN/PA documentation of severe sepsis, but there is physician/APN/PA documentation of septic shock, choose Value "1." In addition: this is the criteria for septic shock: Septic Shock Present Documentation of the presence of septic shock. Is there documentation of the presence of septic shock? Allowable Values 1 (Yes) [cid:[email protected]]There is documentation of Septic Shock. 2 (No) There is no documentation of Septic Shock, or unable to determine. Notes for Abstraction * The criteria for determining that Septic Shock is present are as follows: ( Is it just the documentation of OR does a and b below have to be met??) * There must be documentation of severe sepsis present. ( my pt did not have the criteria met nor was severe sepsis documented) AND * Hypotension persists in the hour after the conclusion of the 30 mL/kg Crystalloid Fluid Administration<javascript:void(0);>, evidenced by * systolic blood pressure (SBP) < 90, or * mean arterial pressure < 65 or * a decrease in systolic blood pressure (SBP) by > 40 mmHg. Physician/APN/PA documentation must be present in the medical record indicating a >40 mmHg decrease in SBP has occurred and is related to infection, severe sepsis or septic shock and not other causes. OR Tissue hypoperfusion is present evidenced by * Initial Lactate level is >= 4 mmol/L My pt had documentation of septic shock, but no severe sepsis or any criteria for it, like I have said. In my opinion, these two rules for severe and shock are contradictory. Amy Crowley Sepsis Coordinator Medical City Denton 3535 South I-35E Denton, Texas 76210 P: 940-384-3254 C: 214-801-2950 DentonRegional.com 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. 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