My understanding is we use the earliest time stamp that confirms the presence of severe sepsis, that can be physician documentation (which is usually late), time of Lactic Acid >2.0, Triage that indicates qSOFA criteria, at least 1 indication of organ dysfunction.
From: Sepsisgroups <sepsisgroups-boun...@lists.sepsisgroups.org> On Behalf Of Schrecengost, Lisa M. Sent: Tuesday, June 26, 2018 1:49 PM To: Cox, Debra M. (RN) <dm...@srhs.com>; sepsisgroups@lists.sepsisgroups.org Subject: Re: [Sepsis Groups] severe sepsis presentation [External] In the body of the physician's note, he says pneumonia (no time). We have a time of sepsis dx as 19:50 in the body. At the D/C impression, he has primary impression as Pneumonia & Additional Impression as severe sepsis... (no times) Our struggle is to find out if we can use the times within the body of the note to meet our severe sepsis criteria, or do we have to take the time the note was opened since he has a dc impression of severe sepsis. I have asked quality net and it goes in circles. I thought we used the time the note was opened only if we did not have any times within the body of the note. For example, I have times for SIRS, the sepsis dx time, and lactate level of 2.9. I thought the time would be 19:50 when all criteria meets, since we have times in the documentation. My coworker says since the dr has severe sepsis as an impression, we have to use time note was opened for severe sepsis presentation time. From: Cox, Debra M. (RN) [mailto:dm...@srhs.com] Sent: Tuesday, June 26, 2018 2:19 PM To: Schrecengost, Lisa M.; sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org> Subject: Re: [Sepsis Groups] severe sepsis presentation [External] Be aware: [This message came from outside of Spartanburg Regional Network] Is there anything in the ED record or nursing documentation showing a source? This can even be "Sepsis ED order" or the triage impression of a code Sepsis. If so, what time is this documentation? Get Outlook for iOS<https://aka.ms/o0ukef> ________________________________ From: Sepsisgroups <sepsisgroups-boun...@lists.sepsisgroups.org<mailto:sepsisgroups-boun...@lists.sepsisgroups.org>> on behalf of Schrecengost, Lisa M. <schrecengo...@acmh.org<mailto:schrecengo...@acmh.org>> Sent: Tuesday, June 26, 2018 10:00:26 AM To: sepsisgroups@lists.sepsisgroups.org<mailto:sepsisgroups@lists.sepsisgroups.org> Subject: [Sepsis Groups] severe sepsis presentation [External] Be aware: [This message came from outside of Spartanburg Regional Network] Hello all..... Need help!! We are having issues with figuring out severe sepsis presentation times. We are having discrepancies at our facility understanding what times to use, especially when the physician has severe sepsis as the impression and there are other times within the note. We have a patient that comes into the ED. The note was opened at 16:37 by the physician. In the body of the report, it says "Time of sepsis diagnosis is 19:50". Pulse of 104 at 16:19. Respirations of 24 at 16:19. Lactate 2.9 at 17:50. He documents in the body of the note "the patient has severe sepsis but not septic shock". Primary impression documented on the ED Physician Report is Pneumonia, additional impression is Severe Sepsis. What time should we collect as Time of Severe Sepsis? Do we take the time the note was opened since he has an impression of severe sepsis or use the times within the body of the note? Thanks for your time, Lisa Lisa Schrecengost RN BSN Quality Management ACMH Hospital One Nolte Drive Kittanning, PA 16201 Phone: 724-543-8871 email: schrecengo...@acmh.org<mailto:schrecengo...@acmh.org> Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.
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