Sould you call it sepsis?

Should you call it sepsis? Two definitions. One major problem.

The problems?

• There are two definitions of sepsis and neither definition is perfect.

• SIRS is commonly used as a diagnostic tool but is a screening tool.

• There is not universal agreement amongst physicians but most insurances have adopted the more specific diagnosis (resulting in denial of payments)

1 / The definitions

First, names matter. What we call things guide how we treat them.

• Sepsis-2: 2/4 SIRS + Infection

• Sepsis-3: "life-threatening organ dysfunction caused by a dysregulated host response to infection". Essentially, infection isn't sepsis unless organ dysfunction is present

Sepsis-2 is too sensitive therefore many will “screen positive” who do NOT have sepsis. However, it does recognize sepsis early. Why is this important? Survival from early recognition and treatment of sepsis is well established.

Sepsis-3 is more specific. (It was designed to be highly specific). It may miss some cases of early sepsis.

Many insurances don't pay hospitals if they use sepsis-2 without end-organ damage, ONLY sepsis-3. Using the more specific diagnosis is an obvious move by them to increase denials and save them money.

2 / What could you do?

• Adopt sepsis-3 only and you may miss cases of sepsis, and patients suffer.

• Use sepsis-2 only, and insurances will refuse to pay you.

• Stop using "sepsis" all together? (Many propose this and say they actually do this) Patients, finances and quality values all suffer.

So, how can you fix this?

3 / Critically think (also use common sense). Medicine is not a cookbook.

1. Use SIRS as a screening tool, not a diagnostic one. Treat for sepsis empirically if you suspect sepsis.

   1. If it is ultimately not sepsis, document "ruled out" - this removes the diagnosis from coding. Then, delete it to make sure it doesn't get carried through to the discharge summary.

   2. It is extremely easy to meet SIRS criteria. Respirations only have to be above 20, and heart rate above 90.

   3. So, infection + 2 SIRS should not automatically diagnose sepsis. Again, it should make you consider sepsis.

2. Consider other causes of SIRS.

3. When end-organ damage is present, document "due to" sepsis.

This way:

• Patients get optimal care.

• The bean counters are happy.

• Your CDI department doesn't bug you with queries.

• You satisfy CMS's compliance bundle (more below in Q/A)

Surviving sepsis guidelines HAVE adopted the sepsis-3 definition but have recommended AGAINST using qSOFA over SIRS, NEWS or MEWS as a single screening tool for sepsis or septic shock.

In Summary:

1. Use SIRS as a screening tool, not a diagnostic one.

2. Consider other causes of SIRS.

3. Document "ruled out" if patient ultimately does not have sepsis after initially empirically treating for such. This removes it from coding. Make sure it's not documented on the discharge summary.

4. Document "due to" sepsis when end-organ damage is present.



Question / Answer

What is CMS's compliance bundle?

CMS requires that hospitals who accept Medicare participate in reporting their performance in the CMS sepsis bundle. This is based on sepsis-2 (and therefore SIRS). A patient is only enrolled if they have "severe sepsis" (sepsis with end-organ damage) or septic shock - not just regular sepsis. The algorithm is complex, but in brief you must get blood cultures, give antibiotics, give 30 cc/kg IVF bolus, document a "sepsis" physical exam and obtain lactic acids all within certain time periods. I could write an entire issue JUST on the sepsis bundle but I'll mention a few caveats here:

1. If the word "sepsis" is EVER introduced as a possible diagnosis, it will trigger a chart audit looking to see if the patient EVER met severe sepsis (or shock) criteria. So, even if YOU don't call it severe sepsis, patients may get enrolled anyhow.

2. Viral sepsis does NOT enroll you into the bundle. However, this must be documented within the first 6 hours that sepsis criteria are met.

3. The National Average of complete compliance with the bundle is 57%

Why NOT just stop saying sepsis?

Briefly, screening tools are useful and if "sepsis" never enters your consideration then you may fail to optimally treat sepsis early vs if you used any of the screening tools (SIRS, NEWS2, qSOFA, etc). Using the screening tools, treating but not diagnosing "sepsis" is imperfect on a population / grand scale.

Also, CMS monitors 30-day mortality rates for pneumonia. If they have "severe sepsis" they are not included in those numbers (CMS is tracking this, who uses Sepsis-2. The term "severe sepsis" does not exist under Sepsis-3). So, if your pneumonia patients are dying more than they should because they also have "severe sepsis," but no one is capturing it, you and your hospital will lose money and look like you're not giving proper care (these numbers are publicly reported).

What don't you use NEWS/NEWS2?

First, what is it? It is a screening tool for sepsis. It does not use any lab data (such as lactic acid) and uses a graduated scale (0, 1 pt, 2 pt, etc) for various vital sign derangements + confusion. The results are low / medium / high risk rather than the all-or-nothing approach like SIRS. It is not something that is commonly used in America to my knowledge. It does seem like a good "middle ground" between SIRS and qSOFA. However, the surviving sepsis guidelines have not adopted one screening tool over another. I do not think you'll see widespread adoption until it is accepted as the screening tool by surviving sepsis, IDSA, SCCM, CMS, insurance companies, etc. It has been adopted by the NHS (UK).

What is SOFA?

SOFA (Sequential organ failure assessment) is a list from 6 organ systems:

1. Respiratory

2. Coagulation

3. Cardiovascular

4. Liver

5. Renal

6. CNS

You need 2 to meet criteria. It is outdated. For example, it uses dopamine dosing as criteria (not a first or second line treatment for septic shock). Insurances attempt to deny claims based on lack of SOFA criteria however patients may have end-organ damage that don't meet the strict definitions of SOFA. For example, you get 0 points for having a Cr of 1.1. By KDIGO criteria , you CAN have AKI with a Cr of 1.1 if your baseline Cr is 0.7 or lower (more on AKI and Cr here: Creatinine — robertoubreMD.com)

qSOFA is a quick screening tool which includes 1. Altered Mental Status 2. Respiratory Rate >22. 3. Systolic BP <100. Like sepsis-3, it is more specific than SIRS / Sepsis-2. However, the surviving sepsis guidelines have recommended AGAINST using qSOFA over SIRS, NEWS or MEWS as a single screening tool for sepsis or septic shock. I will not claim to know all the mortality data on these screening tools, but I'm following the surviving sepsis guidance on this one.

What about Illinois & New York?

Illinois (Gabby's Law) and New York (Rory's Regulations) have laws in place on how to define sepsis. Some other states such as Ohio (Reducing sepsis mortality in Ohio) and Wisconsin (Think Katie First) have initiatives to define sepsis early. These are typically based on cases where sepsis was not recognized early, and the patient (typically a child) died. New York's law use sepsis-2.

My final thoughts:

I like sepsis-3 as a diagnostic definition, but it should either not be based on SOFA or SOFA needs updating. We need an ideal screening tool for early sepsis (that has not yet advanced to end-organ damage) and I believe we will continue to fight this battle until we develop better language and screening tools for that gray area... or develop the always-illusive holy grail of a diagnostic lab.

That’s all for now. I hope that’s helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

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