By: William Baker, MD

Sepsis pearls regarding the CMS bundle “SEP-1”

Severe sepsis: (per SEP-1)

All three within 6 hours of each other

  • Documentation of a suspected infection (not just the dx)
  • Two or more SIRS criteria
    • Temperature >38.3 C or <36.0 C (>100.9 F or <96.8 F)
    • HR > 90
    • RR > 20
    • WBC > 12k or < 4k or > 10% bands
  • Organ dysfunction

Organ dysfunction

Any one of these (that’s new and related to infection):

  • Hypotension:
    • SBP < 90 mmHg
    • MAP < 65 mmHg
    • SBP decrease > 40 with MD/NP/PA saying so and that it’s related to infection and not some other reason (like vomiting/dehydration, meds, etc)
  • Acute respiratory failure: need for new invasive or noninvasive vent
  • Creatinine >2.0 (or hourly urine measured & output <0.5 mL/kg/hour for 2 consecutive hours)
  • Total Bilirubin >2 mg/dL
  • Platelet < 100k
  • INR >1.5 or aPTT >60 sec
  • Lactate > 2 mmol/L

Tips & Caveats

  • Your documentation is powerful. Be clear
  • Document that the patient has “severe sepsis” or “septic shock” and the CMS accepts it as such.
  • Your patient’s got terrible vitals and a bunch of “sepsis +” labs, but your assessment is that these abnormalities are not due to infection? No problem, but you must document, CMS says:
    • If there is physician/APN/PA documentation that SIRS criteria or a sign of organ dysfunction is normal for that patient, is due to a chronic condition, is due to an acute condition that is not an infection, or is due to a medication, it should not be used. Inferences should not be made, MD/NP/PA documentation is required.
    • If there is MD/NP/PA or nursing documentation that a laboratory value is invalid, erroneous or questionable, value disregarded
  • If documentation of viral or fungal infection: case excluded
  • If documentation condition inflammation, not infection: case excluded

Resources:

EMDocBaker’s SEP-1 Flowsheet

ACEP SEP-1 Highlights: https://www.acep.org/content.aspx?id=104615

(If you are really ambitions and have a lot of time on your hands, the entire manual is available at https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic/Page/QnetTier4&cid=1228775436944 )

Faculty Author: William Baker, MD