By: William Baker, M.D.
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
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