Lawsuit Cites Trauma Alerts And Sepsis Alerts

[MechEDoc]

I had a "sepsis fallout" on a cardiac arrest who developed pancreatitis 5 days into their stay and had 6(!!) negative cultures during their stay.... but the lactate drawn after the cardiac arrest was 15 and the ROSC vitals were tachy and I set the vent setting to >20.

I know its maybe unnecessary in this group to explain, but for the few med students floating around, lets enumerate:
Sepsis fallout only goes back 48 hours
Pancreatitis (especially in a ICU patient) is generally an aseptic phenomenon
That many negative blood cultures really cements there was never an infectious etiology
A temporarily dead person doesn't perform a lot of aerobic respiration, so lactate of *only* 15 was a miracle
and I basically induced the SIRS vital signs with my epinephrine/levo drip and vent settings.

yet I had to explain to the higher ups how insane this nasty-gram they sent me was.

But why did you get lactic post-ROSC? It's always going to ridiculously high.

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[DocEspana]

But why did you get lactic post-ROSC? It's always going to ridiculously high.

My ED techs are not paid to think, they just run on auto pilot. They are able to enter results from point of care testing that they do without my approval though.

 

[PianoMedic]

My ED techs are not paid to think, they just run on auto pilot. They are able to enter results from point of care testing that they do without my approval though.

This. And they often forget in the 15 steps between bedside and the machine so they default to “run everything” mode. I often tell them multiple times NOT to run a lactic, only to find a lactic in the chart a few minutes later. Seizure patients are a good example of this, I want to know their sodium if I’m having trouble getting them stopped with Ativan and getting ready to intubate. POC is an hour faster than my lab, and I can get my hypertonic running if their sodium is in the lower 100s or high 90s. Then I find the lactic of 20 in the chart and have to document against it later.

 

[Mount Asclepius]

This. And they often forget in the 15 steps between bedside and the machine so they default to “run everything” mode. I often tell them multiple times NOT to run a lactic, only to find a lactic in the chart a few minutes later. Seizure patients are a good example of this, I want to know their sodium if I’m having trouble getting them stopped with Ativan and getting ready to intubate. POC is an hour faster than my lab, and I can get my hypertonic running if their sodium is in the lower 100s or high 90s. Then I find the lactic of 20 in the chart and have to document against it later.

Almost all of my patients with seizures stop on their own long before they arrive to the ED (and certainly after EMS snows them further when they are already post-ictal). I rarely have to give Ativan and almost never multiple doses. A PNES also breaks better with a different approach.

Sodium in the 90s eh? You must have a unique patient population. I almost never see someone below 110.

Meh. I don’t usually check lactates post-cardiac arrest or after seizures, but if they are run I don’t really care. Easy to explain.

 

[PikminOC]

The code sepsis is egregious. Not every febrile, tachy, 21-year old with flu has sepsis. I see midlevels active sepsis on nearly every patient with a fever, even though there's an obvious source and the patient is clearly not septic. How common is random sepsis in healthy people under 40?

We always talk about how midlevels increase the cost of healthcare. But this is exactly what hospitals want, more tests, more money...

 

[Mount Asclepius]

We always talk about how midlevels increase the cost of healthcare. But this is exactly what hospitals want, more tests, more money...

This provoked me to have a crazy thought. The only way I can think of to fix this is for payers to cut reimbursement for unnecessary testing/treatment. Therefore, is it actually a sleazy way out of the PIT to work for them to deny claims? Maybe its better to join the dark side... Doctors regulating the practice of medicine so it is actually practiced the right way. By doctors, not midlevels. Never thought of it that way.

 

[VA Hopeful Dr]

This provoked me to have a crazy thought. The only way I can think of to fix this is for payers to cut reimbursement for unnecessary testing/treatment. Therefore, is it actually a sleazy way out of the PIT to work for them to deny claims? Maybe its better to join the dark side... Doctors regulating the practice of medicine so it is actually practiced the right way. By doctors, not midlevels. Never thought of it that way.

That's already a thing and it sucks.

 

[Mount Asclepius]

That's already a thing and it sucks.

Correct. I just always previously viewed it entirely as big business trying to keep more money for themselves while screwing patients and physicians. I never considered viewing it though as protecting the practice of medicine by preventing PLPs from over testing and over treating because they didn’t know what they were doing. Just thinking outside the box a little.

 

[VA Hopeful Dr]

Correct. I just always previously viewed it entirely as big business trying to keep more money for themselves while screwing patients and physicians. I never considered viewing it though as protecting the practice of medicine by preventing PLPs from over testing and over treating because they didn’t know what they were doing. Just thinking outside the box a little.

Several years ago something like this was tried with antibiotics for sore throat. Basically, if you prescribed antibiotics for a sore throat without any kind of positive testing, you didn't get paid for the visit.

Not sure what happened with that.

 

[WilcoWorld]

Almost all of my patients with seizures stop on their own long before they arrive to the ED (and certainly after EMS snows them further when they are already post-ictal). I rarely have to give Ativan and almost never multiple doses. A PNES also breaks better with a different approach.

Sodium in the 90s eh? You must have a unique patient population. I almost never see someone below 110.

Meh. I don’t usually check lactates post-cardiac arrest or after seizures, but if they are run I don’t really care. Easy to explain.

I mean, it's rare, but severe hyponatremia should definitely be on your DDx for refractory seizures.

 

[WilcoWorld]

Several years ago something like this was tried with antibiotics for sore throat. Basically, if you prescribed antibiotics for a sore throat without any kind of positive testing, you didn't get paid for the visit.

Not sure what happened with that.

That would be the wrong way to do it though, since many common ABX indications do not require (+) testing (strep, AOM, clinically dx'd pneumonia, cellulitis). The "stick" should come in when you Rx ABX without an appropriate diagnosis, or order a head CT for a migraine, etc.

 

[Janders]

How have we avoided SEP-1 driving us insane where I work?

(1) Fight the good fight in various committees. Especially before there were modifications to the rules (I.e. carveouts to 30mLkg, insisting 99% likely CDIFF shock get Zosyn, etc) it was VERY easy to point out that blanket application of SEP-1 harms people, and basically every doc who attended would agree, within their own perspectives (hospitalists, ED, ICU, vasc surgery, etc). The Nurses and non-clinical admins on said committees also don’t want to overtly harm people, so we could all agree to set realistic goals like setting up a system to draw serial lactates, or set up people to review cases and report on trends of actual importance, try to encourage a method to get blood cx before abx without long delays, etc.

(2) It ISN’T LINKED TO PAYMENT YET. Typically they float these metrics for a few years without linking them to $, and then once they have the infrastructure ready they link it to CMS payments. But SEP-1 got a lot of bad press, has had a lot more professional society pushback than other similar prior metrics, and also got derailed by the COVID train. It was very easy in a hospital awash with metrics and issues to say “hey guys we think this metric sucks and it does NOT affect payment, lets back burner it…” and get everyone to pretty much agree. I promise you the second it is linked to payment it will become a massive issue to everyone.

I LOVE sepsis care. I think SEP-1 is horrible. They need to break it apart. I would consider supporting something like a narrow door-to-abx metric, aimed at people presenting with true septic shock, or applied to only MAP <60 / Lactate >4 primarily septic patients.

These things are hard to abstract, and if you truly want to understand SEP-1 you have to understand each step, and all of the loopholes, and thus read a couple hundred pages of PDFs and also look through the CMS public comments to questions.

Some metrics HAVE led to improved care (I think the ACS/STEMI metrics are the best example; setting door-to-EKG times, door-to-balloon times do likely save/help patients, and encourage spending to develop a system to achieve these goals).

 

[Mount Asclepius]

I mean, it's rare, but severe hyponatremia should definitely be on your DDx for refractory seizures.

Agree that it should be on the differential.

I can count on one finger though the number of seizures for hyponatremia I’ve had as an attending over the years.

I haven’t seen people with sodium levels in the 90s. Only heard rarely of a colleague having a case. I really doubt others are seeing that degree of hyponatremia with any frequency either.

 

[DocEspana]

This. And they often forget in the 15 steps between bedside and the machine so they default to “run everything” mode. I often tell them multiple times NOT to run a lactic, only to find a lactic in the chart a few minutes later. Seizure patients are a good example of this, I want to know their sodium if I’m having trouble getting them stopped with Ativan and getting ready to intubate. POC is an hour faster than my lab, and I can get my hypertonic running if their sodium is in the lower 100s or high 90s. Then I find the lactic of 20 in the chart and have to document against it later.

Oh I'll one better. We have a huge psych and psych-adjacent population so I'm ALWAYS considering psychogenic pseudo-seizures and/or drug seeking flat out lies. But obviously actually seizures are common. So if I see a patient seize or an EMS crew I trust saw it, or they are very convincingly post ictal I'll just work them up. But tons of patients are either "witnessed by family" or not convincing me for whatever reason.

As long as the story is that those people seized within the last 60ish minutes I'll go ahead and ask my techs to run a lactic acid. For me it's easier to document against the lactate of 15 than it is to play this game of "is it a seizure" on 2-3 ambiguous patients every single shift. It is *almost a guarantee* that at least once per shift that tech was told "I need the point of care lactate" AND I order it AND I put it as a note in Cerner that I need the POC lactate.... And yet it's a guarantee that one of those patients per shift gets a point of care troponin instead.

 

[Jabbed]

Agree that it should be on the differential.

I can count on one finger though the number of seizures for hyponatremia I’ve had as an attending over the years.

I also haven’t seen people with sodium levels in the 90s. I really doubt others are seeing that degree of hyponatremia with any frequency either.

I imagine that this would vary by your patient population. My county-style patient population is prone to heavy drinking and I routinely see people in their early 30s with advanced cirrhosis. I’ll have a hyponatremia seizure every few months. I’ve seen maybe 3 people total in the 90s though and that was certainly impressive.

I don’t really worry so much about getting POC Na though. If seizure doesn’t break after 8 mg Ativan I’ll sometimes just give 2-3 amps of NaHCO3, which has the tonicity of 6% saline. Minimal harm if their sodium is normal.

 

[DocEspana]

Several years ago something like this was tried with antibiotics for sore throat. Basically, if you prescribed antibiotics for a sore throat without any kind of positive testing, you didn't get paid for the visit.

Not sure what happened with that.

So it's still a thing. At least for the EM. MIPS (or whatever the acronym is now) for EM is a yearly requirement for a practice to pick a certain number of quality improvement metrics and more or less gamble your future medicare reimbursement against your ability to do it correctly. There are a bunch to pick from, but most EM groups (at least envision, teamhealth and SCP) have picked abx for sore throat.

Any "sore throat" diagnosis of any sort (so tonsillitis and laryngitis also count) CANNOT get antibiotics unless 1) you send a rapid strep or 2) you state that you're giving the antibiotic for some other non-pharyngeal reason.

Amusingly, you don't need a positive test. You don't even need to wait for the results at all. You just need to send the test at all. I've been fully educated by my corporate overlords that if I want to treat a strep negative person, to go right ahead - just make sure I send that test though.

With that said, there is EXCEPTIONALLY good data (though the IDSA won't fully buy in) that you don't need to treat immunocompetent adults for strep throat with antibiotics basically ever. With a few geographic exceptions the strep in the US doesn't cause rheumatic heart disease, immunocompetent adults have shockingly low rates of "secondary" strep complications of any kind (except glomerulonephritis, which abx doesn't prevent) so treating to further lower that is rather pointless, and steroids resolve symptoms faster than abx do. So it's rare (outside of transplants, HIV, ESRD, and diabetes) that I give abx for it at all.

That would be the wrong way to do it though, since many common ABX indications do not require (+) testing (strep, AOM, clinically dx'd pneumonia, cellulitis). The "stick" should come in when you Rx ABX without an appropriate diagnosis, or order a head CT for a migraine, etc.

Amusingly enough: low risk CT scans is another common MIPS category. The one my group uses is low risk head injury, but I believe CT scan of headache without extra-cranial findings is another one of the improvement options

 

[wareagle726]

Almost all of my patients with seizures stop on their own long before they arrive to the ED (and certainly after EMS snows them further when they are already post-ictal). I rarely have to give Ativan and almost never multiple doses. A PNES also breaks better with a different approach.

Love walking in a room and making some statement about "looks like its just a big PNES to me." I know, I'm a child.

 

[JacobMcCandles]

Some metrics HAVE led to improved care (I think the ACS/STEMI metrics are the best example; setting door-to-EKG times, door-to-balloon times do likely save/help patients, and encourage spending to develop a system to achieve these goals).

There’s always the issue of them adding on additional things to these measures through the ED because it’s the path of least resistance. Now we’re expected to give a statin (let’s not even get started on the research, or lack thereof, around statins) while they’re getting ready to go to the cath lab.

 

[WilcoWorld]

There’s always the issue of them adding on additional things to these measures through the ED because it’s the path of least resistance. Now we’re expected to give a statin (let’s not even get started on the research, or lack thereof, around statins) while they’re getting ready to go to the cath lab.

GTFO

 

[VA Hopeful Dr]

That would be the wrong way to do it though, since many common ABX indications do not require (+) testing (strep, AOM, clinically dx'd pneumonia, cellulitis). The "stick" should come in when you Rx ABX without an appropriate diagnosis, or order a head CT for a migraine, etc.

No argument, just pointing out that this is a thing.

 

[JacobMcCandles]

GTFO

I wish it were a joke.

 

[WilcoWorld]

I wish it were a joke.

It is a joke, just the wrong kind.

 

[WorkNoteEmergency]

As bad as the sepsis merry-go-round is here, it could be worse. Recent vacation in Ireland saw this on an ambulance. Can you imagine if that took hold here? Just hoping none of my hospital adminisrators go on vacation in County Kerry.

 

[RustedFox]

As bad as the sepsis merry-go-round is here, it could be worse. Recent vacation in Ireland saw this on an ambulance. Can you imagine if that took hold here? Just hoping none of my hospital adminisrators go on vacation in County Kerry.

Mnemonic clearly written by a drunken leprechaun.

 

[WilcoWorld]

That is amazingly dumb.

 

[DocEspana]

As bad as the sepsis merry-go-round is here, it could be worse. Recent vacation in Ireland saw this on an ambulance. Can you imagine if that took hold here? Just hoping none of my hospital adminisrators go on vacation in County Kerry.

"It feels like you're going to die"

Sepsis alert calls on anxiety *already* happens, but now its going to be formally protocolized.

 

[greatnt249]

There’s always the issue of them adding on additional things to these measures through the ED because it’s the path of least resistance. Now we’re expected to give a statin (let’s not even get started on the research, or lack thereof, around statins) while they’re getting ready to go to the cath lab.

So...by this, you mean you get dinged if you don't give a statin before they go to the cath lab?

 

[CoolDoc1729]

So...by this, you mean you get dinged if you don't give a statin before they go to the cath lab?

If it’s preclicked in the appropriate order set and stocked in the er Pyxis i don’t really care? It’s definitely not my priority when we’re playing ring around the call schedule and the patient is having runs of VT though lol

 

[greatnt249]

If it’s preclicked in the appropriate order set and stocked in the er Pyxis i don’t really care? It’s definitely not my priority when we’re playing ring around the call schedule and the patient is having runs of VT though lol

I guess what I mean is there's nothing more soul-sucking than having clipboard warriors hound you about failing a metric that shouldn't exist to begin with. No one's life is being saved by getting that atorvastatin down their gullet 10 minutes before going on the cath table, I can assure you that.

 

[MechEDoc]

I mean, it's rare, but severe hyponatremia should definitely be on your DDx for refractory seizures.

Devils argument. If it's really refractory, why not just give 2 amps sodium bicarbonate while you're getting labs. Harm is essentially zero and it's hypertonic sodium (but nurses won't freak out about it!).

 

[JacobMcCandles]

So...by this, you mean you get dinged if you don't give a statin before they go to the cath lab?

It’s more of a hospital ding. It hasn’t become a huge issue at this point but still something we’re “supposed” to do.

 

[WilcoWorld]

Devils argument. If it's really refractory, why not just give 2 amps sodium bicarbonate while you're getting labs. Harm is essentially zero and it's hypertonic sodium (but nurses won't freak out about it!).

I think one could make a good argument for that. Would want labs drawn first (if possible) to make sure you don't cloud your diagnosis, I suppose.

 

[greatnt249]

It’s more of a hospital ding.

That's even worse. What committee of clipboard warriors decided that this needed to happen?

 

[JacobMcCandles]

That's even worse. What committee of clipboard warriors decided that this needed to happen?

A committee of non-physicians and non-clinical people.