Everything is Sepsis! (when you're part of CMS)

[sum dude]

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Great post at EMCrit blog regarding proposed (and terrible) CMS core measures which will have you all gouging your eyeballs in October. Was wondering everyone's thoughts and what your hospitals are doing to streamline the treatment of "sepsis" (which CMS is defining as any shock, or SIRS) to meet the core measures?

I don't know about you, but I can't wait to order lactics and cultures on every 20 year old with a cough and fever during flu season, tanking CHF'ers w/ 2L of fluid because their tachycardiac and have lactic of 4, and placing central lines in 80 lb nursing home patients w/ a MAP of 69. Classic CMS--doing a core measure which doesn't improve care, can potentially cause harm, and will increase costs in long run (see blood cx and pna, tight glycemic control leading to hypoglycemia, improved cath times w/o any benefit, etc.)

 

[link2swim06]

I stopped reading when they suggested we obtain a CVP...

 

[emergentmd]

Sepsis protocol, BLAST, etc.... is a JOKE. Everyone with a HR 101 and breathing fast could be septic. I guess I better start cultures on all of my anxiety/psych patients.

 

[Birdstrike]

The ones who will rate our "quality" and pay us based on their view of it. Also the ones who claim to know how to "save money" and "cut costs." Absolute *****s. Welcome to George Orwell's 1984.

 

[Leo Aquarius]

Who are the geniuses who determine CMS crap?

 

[allendo]

My facility is already doing this. Every time I order a blood culture on a kid they add a lactate. I recently had a nurse wanting to order labs and a lactate on someone who sprained their ankle b/c their vitals met SIRS criteria.

 

[Psai]

My facility is already doing this. Every time I order a blood culture on a kid they add a lactate. I recently had a nurse wanting to order labs and a lactate on someone who sprained their ankle b/c their vitals met SIRS criteria.

...
it's like they are actively trying to eradicate conscious thought

 

[Arcan57]

I liked the link to time zero where they complain that their data collection is too hard to do if we document septic shock as occurring when the pt actually first meets criteria for septic shock. Because we all know data collection is the most important thing we can do for a pt.

 

[link2swim06]

My facility is already doing this. Every time I order a blood culture on a kid they add a lactate. I recently had a nurse wanting to order labs and a lactate on someone who sprained their ankle b/c their vitals met SIRS criteria.

Probably should d-dimer him too. I mean he IS tachycardic...

 

[emergentmd]

My facility is already doing this. Every time I order a blood culture on a kid they add a lactate. I recently had a nurse wanting to order labs and a lactate on someone who sprained their ankle b/c their vitals met SIRS criteria.

My facility has too and I am sure most will jump on board very soon. CMS tells the hospital to jump, they start to ask HOW HIGH.

I have ordered more Lactic acid in the past 3 months than I have done in 15 yrs. OH well..... not like I care about containing costs.

 

[CMS1]

CMS is not defining sepsis as "any shock, or SIRS". They are using the current consensus definitions. Perhaps your facility is using a different definition or has developed a very broad inclusion criteria so they never miss a case of sepsis.
You only need to order "lactics" and cultures on patients who are being admitted to the hospital and get coded for sepsis at discharge. Perhaps your hospital has a different policy or process.
There is no requirement to place a central line in any patient with a MAP of 69mmHg.
There is no fluid requirement for a patient with CHF who doesn't have septic shock, is admitted to the hospital, and isn't comfort care before 6 hours from triage. It is not clear yet if documenting hypervolemia/lack of responsiveness to a fluid challenge/passive leg raise or rales on exam is a way of not being required to administer the 30cc/kg crystalloid bolus.

I suspect you are more frustrated with your hospital's process than what CMS is asking for.

I'm sure an astute physician like yourself will have no difficulty in determining who has severe sepsis and needs early antibiotics/screening for septic shock and the appropriate evaluation for hypovolemia/resuscitation needs.

 

[link2swim06]

I hate when guidelines cross into the realm of required recommendations while vastly oversimplifying situations.

This is a huge problem with medicine in general. Indirectly 'fix' one problem that just creates another. Admins want to turn medicine into one giant cookbook because it makes them feel better. Well, guess what. There is a lot of crap we don't have excellent studies for and there is a lot of stuff where clinical acumen and experience means a damn.

If all of sepsis management can be summed up on a flowsheet on the refrigerator in the break room then what have I been wasting my time reading about?

At the end of the day this CMS crap is more about documentation than actual clinical medicine. More paperwork, because we don't have enough of that...

 

[Siggy]

You only need to order "lactics" and cultures on patients who are being admitted to the hospital and get coded for sepsis at discharge.

That doesn't change the fact that when I have a cold and I go for a jog I'm, by definition, septic (elevated HR, elevated RR, infection). Also, from an ED standpoint, shouldn't the admitting diagnosis matter much more than the discharge diagnosis?

 

[allendo]

They are using the SIRS definition in triage to flag patients that could be septic. I tried to explain that I could run a lap around the parking lot and meet the SIRS criteria, you can imagine the blank stares I got. They are casting a wide net to not miss any septic patients, thus placing the blame on the ER if a lactate or blood culture was not ordered and the patient turns septic once admitted. I've tried to explain that we cannot reliably diagnose every patient in the ED with the same diagnosis they have upon discharge. Again blank stares

 

[Doctor Bob]

There's this new push that, in order to reduce CLABSIs, when we "pan culture" people we have to send a BAL as well. A trach aspirate is insufficent to ascribe a positive blood culture to a pulmonary source. So now we're left with the choice of either not culturing people or doing potentially unnecessary BALs on patients.

So if I get pathogen X from the blood, and pathogen X from the trach aspirate, it still counts as a possible CLABSI unless I also recover pathogen X from a BAL sample. I might be able to clinically say "there's clearly a pulm source" but admin doesn't believe me unless there's a positive culture.

 

[Promethean]

I currently work at a personal care facility with adults with intellectual disabilities. A virus just went through the house, and several guys had a night or two of low grade fever, slight tachycardia, and mild coughing/sneezing. I helped several guys get through it by administering the PRN tylenol that I have standing orders for, as well as to push extra fluids, etc. I do everything in my power to avoid sending my guys out to ERs over a self-limiting condition. However, one of the other nurses who works there LOVE to send guys out by ambulance. Less work to do if fewer residents are home. So, she will withhold tylenol (don't want to mask any infections!) and extra fluids (if they don't have a specific order to do it, it ain't going to get done, even if it is the obvious right thing to do and fully within our scope to make that call.) I had a day off, and surprise, surprise, she got one of the guys up to a 100.5 fever and a 105 HR and sent him out.

It took 4 days for him to come home from the admission. When I was getting report from the floor nurse who was discharging him, she said "Oh, you know him, so I don't need to tell you much. The colonoscopy didn't show anything major."

WAIT. WHAT? How did we go from a cold to a colonoscopy? The nurse giving me report had no idea about his hospital course, and I had to wait until he got home to pour through the notes to try to figure out what the hell had happened.

In the ED, he was determined to JUST meet SIRS criteria. (WBC 3900, baseline for this patient, but another criterion met) Which earned him a CT. Unsurprisingly, his lungs were fine, no pneumonia... but is that some rectal wall thickening, inflammation? Admit with diagnosis of sepsis, consult GI, wait in the hospital 2+ days for an opening in the GI lab for a colonoscopy. Nothing to see here, but let's biopsy everything just to be sure. (pending). Oh, hey, while we were cleaning him out his electrolytes got out of whack. How unexpected! Keep him for another day or so to correct his potassium, ship him home.

For brevity, I skipped some other unnecessary consults, blood cultures, IV antibiotics which were started empirically twice and then withdrawn when found not to be needed.

All of this was done to treat a cold. If the patient were verbal, he could have pitched a fit or at least questioned what was being done to him. Instead, because criteria were met, he was processed through a test/treatment assembly line to the tune of tens of thousands of dollars of invasive and medically unnecessary interventions.

This is why physicians need to be able to exercise judgment and not have their performance scored by algorithm. (That won't solve the problem of lazy nurses who won't administer PRNs or keep their patients hydrated, but it will mitigate the amount of harm they can do.)

 

[Leo Aquarius]

They are using the SIRS definition in triage to flag patients that could be septic. I tried to explain that I could run a lap around the parking lot and meet the SIRS criteria, you can imagine the blank stares I got. They are casting a wide net to not miss any septic patients, thus placing the blame on the ER if a lactate or blood culture was not ordered and the patient turns septic once admitted. I've tried to explain that we cannot reliably diagnose every patient in the ED with the same diagnosis they have upon discharge. Again blank stares

Who are the dimwits who give you blank stares and are dictating standards of care? If they aren't holding a medical degree, then they shouldn't be dictating care.

 

[Birdstrike]

Who are the dimwits who give you blank stares and are dictating standards of care? If they aren't holding a medical degree, then they shouldn't be dictating care.

You thought people with medical degrees dictated the standard of care? Ha! You're lucky if it's dictated by anyone with any degree at all. It could be dictated by a degree-less patient (concept of demands for patient "satisfaction"), a person with a business degree (hospital CEO telling you what to do, when to do it, and how), a nursing degree (nurse administrators having more power than many physicians), or last but not least, someone with a law degree altering practice patterns and your thought process by what he or she has successfully sued doctors for in the past.

But a physician dictating it?

Surely, you jest.

 

[LaBusqueda]

Wow...sounds like CMS needs some EM voices over there!

 

[LaBusqueda]

And yes as someone mentioned before.
Why should I/we have to even worry about resource utilization if organizations are going to worry so much about missing something that they sell the farm trying to find x, y, z?!?!?!
Oh wait...they don't care...they are BANKING on us/hospitals missing these to decrease payments.

Sorry, sorry, thought we were supposed to be practicing medicine, I keep forgetting...

 

[Leo Aquarius]

You thought people with medical degrees dictated the standard of care? Ha! You're lucky if it's dictated by anyone with any degree at all. It could be dictated by a degree-less patient (concept of demands for patient "satisfaction"), a person with a business degree (hospital CEO telling you what to do, when to do it, and how), a nursing degree (nurse administrators having more power than many physicians), or last but not least, someone with a law degree altering practice patterns and your thought process by what he or she has successfully sued doctors for in the past.

But a physician dictating it?

Surely, you jest.

How can the highest trained professional in this country - a physician - answer to practice standards of anyone else???

I refuse to work for a hospital that isn't run by physicians, just as all of you should. Nothing will change until we all boycott idiot lawyers- and idiot business men-run hospitals. Just refuse to work at these places.

Let's start stepping up and taking control of our profession. Only work for other doctors, or yourself. That's it. Period. No exceptions. (This vision I'm holding fast to - I don't care if I'm a green resident.)

 

[Siggy]

Who are the dimwits who give you blank stares and are dictating standards of care? If they aren't holding a medical degree, then they shouldn't be dictating care.

My bet is someone with a long list of post nominals, one of which includes "RN."

 

[Doctor Bob]

Who are the dimwits who give you blank stares and are dictating standards of care? If they aren't holding a medical degree, then they shouldn't be dictating care.

Sadly there are always doctors on these committees. Often they are ones who have become somewhat divorced from clinical practice.
Therein lies part of the problem.
Docs who are active in the clinical realm don't have the time to meaningfully participate in administrative processes.
Docs who have the time to be heavily engaged in the administrative processes don't have time to be fully invested in the clinical realm.

So when non-physicians say "hey, we should have docs adhere to this handy protocol flowsheet and then document this 25 point social history on every patient" it seems perfectly reasonable. So the admin docs sign off on it.

 

[Birdstrike]

How can the highest trained professional in this country - a physician - answer to practice standards of anyone else???

Good question. But the reality is that we do, as the rule, not the exception.

I refuse to work for a hospital that isn't run by physicians, just as all of you should.

When you find that place, please let me know. I'll stop, stare, gawk in amazement and take pictures of it. I will then submit those pictures along with my UFO, Big Foot, Chupacabra and Nessie photos. Have you really seen this creature?




http://m.weeklystandard.com/blogs/obamacare-ends-construction-doctor-owned-hospitals_525950.html

 

[allendo]

My bet is someone with a long list of post nominals, one of which includes "RN."

Bingo!! I tell them everyday common sense has left the F***ng building.

 

[sum dude]

CMS is not defining sepsis as "any shock, or SIRS". They are using the current consensus definitions. Perhaps your facility is using a different definition or has developed a very broad inclusion criteria so they never miss a case of sepsis.
You only need to order "lactics" and cultures on patients who are being admitted to the hospital and get coded for sepsis at discharge. Perhaps your hospital has a different policy or process.
There is no requirement to place a central line in any patient with a MAP of 69mmHg.
There is no fluid requirement for a patient with CHF who doesn't have septic shock, is admitted to the hospital, and isn't comfort care before 6 hours from triage. It is not clear yet if documenting hypervolemia/lack of responsiveness to a fluid challenge/passive leg raise or rales on exam is a way of not being required to administer the 30cc/kg crystalloid bolus.

I suspect you are more frustrated with your hospital's process than what CMS is asking for.

I'm sure an astute physician like yourself will have no difficulty in determining who has severe sepsis and needs early antibiotics/screening for septic shock and the appropriate evaluation for hypovolemia/resuscitation needs.

CMS is not defining sepsis as "any shock, or SIRS". They are using the current consensus definitions. Perhaps your facility is using a different definition or has developed a very broad inclusion criteria so they never miss a case of sepsis.
You only need to order "lactics" and cultures on patients who are being admitted to the hospital and get coded for sepsis at discharge. Perhaps your hospital has a different policy or process.
There is no requirement to place a central line in any patient with a MAP of 69mmHg.
There is no fluid requirement for a patient with CHF who doesn't have septic shock, is admitted to the hospital, and isn't comfort care before 6 hours from triage. It is not clear yet if documenting hypervolemia/lack of responsiveness to a fluid challenge/passive leg raise or rales on exam is a way of not being required to administer the 30cc/kg crystalloid bolus.

I suspect you are more frustrated with your hospital's process than what CMS is asking for.

I'm sure an astute physician like yourself will have no difficulty in determining who has severe sepsis and needs early antibiotics/screening for septic shock and the appropriate evaluation for hypovolemia/resuscitation needs.

Actually...if you do work for CMS, you should read your own work, CVP is a quality measure, and it's based on River's (revolutionary but recently updated and proved unnecessary 2/2 Process trial) protocol. Here's your own criteria for "Severe Sepsis":

"In order to establish the presence of severe sepsis, there are three criteria, all three of which must be met within 6 hours of each other.

• Documentation of a suspected source of clinical infection. There may be reference to “possible infection from xx”, “suspect infection from xx”, or similar reference in progress notes, consult notes, or similar physician/APN/PA documentation
• Two or more manifestations of systemic infection according to the Systemic Inflammatory Response Syndrome (SIRS) criteria
• Organ dysfunction,evidenced by any one of the following:
  • Systolic blood pressure (SBP) < 90, or mean arterial pressure < 65, or a systolic blood pressure decrease of more than 40 mmHg from the last previously recorded SBP considered normal for that specific patient
  • Creatinine > 2.0, or urine output < 0.5 mL/kg/hour for 2 hours
  • Bilirubin > 2 mg/dL (34.2 mmol/L)
  • Platelet count < 100,000
  • INR > 1.5 or aPTT > 60 sec
  • Lactate > 2 mmol/L (18.0 mg/dL)"

If they meet this, then we basically are measured on River's protocol from 2001.

The kicker is that sepsis can retroactively be declared (eg CHF patient w/ bil infiltrates who goes on to get pneumonia, a borderline UTI in a pt w/ COPD, pancreatitis pt w/ a stone) and hence doc a hospital even if the treatment was correct. Being that physicians and hospitals adapt to information much faster than our astute CMS agency, to combat this every patient who has a WBC and abnl labs is going to get: (1) cx's, (2) abx's (3), fluids, and excessive work-up which will, in classic CMS M.O., lead to higher costs in the long-run which the government will somehow blame on physicians over-ordering and hospitals gouging patients (see Promethean's post above).

Acep, for their credit, sent at letter to CMS to explain kindly that maybe CMS should look at EBM within the past 10 years. So, yeah, it is a problem, and my frustration is that hospitals over-react to every single CMS measure which is rushed and not evidence-based, doesn't improve care, and increases costs in the long run, eg my latest favorite "possible HTN, follow up provided " in an elderly patient with a broken wrist who has a systolic BP of 139. But I'm sure an astute CMS MD who joined 2 days ago to educate us silly doc's in the trenches is already working on a better version of this, right, and not this outdated, byzantine flow-chart you have listed for your sepsis core measure in October? Right
file:///C:/Users/dec1d9/Downloads/2.2_SEP_v5_0a.pdf

 

[sum dude]

FYI, common-sense fixes are provided by Scott Weingart's blog:

"So how do we fix the CMS measure?

Simple:

1. Keep the Lactate
2. Change the ABX within 3 hours to their new definition of Septic Shock (i.e. the old definition/EGDT definition of Severe Sepsis and Septic Shock), and not their new vision of severe sepsis
3. Eliminate the Blood Culture rule
4. Keep the 30 ml/kg of fluid for the septic shock patients (by their definition) unless clinicians documentwhy they felt the pt should not get this volume
5. Keep the vasopressors
6. Eliminate the focused exam silliness

Alternatively, everything could be fixed by defining the denominator as patients with persistent hypotension after fluids or Lactate>=4"

 

[link2swim06]

FYI, common-sense fixes are provided by Scott Weingart's blog:

"So how do we fix the CMS measure?

Simple:

1. Keep the Lactate
2. Change the ABX within 3 hours to their new definition of Septic Shock (i.e. the old definition/EGDT definition of Severe Sepsis and Septic Shock), and not their new vision of severe sepsis
3. Eliminate the Blood Culture rule
4. Keep the 30 ml/kg of fluid for the septic shock patients (by their definition) unless clinicians documentwhy they felt the pt should not get this volume
5. Keep the vasopressors
6. Eliminate the focused exam silliness

Alternatively, everything could be fixed by defining the denominator as patients with persistent hypotension after fluids or Lactate>=4"

Even this is bad. Let's assume your patient is 71kg. You work in a busy ED and order two liters of NS as your fluid.

Well guess what, you failed the metric and lose. You ordered 28.1 ml/kg.

The CORRECT ANSWER WAS:

You divert busy nurses to hang an additional NS to run 130 cc to meet the CMS metric.

 

[Spinach Dip]

Well I'm glad to see we're cutting costs and all focused on patient-centric care.








(that was sarcasm btw)

 

[CMS1]

Actually...if you do work for CMS, you should read your own work, CVP is a quality measure, and it's based on River's (revolutionary but recently updated and proved unnecessary 2/2 Process trial) protocol. Here's your own criteria for "Severe Sepsis":

"In order to establish the presence of severe sepsis, there are three criteria, all three of which must be met within 6 hours of each other.

• Documentation of a suspected source of clinical infection. There may be reference to “possible infection from xx”, “suspect infection from xx”, or similar reference in progress notes, consult notes, or similar physician/APN/PA documentation
• Two or more manifestations of systemic infection according to the Systemic Inflammatory Response Syndrome (SIRS) criteria
• Organ dysfunction,evidenced by any one of the following:
  • Systolic blood pressure (SBP) < 90, or mean arterial pressure < 65, or a systolic blood pressure decrease of more than 40 mmHg from the last previously recorded SBP considered normal for that specific patient
  • Creatinine > 2.0, or urine output < 0.5 mL/kg/hour for 2 hours
  • Bilirubin > 2 mg/dL (34.2 mmol/L)
  • Platelet count < 100,000
  • INR > 1.5 or aPTT > 60 sec
  • Lactate > 2 mmol/L (18.0 mg/dL)"

If they meet this, then we basically are measured on River's protocol from 2001.

 

[CMS1]

Actually...if you do work for CMS, you should read your own work, CVP is a quality measure, and it's based on River's (revolutionary but recently updated and proved unnecessary 2/2 Process trial) protocol. Here's your own criteria for "Severe Sepsis":

"In order to establish the presence of severe sepsis, there are three criteria, all three of which must be met within 6 hours of each other.

• Documentation of a suspected source of clinical infection. There may be reference to “possible infection from xx”, “suspect infection from xx”, or similar reference in progress notes, consult notes, or similar physician/APN/PA documentation
• Two or more manifestations of systemic infection according to the Systemic Inflammatory Response Syndrome (SIRS) criteria
• Organ dysfunction,evidenced by any one of the following:
  • Systolic blood pressure (SBP) < 90, or mean arterial pressure < 65, or a systolic blood pressure decrease of more than 40 mmHg from the last previously recorded SBP considered normal for that specific patient
  • Creatinine > 2.0, or urine output < 0.5 mL/kg/hour for 2 hours
  • Bilirubin > 2 mg/dL (34.2 mmol/L)
  • Platelet count < 100,000
  • INR > 1.5 or aPTT > 60 sec
  • Lactate > 2 mmol/L (18.0 mg/dL)"

If they meet this, then we basically are measured on River's protocol from 2001.


Dude, there is no requirement to measure a CVP. There is no requirement to use the River's protocol. There is certainly no requirement to use the River's protocol in patients who have just severe sepsis without septic shock. There is a requirement that patients with severe sepsis AND septic shock get a re-assessment of volume status and pressors for MAP<65mmHg after appropriate fluid resuscitation. CMS allows other options for re-assessment of volume status rather than requiring placement of a central line and measurement of CVP. They also do not require ScvO2 measurement.

As far as sepsis being retroactively declared, I'm not exactly sure what you are referring to. Are you referring to a physician having a different impression of what was wrong with the patient when they are admitting them compared to what you thought was wrong when they were in the ED? If that's the case you will need to get over it.

Again, I think most of your beef is with your hospital and their take on the CMS requirements, which as you are describing are not accurate.

 

[Janders]

I read the sepsis measure straight from CMS the night it came out. The entire PDF.

It is horrible. It is WELL-INTENTIONED but it is horrible. There are multiple glaring errors in the construction of this measure. Weingart hits on a number of them in his blog post.

To start, you need 3 criteria (within 6 hours of each other, even if one is temporary/resolves [i.e brief hypotension resolving without intervention]:
(1) Suspected infection
(2) 2xSIRS Criteria (reminder, they use Fever >38.3, HR >90!!, RR>20, WBC >14 or <4 or >10% bands).
(3) "organ dysfunction" which could be hypotension <90SBP, Cr >2, Bili >2, Plt <100k, Lactate >2. Guess what, a CHRONIC CREATININE OF 2.1 COUNTS! Yep, there is currently no loophole in the measure for chronic renal failure...

So wait, someone with a sore throat with RR of 95, Fever of 38.4 and Lactate of 2.1 FALLS INTO THE INITIAL MEASURE!
Or someone with known CRF with baseline Cr 2.4, who presents with HR 95, WBC 15k, and a sore throat.

What do we have to do with this patient with their sore throat?
Within 3 hours of arrival, these two sore throats who have "severe sepsis" by CMS definition need a (A) mandatory lactate measurement (B) broad spectrum abx given (C) blood cultures drawn PRIOR to abx (D) repeat lactate within 6hr if level normal.

So this is just the first stage. Multiple problems with this part of the measure--
*Doesn't take into account chronic lab abnormalities
*Incredibly low bar to mandate blood cx! expensive! evidence based? time consuming! how many false positives will we see?!
*Practically, its hard to ensure blood cx prior to abx in a busy ED. Missing that key point means you "fail" the metric. Surviving sepsis suggests not holding abx more than 45 minutes trying to get cultures.
*who made up this list of organ dysfunction criteria?! As weingart points out, they are not well supported by the literature.
*wait, who said abx within 3 hours of arrival is evidence based? Didn't we GET RID OF the antibiotics for pneumonia within 4 hours of arrival measure, as it caused overuse of antibiotics and didn't show survival benefit? no evidence for 3 hour mark for abx for these patents who aren't even in SHOCK!

So then, if the patient has lactate >4 or MAP <70 (weird number, eh?) you move to the next phase:
(1) Give 30ml/kg bolus [vaguely reasonable, though need a way to opt out if not indicated]
(2) If still hypotensive, apply vasopressors to get MAP >65 (again reasonable, but what if their baseline MAP is 62? No opt out possible in current construction).
(3) If they were hypotensive after that fluid bolus, or they had a Lactate >4 initially, they need a re-examination within 6 hours by a licensed provider to include both a repeat lactate and also at least TWO of the following FOUR options:
A CVP measurement
B SVo2 measurement
C Bedside Echo
D Dynamic assessment at bedside via passive leg raise, etc

OR if you don't like 2 of those four options, you can do a focused exam† including vital signs, cardiopulmonary, capillary refill, pulse and skin findings.

So our sore throat patients DON'T need mandatory repeat lactates or central lines. But there are a ton of other problems with the measure, as I've lightly touched on above. None of this is exaggeration, just cut and pasted from the manual with my commentary.