Is this technically sepsis?

[b-real]

Non-perforated appendicitis and no abscess, + leukocytosis, mild tachycardia (< 110), lactate 2.5. Normal BP. Pt looks extremely well. Asking cause I'm reviewing potential sepsis fallouts (thanks CMS!). I don't believe this meets criteria but was diagnosed as sepsis by admitting physician.


Sent from my iPhone using SDN mobile

---

Members don't see this ad.

 

[TooMuchResearch]

I guess it is if someone calls it sepsis. At face value, it's a person with 2 SIRS criteria, elevated lactate, getting admitted for IV antibiotics and surgical intervention.

On the other hand, it's frickin' standard appy, which despite those above elements isn't even an inpatient admission (at residency hospital, this was observation unless complicated).

 

[b-real]

I guess it is if someone calls it sepsis. At face value, it's a person with 2 SIRS criteria, elevated lactate, getting admitted for IV antibiotics and surgical intervention.

On the other hand, it's frickin' standard appy, which despite those above elements isn't even an inpatient admission (at residency hospital, this was observation unless complicated).

Yeah that's kinda how I see it too. Pt was in the hospital for < 24 hrs.

 

[Rendar5]

I am sorry, but you did make a mistake on that case. You ordered a lactic acid on a case of appendicitis. Don't do that the next time and you won't have an issue.

 

[b-real]

I am sorry, but you did make a mistake on that case. You ordered a lactic acid on a case of appendicitis. Don't do that the next time and you won't have an issue.

LOL it wasn't me! But duly noted.

 

[msgsk]

Technically sepsis, but if I was the admitting provider I wouldn't have documented the word. Especially if you're not going to administer the [unnecessary] fluid bolus and [potentially unnecessary] antibiotics. Of course it's going to be a fallout then

 

[b-real]

Technically sepsis, but if I was the admitting provider I wouldn't have documented the word. Especially if you're not going to administer the [unnecessary] fluid bolus and [potentially unnecessary] antibiotics. Of course it's going to be a fallout then

Agree with this. In this hospital, if the hospitalist or surgeon includes "sepsis" in the impressions/diagnosis, the sepsis bundle evaluation pathway gets triggered. Of course, this turns into a fallout. It doesn't matter if the ED physician didn't diagnose the pt as septic.

 

[msgsk]

Where I work, you (or anyone) can use the word 'sepsis' as a diagnosis, and it won't be a fallout as long as you document your reasoning for not ordering the requisite fluids/antibiotics. Reasons could be "doubted bacterial source of infection", "concern for volume overload", or, as it might have been in this case, "although pt technically meets sepsis criteria, the underlying cause of his illness is best treated with surgery and such an IV fluid bolus is unnecessary". It doesn't really matter the reason, as long as it's addressed it then won't be a fallout. Not sure if the same rules apply where you work, and it's silly, but it's the way of the world.

 

[deleted109597]

Sepsis doesn't require fluid boluses though. Septic shock does. If they're not hypotensive, what are they saying the fallout is? Failure to write the word "sepsis"?

 

[USCDiver]

Severe sepsis requires the bolus and a lactate >2 triggers that level.

 

[southerndoc]

Severe sepsis requires the bolus and a lactate >2 triggers that level.

SEP-1 applies whether you diagnose sepsis or not. If the patient has a lactate >2 or signs of organ dysfunction with a source of infection, he/she must be added to the mix whether the provider diagnosis sepsis or fails to diagnose sepsis. The only way around this is to document why they aren't septic (e.g., lactic acidosis elevated because patient just ran a marathon, no source of infection, etc.). It's hard to justify not being septic with a source of infection (appendicitis).

Take home point is not to order a lactate and cultures unless they're clearly indicated.

This should not be hard to follow if your hospital has set things up correctly. Lactate >2 without hypoperfusion just means blood cultures, antibiotics within 3 hours (time starts when lactate is resulted or when the word sepsis has been mentioned) and a repeat lactate within 6 hours. Septic shock (hypotension or lactate >4) adds 30 mL/kg bolus and reassessment. Vasopressors for persistent hypotension is also in the mix.

My health system has it so that you cannot order cultures without a lactate, and the lactate order is serial (q2 hr) lactates x3 with the nurse having the ability to cancel remaining lactates if lactate is <2. The ED doc -- not the hospitalist or intensivist -- is responsible for documenting a reassessment immediately after the fluid bolus. This is how we avoid fallouts (things get missed during handoffs, which is why we require the ED doc to do the reassessment after fluids are administered).

There are some very weird caveats to SEP-1 (fluids have to be administered over 1 hour, cannot count fluids administered by EMS unless a start/stop time is documented, etc.). Personally, I think this core measure causes more harm than good and I hope it goes the way of the dodo bird fast. Until then, we are stuck with it.

A good review of SEP-1 is available here: Sepsis CMS Core Measure (SEP-1) Highlights // ACEP

 

[emergentmd]

Agree with this. In this hospital, if the hospitalist or surgeon includes "sepsis" in the impressions/diagnosis, the sepsis bundle evaluation pathway gets triggered. Of course, this turns into a fallout. It doesn't matter if the ED physician didn't diagnose the pt as septic.

Admin getting so stressed about getting Sepsis right is getting ridiculous. Some places I work automatically get the sepsis protocol if they meet 2 criteria. They get the full meal deal and IV abx and many times I just send the pt home with viral syndrome.

I admitted a guy with N/V/D with fever, SBP 90's, HR 120's, elevated WBC. He was young, no comorbidity, finally admitted him after 4 liters b/c he was still tachycardic.

Got a nasty email a few dys later wondering why I didn't give him Shotgun abx. I replied stating that it was a virus, and I am not giving Broad spectrum abx for a virus.

Never got a reply and read the pt's diagnosis as a viral syndrome when all cultures ended up negative.

This is how the pt would have been treated 3 yrs ago. Now, most ED and IM docs would start broad spectrum abx.

Ridiculous!!!!!

Another reason I am doing locums. I don't have to worry about any crazy metrics, admin complaints, emails from the Sepsis nurse, Pt satisfaction, Greet times. I just do my shift and go home. They can't touch me b/c they cant replace me.

 

[Apollyon]

They can't touch me b/c they cant replace me.

Why can't they replace you? You're just a hired gun - a mercenary. They just get rid of you, and get another merc.

 

[emergentmd]

Why can't they replace you? You're just a hired gun - a mercenary. They just get rid of you, and get another merc.

Because I do a faster, more reliable, and experienced that all of the full timers. Oh, and I do go along with all of the crazy metrics like sepsis b/c its already ordered before I even see patients. So from Admin standpoint, I am doing a great job.

Oh and There are only 2 full timers at my locums place and they are dropping like flies. Even if they get fully hired and get rid of me, there are 10 more locums places that call me every day for shift coverage.

I just looked at the Aug schedule last night and there are 40% of the shifts not covered. I think I am pretty secure.

 

[Apollyon]

Because I do a faster, more reliable, and experienced that all of the full timers. Oh, and I do go along with all of the crazy metrics like sepsis b/c its already ordered before I even see patients. So from Admin standpoint, I am doing a great job.

Oh and There are only 2 full timers at my locums place and they are dropping like flies. Even if they get fully hired and get rid of me, there are 10 more locums places that call me every day for shift coverage.

I just looked at the Aug schedule last night and there are 40% of the shifts not covered. I think I am pretty secure.

See, but, you miss the point. Even with all of the holes, they could still say, "Emerg, you're gone", and call your, or another, locums company for someone else. Your individual case sounds secure (and, honestly, like a rather ****ty place to work), but your statement above that was a much more general one.

 

[diphenyl]

Yep tech severe sepsis by criteria.
2/4 sirs criteria with source = sepsis. Period.
Lactate > 2 but <4 = severe sepsis without shock

 

[emergentmd]

See, but, you miss the point. Even with all of the holes, they could still say, "Emerg, you're gone", and call your, or another, locums company for someone else. Your individual case sounds secure (and, honestly, like a rather ****ty place to work), but your statement above that was a much more general one.

Absolutely my job is not bulletproof but so is any other EM job. I feel my job is more flexible and bulletproof as a locums where I have some control over my life rather than working at a most SDG or CMG where I am beholden to whoever gets the contract. I may get dumped at one hospital if they change contract, get all full timers but I have 3 other gigs that I can pick up shifts if my main one dries up.

I prefer the flexibility that it allows me. Some months I work 8 shifts if I am busy with home life. Months where kids are busy, I pick up 15 shifts if I want. This month I plan on working 15 shifts and taking in 60K+.

 

[gro2001]

The problem is that clinicians and administrators have confused research definitions with clinical definitions of diseases. SIRS is a research definition. We chose to apply it in clinical use due to lack of a better tool at the time, but we should not be tied to it in practice.

 

[Siggy]

I've had a talk with the sepsis nurse a few time (and have caused SOFA/qSOFA to be a running joke) and one thing I've learned was that if anyone lists sepsis at all... including on a differential, then it falls into sepsis land. On the other hand, someone documenting "This is not sepsis" will pop someone out of the core measure, which I've also done a few times. Lactate of 7 in a metformin OD is NOT septic shock...

 

[emergentmd]

This is all I need to Know about sepsis.

SIRS = temp 100.4+HR>90
Sepsis criteria = SIRS + source

During the winter, a bronchitis/pharyngitis = Sepsis criteria.
Should all of these young healthy pts gets the full meal deal?

If Sepsis criteria is so important, why are PCP clinics not held to the same standard?

So if the same pt presented to UC/PCP they get one course. Go to the ED and you get a 10 k workup.

One one hand we complain about cost and overuse of abx.
On the other hand we create abx resistance and increase healthcare costs.

Where is the clinical acumen in this? When did politicians at CMS/CDC get to dictate pt care without seeing the pt?

 

[HooliganSnail]

Technically sepsis, but if I was the admitting provider I wouldn't have documented the word. Especially if you're not going to administer the [unnecessary] fluid bolus and [potentially unnecessary] antibiotics. Of course it's going to be a fallout then

You only have to administer the bolus if they are septic shock...

A common misconception

 

[TrumpetDoc]

One one hand we complain about cost and overuse of abx.
On the other hand we create abx resistance and increase healthcare costs.

This!
We can "choose wisely" til the freaking cows come home but the ONLY was the real powers that be will get decreased cost is to cut OUR pay. Irrelevant if our pay is only a small % of cost.
They will continue to up regs and crap like this, cut our reimbursement and tout some spin doctored numbers on how healthcare costs are down with reimbursement reform.

And not to mention all the downstream effects, C Diff etc that lead to incr costs.

 

[Birdstrike]

Sepsis is and always was, a clinical diagnosis. Attempts to make it a cut-and-dry numerical diagnosis that fits a formula, is a fools errand, and will continue to confuse the uninitiated.


Sent from my iPhone using SDN mobile