Sepsis timer needs to die.

[emergentmd]

To have any protocols that considered beneficial, the benefits has to outweigh the cons.

I highly doubt taking the cost, human manpower, resources that it is beneficial.

Show me a study that shows this and I’ll be on board but I highly doubt any study takes into account the cost, additional manpower, lost opportunity in caring for other pts, burnout, etc.

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[RustedFox]

Nope, not missing anything (other than perhaps your hospital/system needs your help in herding the ostriches, but sometimes it's easier to just stick your head in the sand).

#1 How did you get a urine prior to cath lab?!

#2 Did they really have a UTI, or just asymptomatic bacteruria? (rhetorical, as here is potentially the first bad documentation by IM).

#3 That patient wasn't septic per information provide. Need infection, 2 SIRS criteria and end organ damage. This is poor documentation by IM.

#4 There is grey area in abstraction. In our system, 'sepsis on admission' means earlier between time of admit order to the hospital or H&P time not 'ED arrival' time. Some systems abstract that differently and count 'ED admission.'

#5 It's all in the documentation and abstraction. Your group should meet with the sepsis folks and inpatient physicians to improve. You also shouldn't be dinged for a fallout or hosed based upon this case. This is where your group or medical director needs to defend you without you ever really even hearing about this being a 'fallout.'

Okay, I'm back. I played golf. Didn't play very well. Maybe that mea-.... nevermind.

To address your points (non-adversarial talk here; I'm not being a sarcastic ass)

1. I didn't get a urine. Someone else did, and IM was IM. EDIT: I'm willing to bet it was a PLP on the IM side, because that's what they do; the look for the 1-2 things that they know and overcall/overtreat them.

2. Don't know. Don't care. Maybe there was a leukocytosis. There probably was; I mean... the patient was having an MI.

3. - Infection (UTI). 2 SIRS (HR, RR of say, 20 because that's the only number the RN staff knows), and end-organ damage (Troponinemia).

4. Yeah, I think I now have evolved a few smartphrases to very clearly document why I did or did not initiate the sepsis bundle at the time of first contact. The sepsis pixie (the sepsis coordinator) at my shop has let me know that "it works; what you do", but I'm not sure that she remembers who I am or really cares. She strikes me as not too bright.

5. I'm with you 100% on this one. I guess I didn't include my smartphrases on this one because I felt that obvious MI was obvious.

Director says that this is not the first time it has happened, so although its far-out, it happens.

 

[Mount Asclepius]

Okay, I'm back. I played golf. Didn't play very well. Maybe that mea-.... nevermind.

To address your points (non-adversarial talk here; I'm not being a sarcastic ass)

1. I didn't get a urine. Someone else did, and IM was IM.

2. Don't know. Don't care. Maybe there was a leukocytosis. There probably was; I mean... the patient was having an MI.

3. - Infection (UTI). 2 SIRS (HR, RR of say, 20 because that's the only number the RN staff knows), and end-organ damage (Troponinemia).

4. Yeah, I think I now have evolved a few smartphrases to very clearly document why I did or did not initiate the sepsis bundle at the time of first contact. The sepsis pixie (the sepsis coordinator) at my shop has let me know that "it works; what you do", but I'm not sure that she remembers who I am or really cares. She strikes me as not too bright.

5. I'm with you 100% on this one. I guess I didn't include my smartphrases on this one because I felt that obvious MI was obvious.

Director says that this is not the first time it has happened, so although its far-out, it happens.

Yeah, I assumed you didn’t order the UA or get the results back prior to cath lab. I was mainly pointing out in jest as it seemed funny to me imagine waiting on a urine prior to cath. "Sorry Mr. Cardiologist, I know I activated the lab, but I have to make sure we follow the sepsis bundle or the sepsis fairy will send me a fallout letter." You were doing what you were supposed to be doing: diagnosing a STEMI, expediting care to the cath lab and correctly focusing on the immediate life threat. Whoever ordered the UA and diagnosed sepsis should be primarly responsible for compliance with the bundle. Occasionally there are cases where sepsis is completely missed in the ED. Your case doesn't sound like one of them.

Just for minor clarification for everyone, RR needs to be >20 to meet SIRS criteria. Also, as far as I'm aware an elevated troponin isn't one of the SEP-1 criteria for end organ damage even though clinically that makes complete sense.

Smartphrases are key to playing the game. I also built a smart phrase in Epic that we use to make sure we meet the documentation criteria. In case you want to see more of how the game is played, here is a PDF the abstractors utilize. The 210 pages though might just make you more upset at our system.

 

[RustedFox]

Yeah, I assumed you didn’t order the UA or get the results back prior to cath lab. I was mainly pointing out in jest as it seemed funny to me imagine waiting on a urine prior to cath. "Sorry Mr. Cardiologist, I know I activated the lab, but I have to make sure we follow the sepsis bundle or the sepsis fairy will send me a fallout letter." You were doing what you were supposed to be doing: diagnosing a STEMI, expediting care to the cath lab and correctly focusing on the immediate life threat. Whoever ordered the UA and diagnosed sepsis should be primarly responsible for compliance with the bundle. Occasionally there are cases where sepsis is completely missed in the ED. Your case doesn't sound like one of them.

Just for minor clarification for everyone, RR needs to be >20 to meet SIRS criteria. Also, as far as I'm aware an elevated troponin isn't one of the SEP-1 criteria for end organ damage even though clinically that makes complete sense.

Smartphrases are key to playing the game. I also built a smart phrase in Epic that we use to make sure we meet the documentation criteria. In case you want to see more of how the game is played, here is a PDF the abstractors utilize. The 210 pages though might just make you more upset at our system.

You're right about 20, but I'm almost certain that whoever programmed the local edition of MediSuck has 20 (not 21) as a criteria.

 

[pollyspockets]

If someone at CMS could get a rectal lobectomy and realize that 2 sirs + infection =\= sepsis, people without sirs can be septic, and lactic acid of 2.2 =\= severe sepsis, and lactic acid >4 =\= septic shock my life would drastically change. Think of all the carpal tunnel we’d be saving from onerous documentation. Has Anyone studied the cost of SEP – 3 to the healthcare system?

 

[hundreddaysoff]

If someone at CMS could get a rectal lobectomy and realize that 2 sirs + infection =\= sepsis, people without sirs can be septic, and lactic acid of 2.2 =\= severe sepsis, and lactic acid >4 =\= septic shock my life would drastically change. Think of all the carpal tunnel we’d be saving from onerous documentation. Has Anyone studied the cost of SEP – 3 to the healthcare system?

"It is difficult to get a man to understand something when his salary depends upon his not understanding it!" - Upton Sinclair, I, Candidate For Governor: And How I Got Licked, 1935

 

[TeddyBoomBoom]

So, you're missing one thing here (and this is the thing that really makes me mad)
Any abnormal vital sign + a bacterial infection later on discovered also counts as "sepsis present on admission" and will hose you.

I had a sepsis "fallout" for acute MI. How?

1. HR = 96 at triage.
2. EKG is a STEMI.
3. Gone to cath lab. No abx given.
4. Foley'd at some point.
5. UTI

IM ostrich writes *sepsis present upon admission*.

I'm hosed.

I just can’t. Too stupid. I think I’ve been protected bc I’m in an an sdg where I *assume* my md/amd have filtered out that bs….

I’m sure it’s taking time out of all of our lives, though….

 

[Mount Asclepius]

I think I’ve been protected bc I’m in an an sdg where I *assume* my md/amd have filtered out that bs….

This is key. In a good group/job you are protected from a lot of metric and patient complaint/satisfaction nonsense.

 

[wholeheartedly]

This seemed interesting along these lines.

Choosing Wisely to Preserve the Clinician Workforce

This Viewpoint discusses how to extend Choosing Wisely principles to identify clinical management practices that lead to unnecessary burdens, approaches to identify and prioritize those low-value practices, the partnerships needed to reduce burdens, and a research agenda for evaluating the...

jamanetwork.com

Also, I was at the IDWeek conference recently and IDSA and some good sepsis researchers are very strongly in your court trying to scrap or revamp these sepsis protocols. They’re just running into a brick wall so far but tryimg to come up with saner alternatives supported by solid data to suggest as a replacement.

Also, a group at Hopkins I belive and another company are making good headway on a better sepsis AI system that reduces false positives and doesn’t constantly alert physicians to bogus crap. It was a really interesting talk about all of the many many issues with EPICs AI and what they were doing differently. I’ll see if I can maybe dig that up.

 

[xaelia]

On this side of the planet, we've inherited the Sepsis Six from the NHS. It's basically designed for unsupervised trainees, because the response to potential severe sepsis is basically "give antibiotics, give 500mL fluid, notify someone with a brain."

We don't have any alerts because (lol) you can't get alerts when all the clinical documentation is on paper.

 

[RoyBasch]

We don't have any alerts because (lol) you can't get alerts when all the clinical documentation is on paper.

This is the real big brain solution.

 

[RustedFox]

On this side of the planet, we've inherited the Sepsis Six from the NHS. It's basically designed for unsupervised trainees, because the response to potential severe sepsis is basically "give antibiotics, give 500mL fluid, notify someone with a brain."

We don't have any alerts because (lol) you can't get alerts when all the clinical documentation is on paper.

What are the "Sepsis Six"?

 

[Dr Mantis Toboggan]

Doc Ock, Sandman, Electro, Mysterio, Kraven the Hunter, Vulture.

Oh wait that’s the Sinister 6.

 

[Janders]

What are the "Sepsis Six"?

(1) VoSyn, the big gun
(2) abNORMAL SALINE (magically shape-shifts to a 30mL/kg volume vis-a-vis the villain they are battling)
(3) Serial Lacate, i.e. “death by a million sticks”
(4) Organ Dysfunction, or as the others call him, ‘minimally elevated creatinine of unclear significance’
(5) Captain Vitale, (VitalE, like Linguini). His cape appears tactically improbable.
(6) The Clipboard. The only scary one of the bunch. Ringleader. Wanted for crimes against humanity on 8 continents.

 

[xaelia]

What are the "Sepsis Six"?

Here, Let Me Google That For You

Passive-aggressively teach your friends how to Google. For all those people who find it more convenient to ask you rather than search it themselves. Not associated with Google.

googlethatforyou.com

 

[RustedFox]

Here, Let Me Google That For You

Passive-aggressively teach your friends how to Google. For all those people who find it more convenient to ask you rather than search it themselves. Not associated with Google.

googlethatforyou.com

Yeah, I deserved that one.
Lol. Got me.

I thought maybe they were altogether different criteria which would (intuitively) require some degree of explanation; but really it comes down to the "Weingart LLS" score.