Getting Sepsis Right

1. Getting Sepsis Right

2. Sepsis • Affects > 1 million Americans/year • 3rd leading cause of death in U.S.- kills 258,000 Americans/year, more than breast, prostate and lung cancer combined • > 700 people die each day from sepsis in U.S. • Occurs in only 10% of U.S. hospital patients but contributes to as many as 50% of all hospital deaths • U.S. spends $24 billion/year to treat sepsis • Only 10-30% of septic patients worldwide receive “excellent care”

3. Sepsis • 80% of cases in hospitalized patients develop sepsis prior to admission • 70% had recently used health services • Post-op patients are 10 times more likely to die of sepsis than PE or MI • Risk factors for post-op sepsis- age > 60, emergency surgery, co-morbidities (cancer, diabetes, hypertension, obesity) and having a co-morbidity increases risk 6X

4. Sepsis • Most common cause of readmissions • Hospitals have difficulty diagnosing in a timely fashion, leading to treatment delays and poor outcomes • Lack of definitive test for sepsis(unlike MI, stroke)

5. Sepsis definitions

9. The Old Sepsis Definition (Sepsis-1) Documented or suspected infection AND two or more of these SIRS criteria: Temperature > 100.4O or < 96.8O F. Pulse > 90 Respirations > 20 WBCs > 12,000 or < 4000/mm3

12. Other Old Related Definitions (Sepsis-1) Severe sepsis: sepsis-induced tissue hypoperfusion or organ dysfunction Septic shock: Hypotension that persists despite adequate fluid resuscitation

13. ACCP/SCCM Consensus Conference1991 (Sepsis-1) Sepsis = Infection + two or more SIRS criteria Severe Sepsis = Sepsis + Organ dysfunction or hypo-perfusion Septic Shock = Severe sepsis with persistent hypotension despite adequate fluids

14. In 2001, more detailed categories added to help clinicians recognize sepsis (Sepsis-2) Levy MM, Fink MP, Marshall JC, et al. 2001CCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.Crit Care Med 2003;31:1250-6.

15. 2016 Sepsis-3 REDUNDANT RETIRED

18. “Third International Consensus Definitions For Sepsis and Septic Shock (Sepsis-3) • Published in February 23, 2016 issue of JAMA Society of Critical Care Medicine and European Society of Intensive Care Medicine "Limitations of the previous definition in 2001 included an excessive focus on inflammation, the misleading model that sepsis follows a continuum through severe sepsis to shock, and inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria. Multiple definitions and terminologies are currently in use for sepsis, septic shock, and organ dysfunction, leading to discrepancies in reported incidence and observed mortality.“ Severe sepsis is now a redundant term

28. Treatment Guidelines

33. APACHE* versus SOFA scores APACHE is severity score and mortality estimation tool specific to ICU patients with multiple disease states; uses worst values within first 24 hours of admission SOFA is also predictive score; ongoing, specific to sepsis and uses values from first 24 hours and every 48 hours thereafter while patient is in ICU * Acute Physiologic And Chronic Health Evaluation

34. SOFA and qSOFA • SOFA clearly requires laboratory tests and data that may not yet be available • The task force recommends clinicians use a streamlined process called quick SOFA(qSOFA) to evaluate patients outside the ICU • Altered mental status • Systolic BP < 100 mm Hg • Respirations 22 or > • If a patient meets any 2 of the qSOFA criteria the guidelines recommend the patient be closely monitored, given more intensive treatment as needed and possibly transferred to the ICU

36. IF YOU THINK THE PROBLEMS WE CREATE ARE BAD, JUST WAIT UNTIL YOU SEE OUR SOLUTIONS.

37. CMS Sepsis Core Measure

44. Caveats for CDI/Coding- The Past • CDI versus coding wars. • Physicians often waited until patient was very ill to call the condition sepsis. • Some hospitals convinced physicians to document SIRS-positive patients as septic even though they were only in a rule-out phase. Many of those patients ended up not having sepsis but were coded as sepsis anyway even in physician indicates “rule out sepsis” in discharge summary.

45. Caveats for CDI/Coding-The Present • If physicians write sepsis in the chart now using the new definition, it will correspond with the old definition's state of severe sepsis. • Some coders may not code severe sepsis unless the physician explicitly writes 'severe.' This may lead to discrepancies in coding practice. • The SIRS criteria came out about 15 years ago, and even today CDI specialists query providers regarding SIRS. SIRS has fairly easy to remember criteria versus those of SOFA, which has six different criteria with scores ranging from 0 to 4.

46. Caveats for CDI/Coding-The Future • As more physicians embrace the new criteria, the effect on coding will be fewer reported cases of sepsis, but a greater percentage of those will be reported as severe sepsis. Hospital administrators will need to be aware that a shift in severity of illness or case mix index data may correspond to the new sepsis definition rather than to coding errors. • Now, some physicians will embrace the sepsis-3 definition while others will continue their pattern of diagnosis based on the sepsis-2 definition. Furthermore, since there will be inconsistencies in coding, that will cause billing and reporting problems. It will be difficult to compare sepsis rates from hospital to hospital and over time until there is uniformity across the country.

47. Caveats for CDI/Coding-The Future • Once new updated guidelines from CMS are provided and implemented, CDI and coding will need to be educated on what those new rules and regulations are. Query questions will need to be updated based on those guidelines as will physicians. • Hospitals will need to set a standard for validating sepsis, determine a start date to adopt the new definitions, ascertain how documentation flow will evolve and work collaboratively among physician leadership, the CDI team, and HIM to develop facility-specific definitions and establish an in-house query policy for sepsis.

48. Caveats for CDI/Coding • Inpatient quality reporting must follow specifications and guidelines for each quality measure based on predetermined bundles. If the new definition is what everyone is reporting, then quality measures and reporting will have to adjust as well. Guidance is needed from those quality programs. Abstractors will need to know what sepsis criteria to follow when reviewing documentation on hospital adherence to these measures. • The National Quality Forum measure is very clear: Hospitals will still have to expend energy according to the sepsis-2 definition and report to CMS. What will change is increased confusion for hospitals that grapple with two definitions. Physicians may use the new definitions, but the hospitals will use the old ones to report to CMS. They will have to go back to physicians to query what they meant in the record, which will be onerous and challenging for some facilities.

49. Caveats for CDI/Coding • Sepsis-3 states that patients with an infection meeting their sepsis criteria should be coded as R65.20 (severe sepsis) but this is impossible since this code in ICD-10-CM can only be assigned if physician documents “severe sepsis” not sepsis alone or if documents that acute organ dysfunction is associated with sepsis • ICD-10-CM still has multitude of codes for sepsis without organ dysfunction (A40-A41) • Must code what physician documents regardless of clinical criteria used to arrive at that diagnosis

50. Caveats for CDI/Coding • For severe sepsis, “use additional code to identify specific acute organ dysfunction”; however, if no organ dysfunction is documented or coded, RAC may say severe sepsis code is invalid • Any coding of R65.20 or R65.21 subjects record to sepsis core measure eligibility • New 2016 definitions do not currently align with CMS sepsis core measure and unknown when this will occur • SIRS due to infection was built into ICD-9 in 2001 but can’t be coded as sepsis in ICD-10-CM • Continue to code sepsis, severe sepsis and septic shock using most current version of ICD-10-CM