As Director of Quality at my hospital, Dr. Berg's comments make me feel stuck between a rock and a hard spot. Ignore a core measure? I agree with nearly every point made detailing the problems with the CMS core measure . . . from the definitions of severe sepsis and shock to blood cultures in all cases, to indiscriminate use of fluids, to reexaminations that require checking capillary refill in adults-these requirements are certainly not beyond controversy. The problem faced by my hospital-and I'm sure others-is that we devoted significant resources to ensure compliance. We've trained nurses to abstract data using a 60 page algorithm released by CMS and have considerable staff time tied up in data collection. We've logged countless IT hours to leverage the EMR to help us come into compliance. We've launched a massive education campaign trying to teach our staff and providers the nuances of the core measure. If we return to our more logical protocols for sepsis, we will look bad on HospitalCompare.gov. How will we know that sepsis wont become a major contributor to our Value Based Purchasing score and hurt us financially? How do we know that California wont adopt this as part of its 2020 Waiver in which we are paid for performance not service? If CMS listens to experts like Dr. Berg, how will I explain to staff and providers that we are reversing course (again)? How will we keep their trust when educating to new care protocols imposed by the government?
I have trouble giving 30cc/kg of fluid to a pt with CHF or renal failure and severe sepsis when they are not hypotensive (<65map). But maybe this is what the pt needs. I have yet to see flash pulmonary edema when I have followed the protocols, but I always worry... Any thoughts on judging the appropriated amount of fluids to give?
Rick - I can't predict the future, but you've cited a handful of the serious problems with this core measure. I totally understand your frustration; the measurement logic is tremendously labor-intensive. We all need to play along, for now, but I think we'll see this change in the new future.
Ryan - there are a bunch of different modifications to SIRS used in various sub-populations, but the specific elements that I reference come from SCCM in their original Stop Sepsis campaign. Scott Weingart has been recommending these for years, and many systems have followed suit.
Mark - in general, I think 30mL/kg or a similar volume of fluid (2-3L) is exactly what patients need. Occasionally we see patients who have concomitant pulmonary edema of hypervolemia, and then we need to exercise our judgment. In those with a history of ESRD of CHF, though, I would have no reservations about giving the fluid.
Best, Cameron Berg
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Rick R. - January 20, 2016 9:54 PM
As Director of Quality at my hospital, Dr. Berg's comments make me feel stuck between a rock and a hard spot. Ignore a core measure? I agree with nearly every point made detailing the problems with the CMS core measure . . . from the definitions of severe sepsis and shock to blood cultures in all cases, to indiscriminate use of fluids, to reexaminations that require checking capillary refill in adults-these requirements are certainly not beyond controversy. The problem faced by my hospital-and I'm sure others-is that we devoted significant resources to ensure compliance. We've trained nurses to abstract data using a 60 page algorithm released by CMS and have considerable staff time tied up in data collection. We've logged countless IT hours to leverage the EMR to help us come into compliance. We've launched a massive education campaign trying to teach our staff and providers the nuances of the core measure. If we return to our more logical protocols for sepsis, we will look bad on HospitalCompare.gov. How will we know that sepsis wont become a major contributor to our Value Based Purchasing score and hurt us financially? How do we know that California wont adopt this as part of its 2020 Waiver in which we are paid for performance not service? If CMS listens to experts like Dr. Berg, how will I explain to staff and providers that we are reversing course (again)? How will we keep their trust when educating to new care protocols imposed by the government?
Ryan D. - January 28, 2016 10:19 AM
Still having trouble finding articles related to modified sirs criteria. Can anyone give me a title or link? Thanks.
Mark W. - February 16, 2016 8:30 AM
I have trouble giving 30cc/kg of fluid to a pt with CHF or renal failure and severe sepsis when they are not hypotensive (<65map). But maybe this is what the pt needs. I have yet to see flash pulmonary edema when I have followed the protocols, but I always worry... Any thoughts on judging the appropriated amount of fluids to give?
cameron b. - February 19, 2016 9:46 PM
Hey everyone,
Great questions...
Rick - I can't predict the future, but you've cited a handful of the serious problems with this core measure. I totally understand your frustration; the measurement logic is tremendously labor-intensive. We all need to play along, for now, but I think we'll see this change in the new future.
Ryan - there are a bunch of different modifications to SIRS used in various sub-populations, but the specific elements that I reference come from SCCM in their original Stop Sepsis campaign. Scott Weingart has been recommending these for years, and many systems have followed suit.
Mark - in general, I think 30mL/kg or a similar volume of fluid (2-3L) is exactly what patients need. Occasionally we see patients who have concomitant pulmonary edema of hypervolemia, and then we need to exercise our judgment. In those with a history of ESRD of CHF, though, I would have no reservations about giving the fluid.
Best,
Cameron Berg