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While sepsis continues its role as a scourge of humanity, the Centers for Medicare and Medicaid Services have changed the definition. What does this mean for you? Dr. Cam Berg breaks it down.
Great Discussion! Thank you very much for the overview. I agree that taking physician judgement out of the picture of treating septic patients is ridiculous and making guidelines that are not based on evidence is even more outrageous. I fully support the idea of starting a petition to change this and know about 100 other docs at my hospitial who are equally outraged by this that would be willing to sign!
Thanks again for all your help and hard work!!
Thanks, Jennifer! Anyone else interested in organizing?
Thanks for the great discussion of the sepsis core measure!
We have been using the CMS definitions for sepsis for the last five years in the DSRIP program for California public hospitals and have struggled with defining the care and abstracting the data. A few of the challenges:
1) Determining whether an undifferentiated ER patient has severe sepsis is difficult, yet our care is judged as though an elevated lactate is always from sepsis. Pancreatitis, trauma, heart failure exacerbations all trigger positive screens, often with lactates > 2.
2) Blood cultures for every septic patient with a lactate > 2 doesn't make sense. Our most common episode of bundle noncompliance is acute appendicitis because we don't draw blood cultures prior to perioperative antibiotics.
3) Giving the fluid bolus every time makes our providers nervous and at times noncompliant. A 30ml/kg fluid challenge for lactate > 4mmol/L is required without regard for bedside assessment of volume status, which, as you mentioned in the podcast, doesn't makes sense to our providers.
4) Assessing for compliance with pressors is difficult. What if there is a transient drop in BP after the fluid bolus? What if it happens 30 minutes after bolus completion? 120 minutes after bolus completion? What if it responds to a second fluid bolus?
Thanks for starting this important conversation. We're behind you in ensuring that our national efforts to improve the quality of care don't impede our ability to provide the highest quality of care to our patients.
This is amazing information! It's absolutely crazy that we're expecting ED providers to obtain blood cultures for patients with appendicitis (not to mention pyelo, cellulitis, pneumonia, etc.). Thanks for the feedback.
Any chance of a nice algorithm or written brief?
Clarification to your comment - looks like chronic illness should NOT be used to define severe sepsis
This should get more attention. I spent a long time looking to find this.
i have one that i put together. send me an email: email@example.com
I think the ultimate chance for harm will come from people receiving vasopressors for low BP after 30ml/kg fluid challenge.This is the an easy "fail" by the CMS standard if they don't get started on pressors after a single fluid challenge. Especially bad potential outcomes if they are getting a central line.
I would definitely sign a petition.
Thanks for finding that clarification, Shawn.
CMS is an enigma. In the words of Butch Cassidy and the Sundance kid, "who are these guys"? Seriously, who are they-what are their names, what is their reasoning or evidence, and how are they qualified to make brobdignagian dicti to which we all need adhere? Can one of them go public and talk to us about their reasoning?
Scott....All Doctors are equal, except some are more equal than others. Lest this be mistaken for a political belief, I want to make it clear that this is a reflection that CMS is a grotesquely surreal as anything out of "Animal Farm."
For the modified SIRS criteria to use in triage you mentioned in your talk a few months ago, where were those derived from? Is there literature support for using just vital sign parameters to identify SIRS?
I know I'm in the minority, but I feel as if the benefits of mandating a large fluid bolus might outweigh the harms to patients. During my ICU rotation, I saw some physicians severely under-resuscitate patients in septic shock because of fear of pulmonary edema. They would completely skip crystalloid and go straight to pressers, TLC, and in some instances furosemide (depending on the CVP). Obviously, the management of septic shock by an experienced and evidence based physician will outperform these non-individualized CMS measures, but I think this idealism might be ignoring the unfortunate reality that many doctors are much less adept at critical care than they think they are.
What you do matters.