cms sepsis abstraction guidelines

Although empiric combination antibiotics against gram-negative bacteria do not improve overall mortality, combination antibiotics are recommended for patients at high risk for multidrug-resistant organisms. The SEP-1 performance measure requires, among other critical interventions, timely administration of antibiotics to patients with sepsis or septic shock. Moreover, isotonic saline is associated with hyperchloremia and metabolic acidosis, and it can reduce renal cortical blood flow.4042. Septic shock involves relative vasopressin deficiency. March 1, 2021 Surveillance Strategies for Tracking Sepsis Incidence and Outcomes The Journal of Infectious Diseases July 21, 2020 Assessment of Health Care Exposures and Outcomes in Adult Patients With Sepsis and Septic Shock JAMA Network Open July 7, 2020 Sepsis Among Medicare Beneficiaries: 1. 2 Incorporate the "Surviving Sepsis Campaign" evidence-based guidelines, including the 3- S Hospital teams create their protocol from these tools, and are guided by the website in collecting data for measurement, assessment and aggregate analysis. Medial pivot total knee arthroplasty: Mid-term results. 4/12/2017 10:36:07 AM, is there an evaluation or assessment model or tool, Certified Professional in Patient Safety (CPPS). With this in mind, fluid resuscitation should be managed as follows during consecutive phases28: Rescue: During the initial minutes to hours, fluid boluses (a 1- to 2-L fluid bolus of crystalloid solution) are required to reverse hypoperfusion and shock, Optimization: During the second phase, the benefits of giving additional fluid to improve cardiac output and tissue perfusion should be weighed against potential harms27, Stabilization: During the third phase, usually 24 to 48 hours after the onset of septic shock, an attempt should be made to achieve a net-neutral or a slightly negative fluid balance, De-escalation: The fourth phase, marked by shock resolution and organ recovery, should trigger aggressive fluid removal strategies.27. These recommendations are based on our understanding of autoregulation of blood flow in the vascular beds of central organs (brain, heart, kidneys). To evaluate the current antibiotic tables specified for SEP-1 (Table 5.0: Monotherapy Antibiotics, Sepsis, Combination Antibiotic Therapy Table; Table 5.1: Antibiotic Generic/Trade Name Crosswalk, Sepsis), the MATS WG members were asked to complete a survey providing their approval or disapproval for each antibiotic listed in Table 5.0 and each antibiotic drug class combination listed in the Combination Antibiotic Therapy Table. Sepsis affects 750,000 patients each year in the United States and is the leading cause of death in critically ill patients, killing more than 210,000 people every year.1 About 15% of patients with sepsis go into septic shock, which accounts for about 10% of admissions to intensive care units (ICUs) and has a death rate of more than 50%. The data analyzed is the de-identified data the institution reported to CMS. The survey respondents cited a common concern of large amounts of antibiotic resistance as to why ampicillin-sulbactam, levofloxacin, and moxifloxacin were not approved. , Clinicians should move away from using static measures to assess volume status. Core Measures - CMS SE Home White blood cell count less than 4 109/L or greater than 12 109/L, or more than 10% bands. PDF Severe Sepsis and Septic Shock Management Bundle v5 Source control is imperative in managing sepsis and septic shock. Altered mental status (Glasgow Coma Scale score < 15). Cadena Defamatory View Full Measure Inventory Request An Account A second vasopressor is routinely added when norepinephrine doses exceed 40 or 50 g/min. Some have cautioned against giving too much fluid, especially in patients who have limited cardiorespiratory reserve.26 Overzealous fluid administration can result in pulmonary edema, hypoxemic respiratory failure, organ edema, intra-abdominal hypertension, prolonged ICU stay and time on mechanical ventilation, and even increased risk of death.26,27. After infusing large volumes of crystalloid fluids, albumin can be considered to improve blood pressure. Nonetheless, clinicians should practice extreme caution with etomidate use in septic shock (Table 3).73, Randomized controlled trials of corticosteroids in septic shock. We believe, however, that not all of the antibiotics outlined in SEP-1 (Table 5.0: Monotherapy Antibiotics, Sepsis, Combination Antibiotic Therapy Table; Table 5.1: Antibiotic Generic/Trade Name Crosswalk) are appropriate, and that the use of antibiotics outlined in the SEP-1 measure are not consistently in alignment with prudent antimicrobial stewardship. #0500 severe sepsis and septic shock: management bundle. Your comment will be reviewed and published at the journal's discretion. Respondents were also asked to provide suggestions for monotherapy antibiotics not listed in Table 5.0. Antibiotic-resistant infections have added to the challenges of optimally managing sepsis, causing 2 million illnesses and approximately 23000 deaths each year, in the United States [2]. doi: 10.1001/jamanetworkopen.2021.38596. Dragan Clinician reviewers underwent one hour of training on SEP-1 abstraction by the lead investigator (C.R.) , Albumin has no clear benefits over balanced crystalloids and is more expensive. The initial antimicrobial drugs should be broad-spectrum, covering all likely pathogens. Adding vasopressin as a replacement hormone has been shown to have a sparing effect on norepinephrine, resulting in a lower dose needed. Search for other works by this author on: Critical Care Center, Emory University School of Medicine, Department of Emergency Medicine, University of Tennessee College of Medicine, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Correspondence: T. J. Kim, Quality Improvement, Infectious Diseases Society of America, 1300 Wilson Blvd, Ste 300, Arlington, VA 22209 (, Torio C, Moore B. One can consider using albumin in sepsis if a significant amount of resuscitative fluid is required to restore intravascular volume.17 But comparisons of crystalloids and albumin, either for resuscitation or as a means to increase serum albumin in critically ill patients, have found no benefit in terms of morbidity or mortality.4345 When considering albumin to treat sepsis or septic shock, clinicians should remember its lack of benefit and its substantial cost20 to 100 times as much as crystalloids, with an additional cost greater than $30,000 per case with use of albumin.46, Hydroxyethyl starch, another colloid, was associated with a higher mortality rate and a higher incidence of renal failure in septic patients and should not be used for resuscitation (Table 1).47, Randomized controlled trials of volume replacement in sepsis and septic shock. Technical Resources & Guidelines; I Survived Sepsis. A higher goal of 80 to 85 mm Hg may help patients with chronic hypertension,49 while a lower target may be better tolerated in patients with reduced systolic function, older patients, and patients with end-stage liver disease. Comparison of Modification of Antibiotic Tables for Severe Sepsis and Septic Shock: Management Bundle (SEP-1) Workgroup Recommendation to Antibiotic Specifications for Table 5.0: Monotherapy Antibiotics, Sepsis Version 5.1, Comparison of Modification of Antibiotic Tables for Severe Sepsis and Septic Shock: Management Bundle (SEP-1) Workgroup Recommendation to Antibiotic Specifications for Combination Antibiotic Therapy Table Version 5.1. , One problem is that it relies on the clinicians ability to identify infection as the cause of organ dysfunction, which may not be apparent early on, making it less sensitive than SIRS for diagnosing early sepsis.10 Also, preexisting chronic diseases may influence accurate qSOFA and SOFA measurement.11 In addition, qSOFA has only been validated outside the ICU, with limited utility in patients already admitted to an ICU.12, Studies have suggested that the SIRS criteria be used to detect sepsis, while qSOFA should be used only as a triaging tool.11,13, Delay in giving appropriate antibiotics is associated with a significant increase in mortality rate.1416 Appropriate antimicrobials should be initiated within the first hour of recognizing sepsis, after obtaining relevant samples for cultureprovided that doing so does not significantly delay antibiotic administration.17. The instructions and . Centers for Medicare & Medicaid Services (CMS) IMPAQ International, LLC Page 1 Summary of Sepsis TEP Evaluation of Measures 5/25/2021 The materials presented in this document do not represent final measure specifications for the Sepsis outcome measure . Central venous oxygen saturation-guided resuscitation (requiring central vascular access) does not offer any advantage over lactate-guided resuscitation.38 Microvascular assessment devices are promising tools to guide resuscitation, but their use is still limited to clinical research. The networks are engaged and enthusiastic. J Hosp Med. , , This series is coordinated by Michael J. Arnold, MD, contributing editor. The initial antibiotic should be broad-spectrum, based on local sensitivity patterns, with daily assessment of appropriate antibiotic de-escalation and cessation. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. This site is best viewed with Internet Explorer version 8 or greater. We also recognize the difficult situation CMS must address to decrease the high mortality rate and costs associated with sepsis. CI Addressing this gap, the Severe Sepsis Bundles require that every single step be completed for every severely septic patient. For more information, the CMIT User Guide contains details concerning the use of the system. 2016. Measure submission and evaluation worksheet 5.0. . Consistent with the guidelines of the Surviving Sepsis Campaign, this composite measure evaluates the processes associated with high-quality care for patients with severe sepsis or septic shock. , It has potent alpha-and beta-adrenergic activity, which increases mean arterial pressure by increasing cardiac output and vasomotor tone. Y 1 , According to CMS, " The purpose of the Severe Sepsis and Septic Shock Early Management Bundle measure is to facilitate the efficient, effective, and timely delivery of high quality sepsis care in support of the Institute of Medicine's aims for quality improvement. data element, an IV or IO antibiotic must be administered In recent projects where they have been applied, patients with severe sepsis are staying alive, increasingly spared the most harmful consequences of the disease. Task force of the European Society of Intensive Care Medicine, Evaluation of pulse pressure variation validity criteria in critically ill patients: a prospective observational multicentre point-prevalence study, Predicting fluid responsiveness by passive leg raising: a systematic review and meta-analysis of 23 clinical trials, Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial, Lactate measurements in sepsis-induced tissue hypoperfusion: results from the Surviving Sepsis Campaign database, Emergency Medicine Shock Research Network (EMShockNet) Investigators, Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial, Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28-day mortality among patients with septic shock: The ANDROMEDA-SHOCK Randomized Clinical Trial, SMART Investigators and the Pragmatic Critical Care Research Group, Balanced crystalloids versus saline in critically ill adults, Effect of a buffered crystalloid solution vs saline on acute kidney injury among patients in the intensive care unit: the SPLIT Randomized Clinical Trial, Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation, A comparison of albumin and saline for fluid resuscitation in the intensive care unit, The clinical use of albumin: the point of view of a specialist in intensive care, Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial, Albumin versus other fluids for fluid resuscitation in patients with sepsis: a meta-analysis, Hydroxyethyl starch 130/0.42 versus Ringers acetate in severe sepsis, Source control in the management of sepsis, High versus low blood-pressure target in patients with septic shock, Optimizing mean arterial pressure in septic shock: a critical reappraisal of the literature, Comparison of dopamine and norepinephrine in the treatment of shock, Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis, Vasopressors for the treatment of septic shock: systematic review and meta-analysis, Current use of vasopressors in septic shock, Effect of early vasopressin vs norepinephrine on kidney failure in patients with septic shock: the VANISH Randomized Clinical Trial, Vasopressin versus norepinephrine infusion in patients with septic shock, Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. , Fact sheets, brochures, and posters for patients, Fact sheets, infographics, and brochures for healthcare professionals, Sample social media messages, news releases, drop-in articles, and more, Brochures and fact sheets for Spanish speakers. Manageiro While this exception is necessary and does not penalize hospitals or physicians for administering an antibiotic not listed in the SEP-1 antibiotic tables, further effort is needed to promote the practice of antimicrobial stewardship to combat the growing issues of antibiotic resistance, adverse drug events, and increased risk for C. difficile infections. In January 2013, the State of New York mandated that all state hospitals initiate processes for early detection and treatment of sepsis. et al. Singer et al8 compared SOFA and SIRS and identified 3 independent predictors of organ dysfunction associated with poor outcomes in sepsis to create the simplified qSOFA: Respiratory rate at least 22 breaths/minute, Systolic blood pressure 100 mm Hg or lower. In three to four months, says Levy, we should have 30 to 50 hospitals collecting data on the sepsis bundles.Given such progress, says Levy:Our expectation that this would become a global effort at improving sepsis care and reducing mortality rates is in fact becoming a reality., Townsend is equally optimistic about reaching the implementation phase of the Surviving Sepsis Campaign:The resources are there, the measures have matured and are ready to deploy. They introduced the Surviving Sepsis Campaign at a series of international critical care medicine conferences in 2004, setting in motion an unprecedented process of global collaboration among three leading professional organizations in the field of sepsis: Levys SCCM, the European Society of Intensive Care Medicine, and the International Sepsis Forum. During resuscitation, a goal mean arterial pressure of 65 mm Hg is preferred, using norepinephrine (with vasopressin if needed) to achieve it. IO. . . Last, the macrolide antibiotic telithromycin (Ketek), specified in Table 5.1 for SEP-1, has been discontinued due to business reasons [22]. 2021;4 (12):e2138596. Sepsis can arise from infections as common as a urinary tract infection, a skin infection, appendicitis, or a dental abscess. Levofloxacin has been shown to be efficacious against many pathogens, namely, pneumonia caused by the Haemophilus species [14]; however, levofloxacin resistance has been observed in Haemophilus influenzae [15, 16], Pseudomonas aeruginosa, and E. coli [17]. et al. , They are principles key to transforming health care: teamwork and adherence to standards. Matthaiou Educational Materials |Sepsis | CDC . 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