Sepsis has been a hot topic for CDI specialists for years. Severe sepsis and septic shock bundles are being tracked and measured as part of the Inpatient Quality Reporting (IQR) program mandated by CMS. Therefore, the need for a clear identifications of these conditions is more important than ever. The 2016 Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) and development of the Sequential Organ Failure Assessment (SOFA) scale is the latest risk assessment for sepsis definitions.
Systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock were initially defined in 1991 by a consensus panel organized by the American College of Chest Physicians and the Society of Critical Care Medicine. The definitions were revisited in 2001 during the International Sepsis Definitions Conference, which included members from ACCP, SCCM, the American Thoracic Society, the European Society of Intensive Care Medicine, and the Surgical Infection Society. For simplicity, SIRS was defined by four variables: temperature, heart rate, respiratory rate and white blood cell count. However, SIRS can have many causes and was found to be overly sensitive in the definition for sepsis.
The proposed new 2016 definition of sepsis is considered “a life-threatening organ dysfunction caused by a dysregulated host response to infection”. This implies that the elements needed for the diagnosis are an infection that the physician suspects, associated with a dysregulated host response. This then leads to life-threatening organ dysfunction.
Sepsis-3 leaves clinicians with the challenge of determining whether a given patient is infected, and whether organ dysfunction is attributable to such infection. Often, these can be difficult determinations. It is also important to note that a source of infection is not identified in up to 50% of patients who present with sepsis, and a positive culture is not required to make a diagnosis of sepsis. The resultant development of the Sequential (Sepsis-Related) Organ Function Assessment (SOFA) scale assists to identify organ dysfunction and the seriousness of the infection. SOFA scoring utilizes criteria in evaluating respiratory function, coagulation, liver function, cardiovascular function, nervous system function (Glasgow Coma scale), and renal function. Also in use is a qSOFA (quick SOFA) which is a bedside prompt to help physicians identify patients at risk for sepsis. The qSOFA uses only three criteria in patients with a suspected infection: low blood pressure, high respiratory rates and altered mental status.
What does all this mean for the CDI professional? Actually nothing has really changed. A CDI professional has always had the role to ensure the documentation of sepsis is consistent, concise, and without conflicting documentation. For patients with chronic underlying conditions, CDI professionals can encourage physicians to document any deviations from baseline function in these body systems. Of importance would be to ensure documentation links the cause in any deviations from baseline system function, or new dysfunction, as being due to sepsis and not other conditions such as dehydration, cancer, or alcoholism. SIRS response to an infection may no longer be considered specific enough to define sepsis.
References: JAMA. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), 2016: 315(8): 801-810. Doi:10.1001/jama.2016.0287. https://www.ncbi.nlm.nih.gov/pubmed/26903338.
By Barb Brant, MPA RN CDIP CCDS CCS