Episode 20: Sepsis Core Measures

In our experience, the CMS (Centers for Medicare & Medicaid Services) core measures for sepsis have been misunderstood. I have personally heard multiple comments on how we have to give large amounts to fluids to all septic patients to stay in compliance. I have personally seen patients that are fluid overloaded because of these misunderstandings. In addition, these misunderstands have lead to hospitals reporting failures to CMS when in fact they have been compliant. For these reasons we decided to discuss the CMS core measures for sepsis.

We presented this at the 1st Annual Native American and Rural Emergency Medicine Conference that was held in Flagstaff, AZ in May 2019. We included the slides for a more in depth summary. Feel free to distribute these slides, but remember they are under the creative commons license and you must reference us if you use the slides.

I recommend that you think of the sepsis core measures in three distinct categories: sepsis, severe sepsis, and septic shock. I will discuss these 3 categories separately.

Sepsis: the core measures defines sepsis as having 2 SIRS criteria and a source of infection. The SIRS criteria are:

• Temp >38°C (100.4°F) or < 36°C (96.8°F)
• Heart rate > 90
• Respiratory rate > 20 or PaCO2 < 32mmhg
• WBC > 12,000/mm³, < 4,000/mm³, or > 10% bands

It is important to remember that the core measures do NOT apply to simple sepsis. Management of simple sepsis is based on your clinical judgement.

Severe Sepsis: the core measures define severe sepsis as sepsis with a lactic > 2 OR sepsis with evidence of end organ damage. Examples of end organ damage are as follows:

• Systolic blood pressure < 90 mmHg or MAP < 65 mmHg
• >40 mmHg decrease in SBP from baseline
• Acute respiratory failure
• Creatinine > 2.0
• Urine output < 0.5 mL/kg/hour for 2 hours
• Total bilirubin > 2 mg/dl
• Platelet count < 100,000
• INR > 1.5 or aPTT > 60 sec

It is important to remember that the end organ damage and SIRS criteria must be the result of the infection and not from a chronic condition or medication. For example, a patient on warfarin with an INR of 2 or a patient with chronic kidney disease with baseline creatinine of 3.0 cannot be used for evidence of end organ damage if documented as such by the provider.

Septic Shock: septic shock is defined as severe sepsis with a lactic acid >= 4.0 OR severe sepsis with persistent hypotension (SBP < 90 mmHg or MAP < 65 mmHg or >40 mmHg decrease in SBP from baseline). The core measures also state that if the provider states the patient has septic shock then the patient needs to meet the core measures for septic shock even if the patient doesn’t meet the above criteria.

Core Measures: patients with sepsis can be placed in one of the above 3 categories. It is important to remember that simple sepsis is not part of the core measures and therefore you can treat according to your clinical judgement. The core measures are as follows:

• Severe Sepsis (the following needs to be completed within 3 hours)
  
  • Measure serum lactate
  • Obtain blood cultures prior to antibiotics
  • Administer broad spectrum antibitoics
• Septic Shock (the following needs to be completed within 3 hours)
  • Complete the measures for severe sepsis
  • Resuscitate with 30 mL/kg crystalloid fluids
• The following needs to be completed within 6 hours after presentation
  • Repeat lactate if initial lactate was > 2
  • Repeat volume status and tissue perfusion assessment if septic shock
  • Vasopressor administration if hypotension persists after fluids

I would like to point out a few things that are commonly misunderstood about the above core measures. The 30 mL/kg bolus is only when the patient has septic shock. I cannot stress this point enough. If the patient doesn’t have septic shock, you can use fluids according to your clinical judgement and the 30 mL/kg bolus is not required!

I would also like to state that the repeat volume status and tissue perfusion assessment has multiple specific points that need to be met. However, the core measures state that if the provider charts “after fluid bolus I reassessed the fluid status” it is sufficient to meet the measure.

Lastly, in our hospital many providers had patient encounters that failed the core measures because they just didn’t chart appropriate. Please chart what you did and the timing. Also, chart when there is a reason you are not following the core measures as this often will help you stay in compliance with the measures.

For specific details on the acceptable exclusions and ways to improve your charting, please see the included slides and listen to the episode!

Episode 20: Sepsis Core Measures

Presentation Slides