PWS Attachment D- Sample Instrument.docx

VHA CMS NATIONAL HOSPITAL INPATIENT QUALITY MEASURES

SEPSIS INSTRUMENT

Fourth Quarter, FY2024

Organizational Identifiers

VAMC

CONTROL

QIC

BEGDTE

REVDTE

Facility ID Control Number Abstractor ID Abstraction Begin Date Abstraction End Date Pre-fill QI pre-fill Auto-fill Auto-fill Auto-fill

Patient Identifiers

SSN

FIN

PTNAMEF

PTNAMEL

BIRTHDT

SEX

RACE

ETHNICITY

COHORT

AGE

PREGNANT

Patient SSN

FIN

First Name Last Name Birth Date Sex Race Ethnicity Cohort Age Pregnant Pre-fill: no change Pre-fill: no change Pre-fill: no change Pre-fill: no change Pre-fill: no change Pre-fill: no change Pre-fill: no change Pre-fill: can change Pre-fill: no change Calculate age at ADMDT QI pre-fill: no change

Administrative Data

1. Female

2. Male

3. Intersex

4. None of the Above, Other, or Unable to Determine

5. Preferred Not to Answer

Please note that the response values for this question differ from response values used in other instrument questions. For example, this question uses value 4 for none of the above, other, or unable to determine; other instrument questions may use value 99.

Selecting value “3”:

· Intersex is a general term used to refer to individuals born with, or who develop naturally in puberty, biological sex characteristics that are typically male or female.

Selecting value “4”:

· If the patient does not describe themselves as female, male, intersex, describes themselves in other terms, or if the medical record does not include information about the patient’s biological sex assigned at birth, select value 4.

· Consider the sex to be unable to be determined and select value 4 if there is contradictory documentation, or if the sex assigned at birth is not documented or not available.

Suggested Data Sources: Consultation Notes, Emergency Department Record, Face Sheet, History and Physical, Nursing Admission Notes, Progress Notes.

mm/dd/yyyy

Abstractor may enter 99/99/9999 if arrival date is unable to be determined

<= 6 months prior to or = admdt and < = dcdt

Arrival date is the EARLIEST recorded date on which the patient arrived in the hospital’s acute care setting. Acute care setting includes:

· Emergency Department

· Direct admission to cath lab, endoscopy or surgery

· Direct admission to observation

· Direct admission to a nursing floor ONLY ACCEPTABLE SOURCES: *Emergency Department record; nursing unit admission assessment/admitting note; observation record; procedure notes (such as cardiac cath, endoscopies, surgical procedures)

· Review the ONLY ACCEPTABLE SOURCES to determine the earliest date the patient arrived in the acute care setting.

Suggested Priority sources for patients who arrive in the ED:

1) ED Registration Date (found in Past Clinic Visits/CVP)

2) ED Progress Note - Triage Date, Arrival Date

3) ED Vital Signs, ECG date, Physician orders Suggested Priority sources for Non-ED Arrivals such as Direct Admit to inpatient unit or observation:

1) Nurse’s Admission Note/admission assessment

2) EADT Date Other Arrivals (transfers from other ED or hospital inpatient/ outpatient OR Direct Admit for procedure, e.g. cath lab)

1) If transferred from an ED or hospital within your hospital’s system and there is one medical record for the care provided at both facilities, use the arrival date at the first facility.

2) Use EARLIEST arrival date for procedure, e.g., cath lab, endoscopy, surgery Additional Guidelines for Abstraction

· Arrival date may differ from admission date. The intent is to utilize any documentation which reflects processes that occurred after arrival at the ED or after arrival to the nursing floor/observation/cath lab as a direct admit

· If the earliest date documented appears to be an obvious error, this date should not be abstracted.

Cont’d next page

Additional Guidelines cont’d Example: ED MAR has a med documented as 1430 on 11-03-20xx. All other dates in ED record are 12-03-20xx. The 11-03-20xx would not be used because it appears to be an obvious error.

· *The ED Record may include ED Face/Cover Sheet, Registration/sign-in forms, triage record, Consent/Authorization for treatment forms, vital sign record, physician orders, ECG reports, telemetry/rhythm strips, laboratory reports, x-ray reports, head CT scan, CTA, MRI, MRA reports If arrival date is unable to be determined from any of the ONLY ACCEPTABLE SOURCES, enter 99/99/9999.

Pre-filled: can be modified >= arrvdate and < = dcdt

Pre-filled; can be modified if abstractor determines that the date is incorrect.

· Admission date is the date the patient was actually admitted to acute inpatient care.

· For patients who are admitted to Observation status and subsequently admitted to acute inpatient care, abstract the date that the determination was made to admit to acute inpatient care and the order was written. Do not abstract the date that the patient was admitted to Observation.

· If there are multiple inpatient orders, use the order that most accurately reflects the date that the patient was admitted.

· The admission date should not be abstracted from the earliest admission order without regards to substantiating documentation. If documentation suggests that the earliest admission order does not reflect the date the patient was admitted to inpatient care, this date should not be used.

ONLY ALLOWABLE SOURCES: Physician orders (priority data source), face sheet Exclusion: admit to observation, arrival date

1. Yes

2. No 1,2

If 2, go to dcdate

Select “Yes” in the following types of transfers:

· Transferred from any emergency department (ED) or observation (OBS) unit OUTSIDE of your hospital: applies even if the ED or OBS unit is part of your hospital’s system (e.g., your hospital’s free-standing or satellite ED), has a shared medical record or provider number, or is in close proximity.

· Transferred from an outside hospital where he/she was an inpatient or outpatient (also applies same as above)

· Long term acute care (LTAC): Any LTAC hospital or unit (outside or inside your hospital)

· Acute rehabilitation: Rehab UNIT in OUTSIDE hospital; free-standing rehab hospital/facility/pavilion OUTSIDE your hospital; OR rehab HOSPITAL INSIDE your hospital

· Psychiatric: Psych UNIT in OUTSIDE hospital; free-standing psych hospital/facility/pavilion outside your hospital; OR psych HOSPITAL INSIDE your hospital

· Cath. lab, same day surgery, or other outpatient department of an outside hospital

· Disaster Medical Assistance Team (DMAT): Provides emergency medical assistance following catastrophic disaster or other major emergency Select “No” in the following types of transfers:

· Urgent care center

· Psych or rehab UNIT INSIDE your hospital

· Dialysis center (unless documented as an outpatient department of an outside hospital)

· Same Day Surgery or other outpatient department inside your hospital

· Clinic (outside or inside your hospital)

· Hospice facility (outside or inside your hospital)

· Assisted living facilities and nursing homes

· Skilled nursing facility (SNF) care: outside or inside your hospital providing SNF level of care to patient Cont’d next page

· Conflicting documentation and/or unable to determine type of transfer UNLESS there is supporting documentation for one setting over another Examples:

· One source reports patient was transferred from an outside hospital’s ED, another source reports patient was transferred in from an urgent care center. No additional documentation. Select “No.”

· One source states patient came from physician office, another source reports patient was transferred from an outside hospital’s ED, and transfer records from the outside hospital’s ED are included in the record. Select “Yes.”

· Cases other than conflicting documentation, and you are unable to determine type of transfer (e.g. “Transferred from ABC” documented and documentation is not clear whether ABC is a hospital or not.)

Suggested Data sources: Ambulance record, Any DMAT documentation, ED record, Face sheet, History and physical, Nursing admission assessment, progress notes, Transfer sheet

1. Inpatient Acute Care – Another VAMC

2. Inpatient Acute Care – Non-VHA facility

3. Outpatient/Emergency/Observation – Another VAMC

4. Outpatient/Emergency/Observation – Non-VHA facility

5. Ambulatory Surgery Center – Another VAMC

6. Ambulatory Surgery Center – Non-VHA facility

7. Long Term Acute Care Hospital (LTACH) – Another VAMC

8. Long Term Acute Care Hospital (LTACH) – Non-VHA facility

9. Acute Rehabilitation – Another VAMC

10. Acute Rehabilitation – Non-VHA facility

11. Other 1,2,3,4,5,6,7,8,9,10,11

If trnsfr = 1 and transfrloc <> 11, the case is excluded; else if 11, go to trnsfroth Review the transfer documentation and enter the type of facility from which the patient was transferred.

Acute Care Facilities include:

· Acute Short Term General and Critical Access Hospitals

· Cancer Hospitals

· Department of Defense and Veteran’s Administration Hospitals Outpatient/Emergency/Observation:

· Transferred from any emergency department (ED) or observation (OBS) unit OUTSIDE of your hospital: applies even if the ED or OBS unit is part of your hospital’s system at another location (e.g., your hospital’s free-standing or satellite ED), has a shared medical record or provider number, or is in close proximity.

Ambulatory Surgery Center: Cath. lab, same day surgery, or other outpatient department of an outside hospital Long Term Acute Care Hospital (LTACH): A LTACH is a facility that specializes in the treatment of patients with serious medical conditions that require care on an ongoing basis but no longer require intensive care or extensive diagnostic procedures. These patients typically require more care than they can receive in a rehabilitation center, skilled nursing facility, or at home. The LTACH must be an ACUTE care facility. Do not include Long Term Care facilities, Assisted Living facilities, or nursing homes.

Acute Rehabilitation: Inpatient Rehabilitation Facility/Hospital, Rehabilitation Unit of a Hospital, Chemical Dependency/Alcohol Rehabilitation Facility at another location.

Exclusion Statement: Documentation that the patient was transferred from an inpatient, outpatient or emergency/observation department of an outside hospital or an outside ambulatory surgery center excludes the case from the Sepsis measure.

Text box

If trnsfr = 1, go to end and the case is excluded.

Enter the type of facility from which the patient was transferred in the text box. Specify whether it was a VHA or non-VHA facility.

Exclusion Statement: Documentation that the patient was transferred from an inpatient, outpatient or emergency/observation department of an outside hospital or from an ambulatory surgery center excludes the case from the Sepsis measure.

Pre-filled: cannot be modified Pre-filled; cannot be modified The computer pre-fills the discharge date from the API-PM pull list. This date cannot be modified in order to ensure the selected episode of care is reviewed.

UMT

Pre-filled: cannot be modified Pre-filled; cannot be modified The computer Pre-fills the discharge time from the API-PM pull list. This time cannot be modified in order to ensure the selected episode of care is reviewed.

(3 alpha-numeric characters/decimal point/four alpha-numeric characters Pre-filled: can be modified Cannot enter 000.0000, 123.4567, or 999.9999

Will pre-fill from PTF with ability to change. Do NOT change the principal diagnosis code unless the principal diagnosis code documented in the record is not the code displayed in the software.

othrcode1 othrcode2 othrcode3 othrcode4 othrcode5 othrcode6 othrcode7 othrcode8 othrcode9 othrcode10 othrcode11 othrcode12 othrcode13 othrcode14 othrcode15 othrcode16 othrcode17 othrcode18 othrcode19 othrcode20 othrcode21 othrcode22 othrcode23 othrcode24 Enter the ICD-10-CM other diagnosis codes:

(3 alpha-numeric characters/decimal point/four alpha-numeric characters)

Pre-filled: cannot be modified

If enabled, can enter up to 24 codes

If enabled, abstractor can enter xxx.xxxx in code field if no other diagnosis codes found.

Will be pre-filled from PTF with up to 24 ICD-10-CM other diagnosis codes. Cannot be modified.

If no other diagnosis codes are received from PTF, abstractor is to verify codes documented in the record and enter. If no other diagnosis codes are found in the record, enter xxx.xxxx.

prinpx (code) prinpxdt (date) Enter the ICD-10-PCS principal procedure code and date the procedure was performed.

(Must be 7 alpha-numeric characters) Abstractor can enter xxxxxxx in code field and 99/99/9999 in date field if there is no principal procedure Cannot enter 0000000 mm/dd/yyyy Abstractor can enter 99/99/9999 If no principal procedure, auto-fill othrpx and othrpxdt with xxxxxxx and 99/99/9999 > = admdt and

Principal procedure= that procedure performed for definitive treatment, rather than for diagnostic or exploratory reasons, or was necessary to treat a complication. The principal procedure is related to the principal diagnosis and needs to be accurately identified.

· VA records do not identify the principal procedure; use the above definition of principal procedure to determine the correct code to enter if there are multiple procedures during the episode of care. Ask for assistance from your RM or Quality Insights if you are uncertain.

If no procedure was performed during the episode of care, fill ICD-10-PCS code field with default code xxxxxxx. Do not enter 9999999 or 0000000 to indicate no procedure was performed.

Date of the principal procedure is to be filled with 99/99/9999 if no procedure was performed.

If the principal procedure date is unable to be determined from the medical record documentation, or if the procedure date documented in the record is obviously in error (e.g. 02/42/20xx) and no other documentation is found that provides this information, enter 99/99/9999.

othrpx1 othrpx2 othrpx3 othrpx4 othrpx5

(codes) othrpxdt1 othrpxdt2 othrpxdt3 othrpxdt4 othrpxdt5

(dates) Enter the ICD-10-PCS other procedure codes and dates the procedures were performed.

(Must be 7 alpha-numeric characters) Abstractor can enter xxxxxxx in code field and 99/99/9999 in date field if no other procedure was performed mm/dd/yyyy Abstractor can enter 99/99/9999 > = admdt and

Can enter 5 codes and dates Can enter 5 procedure codes, other than the principal procedure code. Enter the ICD-10-PCS codes and dates corresponding to each of the procedures performed, beginning with the procedure performed most immediately following the admission.

· If no other procedures were performed, enter default code xxxxxxx in the code field and default date 99/99/9999 in the date field.

· If no other procedure was performed, it is only necessary to complete the xxxxxxx and 99/99/9999 default entries for the first code and date. It is not necessary to complete the default entry five times.

· If the date of a procedure is unable to be determined from the medical record documentation, or if the procedure date documented in the record is obviously in error (e.g. 02/42/20xx) and no other documentation is found that provides this information, enter 99/99/9999.

1. Home

· Assisted Living Facilities (ALFs) – includes assisted living care at nursing home/facility

· Court/Law Enforcement – includes detention facilities, jails, and prison

· Home – includes board and care, domiciliary, foster or residential care, group or personal care homes, retirement communities, and homeless shelters

· Home with Home Health Services

· Outpatient Services including outpatient procedures at another hospital, outpatient Chemical Dependency Programs and Partial Hospitalization

2. Hospice – Home (or other home setting as listed in #1 above)

3. Hospice – Health Care Facility

· General Inpatient and Respite, Residential and Skilled Facilities, and Other Health Care Facilities

4. Acute Care Facility

· Acute Short Term General and Critical Access Hospitals

· Cancer and Children’s Hospitals

· Department of Defense and Veteran’s Administration Hospitals

5. Other Health Care Facility

· Extended or Immediate Care Facility (ECF/ICF)

· Long Term Acute Care Hospital (LTACH)

· Nursing Home or Facility including Veteran’s Administration Nursing Facility

· Psychiatric Hospital or Psychiatric Unit of a Hospital

· Rehabilitation Facility including, but not limited to: Inpatient Rehabilitation Facility/Hospital, Rehabilitation Unit of a Hospital, Chemical Dependency/Alcohol Rehabilitation Facility Cont’d next page

· Skilled Nursing Facility (SNF), Sub-Acute Care or Swing Bed

· Transitional Care Unit (TCU)

· Veteran’s Home

6. Expired

7. Left Against Medical Advice/AMA

99. Not documented or unable to determine

· Only use documentation written on the day prior to discharge or the day of discharge when abstracting this data element. For example: Discharge planning notes on 04-01-20xx document the patient will be discharged back home. On 04-06-20xx, the nursing discharge notes on the day of discharge indicate the patient was being transferred back to skilled care. Enter “5”.

· Discharge disposition documentation in the discharge summary, a post-discharge addendum, or a late entry, may be considered if written within 30 days after discharge date and prior to the pull list date

· If there is documentation that further clarifies the level of care, that documentation should be used to determine the correct value to abstract. If documentation is contradictory, use the latest documentation. For example: Discharge planner note from day before discharge states “XYZ Nursing Home”. Nursing discharge note on day of discharge states “Discharged: Home.” Select value “1”.

· If the medical record states the patient is being discharged to assisted living care or an assisted living facility (ALF) and the documentation also includes nursing home, intermediate care or skilled nursing facility, select Value “1” (“Home”).

· If documentation is contradictory, and you are unable to determine the latest documentation, select the disposition ranked highest (top to bottom) in the following list.

o Acute Care Facility o Hospice – Health Care Facility o Hospice – Home o Other Health Care Facility o Home

· Values “2” and “3” hospice include discharges with hospice referrals and evaluations.

· If the medical record states only that the patient is being discharged to another hospital and does not reflect the level of care that the patient will be receiving, select “4”.

Cont’d next page

Discharge disposition cont’d

· If the medical record states the patient is being discharged to nursing home, intermediate care or skilled nursing facility without mention of assisted living care or assisted living facility (ALF), select Value “5” (“Other Health Care Facility”).

· If the medical record identifies the facility the patient is being discharged to by name only (e.g., Park Meadows) and does not reflect the type of facility of level of care, select “5”.

· Selection of option “7” (left AMA):

· Explicit “left against medical advice” documentation is not required (e.g., “Patient is refusing to stay for continued care”- select “7”). For the purposes of this data element, a signed AMA form is not required.

· If any source states the patient left against medical advice, select value “7”, regardless of whether the AMA documentation was written last.

· Documentation suggesting that the patient left before discharge instructions could be given without “left AMA” documentation does not count.

· Select value “99” or unable to determine if the medical record states only that the patient is being “discharged” and does not address the place or setting to which the patient was discharged.

Excluded Data Sources: Any documentation prior to the last two days of hospitalization, coding documents Suggested Data Sources: Discharge instruction sheet, discharge planning notes, discharge summary, nursing discharge notes, physician orders, progress notes, social service notes, transfer record

1. Yes

2. No 1,2 If 1, the case is excluded

ONLY ACCEPTABLE SOURCE: Signed consent form for clinical trial In order to answer “Yes”, BOTH of the following must be documented:

1. There must be a signed consent form for the clinical trial. For the purposes of abstraction, a clinical trial is defined as an experimental study in which research subjects are recruited and assigned a treatment/intervention and their outcomes are measured based on the intervention received. Treatments/interventions most of include use of drugs, surgical procedures, and devices. Often a control group is used to compare with the treatment/intervention. Allocation of different interventions to participants is usually randomized; AND

2. There must be documentation on the signed consent form that during this hospital stay the patient was enrolled in a clinical trial in which patients with sepsis/septic shock were being studied. Patients may be newly enrolled in a clinical trial during the hospital stay or enrolled in a clinical trial prior to arrival and continued active participation in that clinical trial during this hospital stay.

In the following situations, select "No":

1. There is a signed patient consent form for an observational study only. Observational studies are non-experimental and involve no intervention (e.g., registries). Individuals are observed (perhaps with lab draws, interviews, etc.), data is collected, and outcomes are tracked by investigators. Although observational studies may include the assessment of the effects of an intervention, the study participants are not allocated into intervention or control groups.

2. It is not clear whether the study described in the signed patient consent form is experimental or observational.

3. It is not clear which study population the clinical trial is enrolling. Assumptions should not be made if the study population is not specified.

Exclusion Statement: Documentation that the patient was enrolled in a clinical trial for sepsis, severe sepsis or septic shock treatment or intervention excludes the case from the Sepsis measure.

1. Yes

2. No, or unable to determine 1,2

If 2, auto-fill sepdt2 as 99/99/9999 and septm2 as 99:99 and go to shkpres

Presence of Severe Sepsis may be identified based upon clinical criteria or physician/APN/PA documentation of severe sepsis. For the purposes of this question, look for documentation of severe sepsis.

Acceptable Documentation:

· In order to select value “1”, documentation MUST say “severe sepsis”.

· Other Documentation Acceptable to Select value “1” (Yes):

· Documentation of severe sepsis within an order set, protocol, checklist, alert, screening tool, etc., if date and time is present and is the earliest date and time severe sepsis is recorded.

· Documentation of severe sepsis in pre-hospital records (e.g., ambulance records, nursing home records) that is considered part of the medical record.

· If there is more than one presentation of severe sepsis abstract only the first presentation.

· Documentation to Select value “2” (No)

· The title or heading of an order set, protocol, checklist, alert, screening tool, etc. reflecting physician/APN/PA severe sepsis

· Severe sepsis met by physician/APN/PA documentation only, and is documented as due to a viral, fungal, or parasitic infection

· Severe sepsis documented in a discharge note, discharge summary, or documented after the time of discharge.

· If at the same time or within six hours after physician/APN/PA documentation of severe sepsis there is additional physician/APN/PAdocumentation indicating:

· Patient is not septic

· Patient does not have sepsis or severe sepsis

· Patient does not have severe sepsis, and severe sepsis was not met by physician/APN/PA documentation that severe sepsis was present.

· Severe sepsis is due to a viral, fungal, or parasitic infection.

Cont’d next page

· For documentation of severe sepsis accompanied by a qualifier, use the table below.

· Select value “1” for documentation containing a positive qualifier.

· Select value “2” for documentation containing a negative qualifier OR documentation containing both a positive and negative qualifier.

Qualifiers list is not all inclusive.

Severe Sepsis Inclusion: PHYSICIAN/APN/PA DOCUMENTATION ONLY of severe sepsis Exclusions:

· Bacteremia

· Septicemia Suggested Data Sources: Any physician/APN/PA documentation

septm2

Enter the earliest date and time a physician/APN/PA documented the presence of severe sepsis.

<= dcdt/dctm

UMT

If physician/APN/PA documentation states severe sepsis was present on admission or indicates the patient was admitted with severe sepsis, use the earliest date of the physician/APN/PA documentation of severe sepsis based on the following criteria:

· For patients with multiple severe sepsis presentation dates and times, only abstract the earliest presentation date and time.

Example: Physician note states: “severe sepsis on admit.” Documentation includes Arrival time to unit 4/2/21 0344, Admit Order 4/2/21 0231, and physician note is dated and timed 4/2/21 0236. Use 4/2/21 0231 the physician admit order because documentation indicates the patient was admitted with severe sepsis and the admit order is the earliest date and time.

· If severe sepsis is documented in a physician/APN/PA note without a specific date or documented using the acronym POA (Present on Admission), the following apply:

· If it is the only documentation of severe sepsis in the note, use the date and time the note was started or opened.

· If a timestamp reflecting the note opened or started date and time is unavailable, use the following sources in priority order.

1. Provider patient care initiated date and time (e.g., Seen date and time, contact date and time, etc.)

2. Earliest date and time at the beginning of the note reflecting when the note was opened or started.

· If severe sepsis is documented multiple times within the same note, use the earliest specified date and time.

Severe Sepsis cont’d

· ED Patients: Use the earliest documented arrival date and time for patient who enter the ED with physician/APN/PA documentation of

· Severe sepsis clinical criteria met in pre-hospital records.

· severe sepsis in pre-hospital records.

· Severe sepsis was present on arrival.

· Severe sepsis was present with a documented presentation date/time that is prior to arrival.

· Direct Admit Patients: Use the earliest documented date and time patient arrives to floor or unit with physician/APN/PA documentation of severe sepsis in pre-hospital records or documentation that severe sepsis was present on admission

· If the only documentation of severe sepsis being present is in a physician/APN/PA note that severe sepsis was present on admission, use the earliest date and time of the following:

· Physician/APN/PA note

· Admit order

· Disposition to inpatient

· Arrival to floor or unit Suggested Data Sources: Any physician/APN/PA documentation

1. Yes

2. No, or unable to determine 1, 2

If 2, auto-fill shkdt as 99/99/9999 and shktm as 99:99 and go to covid

Presence of Septic Shock may be identified based upon clinical criteria or physician/APN/PA documentation of septic shock. For the purposes of this question, look for documentation of septic shock or severe sepsis with shock.

Acceptable Documentation:

· In order to select value “1”, documentation MUST say “septic shock” or “severe sepsis with shock.”

· Other Documentation Acceptable to Select value “1” (Yes):

· Documentation of septic shock within an order set, protocol, checklist, alert, screening tool, etc., if date and time is present and is the earliest date and time septic shock is recorded.

· Documentation in pre-hospital records (e.g., ambulance records, nursing home records) that is considered part of the medical record

· If there is more than one presentation of septic shock or severe sepsis with shock, abstract only the first presentation.

· Documentation to Select value “2” (No)

· The title or heading of an order set, protocol, checklist, alert, screening tool, etc. reflecting physician/APN/PA documentation of septic shock

· Septic shock met by physician/APN/PA documentation only, and is documented as due to a viral, fungal, or parasitic infection

· Septic shock documented in a discharge note, discharge summary, or documented after the time of discharge.

· If at the same time or within six hours after physician/APN/PA documentation of septic shock, there is additional physician/APN/PA documentation indicating:

· Patient is not septic

· Patient does not have septic shock or severe sepsis with shock

Cont’d next page

· Patient does not have septic shock, and septic shock was not met by physician/APN/PA documentation that septic shock was present.

· Septic shock is due to a viral, fungal, or parasitic infection.

· For documentation of septic shock accompanied by a qualifier, use the table below.

· Select value “1” for documentation containing a positive qualifier.

· Select value “2” for documentation containing a negative qualifier OR documentation containing both a positive and negative qualifier.

Qualifiers list is not all inclusive.

Septic Shock Inclusion: PHYSICIAN/APN/PA DOCUMENTATION ONLY of septic shock or severe sepsis with shock.

Exclusions:

· Bacteremia

· Septicemia Suggested Data Sources: Any physician/APN/PA documentation

shktm

If shkpres=1 AND shkdt/shktm – sepdt2/septm2 <= 6 hours, auto-fill sepshk = 1

If physician/APN/PA documentation states septic shock or severe sepsis with shock was present on admission, or indicates the patient was admitted with septic shock or severe sepsis with shock, use the earliest date of the physician/APN/PA documentation of septic shock or severe sepsis with shock based on the following criteria:

· For patients with multiple septic shock presentation dates and times, only abstract the earliest presentation date and time.

Example: Physician note states: “septic shock on admit.” Documentation includes Arrival time to unit 4/2/21 0344, Admit Order 4/2/21 0231, and physician note is dated and timed 4/2/21 0236. Use 4/2/21 0231 the physician admit order because documentation indicates the patient was admitted with septic shock and the admit order is the earliest date and time.

· If septic shock is documented in a physician/APN/PA note without a specific date or documented using the acronym POA (Present on Admission), the following apply:

· If it is the only documentation of septic shock in the note, use the date and time the note was started or opened.

· If a timestamp reflecting the note opened or started date and time is unavailable, use the following sources in priority order.

1. Provider patient care initiated date and time (e.g., Seen date and time, contact date and time, etc.)

2. Earliest date and time at the beginning of the note reflecting when the note was opened or started.

· If septic shock is documented multiple times within the same note, use the earliest specified date and time.

· ED Patients: Use the earliest documented arrival date and time for patient who enter the ED with physician/APN/PA documentation of:

· Septic shock clinical criteria met in pre-hospital reocrds.

· Septic shock in pre-hospital records.

· Septic shock was present on arrival.

· Septic shock was present with a documented presentation date/time that is prior to arrival.

Cont’d next page

Septic Shock date and time cont’d

· Direct Admit Patients: Use the earliest documented date and time patient arrives to floor or unit with physician/APN/PA documentation of septic shock in pre-hospital records or documentation that septic shock was present on admission

· If the only documentation of septic shock being present is in a physician/APN/PA note that septic shock was present on admission, use the earliest date and time of the following:

· Physician/APN/PA note

· Admit order

· Disposition to inpatient

· Arrival to floor or unit Suggested Data Sources: Any physician/APN/PA documentation

1. Yes

2. No

1,2 If 1, the case is excluded

· Physician/APN/PA documentation any time during the hospital stay that coronavirus or COVID-19 is suspected or present will exclude the case from the Sepsis Bundle measure.

· Select value "1" (Yes) for COVID-19 only if the physician/APN/PA documented the terms “possible” “probable” “likely” “suspected” “present” or “confirmed,” or synonomous with these terms in relation to COVID-19.

· Select value “2” (No):

· If the physician/APN/PA refers to a previous diagnosis of COVID-19 (e.g., “recent COVID-19” or “history of COVID-19”).

· For documentation that COVID-19 is suspected or present if there is physician/APN/PA documentation that coronavirus or COVID-19 is not suspected or present within six hours following the initial documentation that coronavirus or COVID-19 is suspected or present.

Example: ED MD note at 07:00: “suspect COVID-19 is cause of current respiratory symptoms.” Admitting MD note at 11:15: “possible pneumonia, COVID-19 test negative.” Select value 2 because there is subsequent physician documentation within 6 hours indicating COVID-19 is not present.

· If the physician/APN/PA only orders a COVID-19 test without documentation that COVID-19 is suspected, present, or confirmed, select value “2”.

Documentation that coronavirus or COVID-19 is possible, probable, likely, suspected, present, or confirmed will exclude the case from the Sepsis Bundle Measure.

· SEPINF, INFDT, INFTM

· SEPSIRS, SEPSIRSDT, SEPSIRSTM

· SEPORG, SEPORGDT, SEPORGTM

In order to establish the presence of severe sepsis by clinical criteria, all three clinical criteria (documentation of infection, two or more manifestations of systemic infection and at least one manifestation of organ dysfunction) must be met within six hours of each other. The three clinical criteria do not need to be documented in any particular order.

Documentation of conditions commonly associated with Severe Sepsis that are acceptable for infection. This is not all-inclusive.

infarcted/perforated bowel

1. Yes

2. No or unable to determine 1,2

If 2, go to sepsirs

The intent of this question is to determine if there is physician/APN/PA or nursing documentation of the presence of infection.

Documentation of an infection:

· Physician/APN/PA or nursing documentation referencing the presence of an infection (refer to table) is acceptable.

· If an antibiotic is ordered for a condition that may be inflammation or a sign or symptom of an infection this may be considered documentation of an infection (e.g., ceftriaxone ordered for colitis; Zosyn 3.375 g IV q6hr for cough).

· Documentation of infection within an order set, protocol, checklist, alert, screening tool, etc., if date and time are present and is the earliest date and time infection is recorded.

Exclusions: Documentation that is NOT acceptable for an infection.

· Do not use physician/APN/PA documentation of an initial infection if there is additional physician/APN/PA documentation within the following 6 hours indicating that the infection is not present or is due to a viral, fungal, or parasitic source.

Examples of Exclusions:

· ED physician/APN/PA documents rule out UTI and pneumonia at 0500. At 1000 hospitalist documents no infection present. Disregard ED physician/APN/PA documentation of rule out UTI and pneumonia.

· Colonization, positive screens, or positive cultures (e.g., MRSA, VRE, or for other bacteria) without physician/APN/PA documentation referencing an infection.

· ED APN Note at 1500 documents “Likely pneumonia.” Hospitalist Note at 1830: “CXR with PNA r/t influenza.” disregard the infection documentation of pneumonia at 1500 because of the physician documentation within six hours after 1500 attributing pneumonia to a viral infection.

· History of infection, recent infection, or recurrent infection that is not documented as a current or active infection.

· The title or heading of an order set, protocol, checklist, alert, screening tool, etc. reflecting infection.

· Orders for tests or screens without documentation of a suspected infection.

· Results of tests without documentation of a suspected infection (e.g., infiltrates on chest x-ray, positive cultures).

· Signs or symptoms of an infection without supportive documentation.

· Documentation of an infection only in a discharge note, discharge summary or documented after the time of discharge.

· For documentation of an infection accompanied by a qualifier, use the table below.

· Select Value “1” for documentation containing a positive qualifier.

· Select Value “2” for documentation containing a negative qualifier OR documentation containing both a positive and negative qualifier.

Qualifiers list is not all inclusive.

Concern for

Suggested Data Sources: Any physician/APN/PA documentation including ED record infdt inftm Enter the earliest date and time physician/APN/PA or nursing documentation of the presence of infection is found in the medical record.

< = sepdt2/septm2 (if valid date) or < = shkdt/shktm (if valid date)

· Enter the earliest date and time physician/APN/PA or nursing documentation of infection is found in the medical record.

· ED Patients: Use the earliest documented arrival date and time for patient who enter the ED with documentation of infection in pre-hospital records or documentation that infection was present on arrival.

· Direct Admit Patients: Use the earliest documented date and time the patient arrives to the floor or unit with documentation of infection in pre-hospital records or documentation that infection was present on arrival.

· If the only documentation of infection being present is in a physician/APN/PA or nursing note that infection was present on admission (POA), use the earliest date and time the note was started or opened:

· If a timestamp reflecting the note opened or started date is unavailable, use the following sources in priority order:

1. Provider Patient Care initiated date and time (e.g., Seen date/time, Contact date/time, etc.

2. Earliest date at the beginning of the note reflecting when the note was opened or started sepsirs1 sepsirsdt1 sepsirstm1 sepsirs2 sepsirsdt2 sepsirstm2 sepsirs3 sepsirsdt3 sepsirstm3 sepsirs4 sepsirsdt4 sepsirstm4

Is there documentation in the medical record of two (2) or more of the following manifestations (indications) of systemic infection:

For each manifestation found, enter the earliest date and time of documentation.

(If 1, enable date/time) Date

>= arrvdate and <= dcdt/dctm

Time

UMT

2. No □

4. White blood cell count >12,000 or <4,000 or >10% bands Enter Report Date/Time

1. Yes □ 2. No □

The intent of this question is to determine if there is documentation of two or more manifestations (indications) of systemic infection according to the Systemic Inflammatory Response Syndrome (SIRS) criteria, which are:

· Temperature >38.3 C or <36.0 C (>100.9 F or <96.8 F)

· Heart rate (pulse) >90

· Respiration >20 per minute

· White blood cell count >12,000 or <4,000 or >10% bands Date and Time: For each indication of systemic infection, enter the earliest date and time documentation of that manifestation (indication) was found in the medical record.

To determine the laboratory test value date and time for severe sepsis criteria, use the following sources in priority order.

· Primary source: Laboratory test value result released time from lab reports

· Supporting sources in priority order if primary source not available:

· Time within a narrative note that is directly associated with the laboratory test value

· Time the laboratory test value is documented in a non-narrative location (e.g., sepsis flow sheet)

· Laboratory test sample draw or collected time

· If any SIRS criteria are due to the following, the value should NOT be used. Inferences should not be made. The abnormal value or reference to the abnormal value must be in the same documentation (i.e., same sentence or paragraph).

· Normal for that patient (e.g. “History paroxysmal atrial fibrillation, pulse frequently > 90.”)

· Is due to a chronic condition

· Is due to a medication (e.g., “Respiratory rate increased after albuterol inhaler.”)

· If any SIRS criteria is due to an acute condition that has a non-infectious source/process, it should NOT be used. Example: “WBC < 4000 due to chemo.”

· If any SIRS criteria is due to the following, the criteria value should be used:

· Acute condition (“HR increased r/t acute heart failure.”) Cont’d next page

· Acute on chronic condition (“Respiratory rate increased r/t acute exacerbation COPD”)

· Infection (“Antibiotic order indication: cholecystitis.”)

· Physician/APN/PA documentation of a term that is defined by a SIRS criteria is acceptable in place of an abnormal value when the term is documented as normal for the patient, due to a chronic condition, a medication or an acute condition that has a non-infectious source/process.

· Examples include but not limited to:

· Tachypnea (Respiration > 20)

· Tachycardia (Heart Rate > 90)

· Leukopenia (WBC count < 4000)

· Leukocytosis (WBC count > 12,000)

· If there is conflicting documentation within the same physician/APN/PA documentation or within two or more separate pieces of physician/APN/PA documentation indicating SIRS criteria is normal for the patient, due to a chronic condition or medication AND due to or possibly due to an infection, severe sepsis, septic shock, or severe sepsis with shock, abstract the value based on the documentation closest to and before the Severe Sepsis Presentation Time.

· Examples:

· Vital Signs Flowsheet indicates elevated heart rate of 125, PA documentation “chronic A-Fib, rate controlled. The elevated heart rate of 125, would be used as SIRS criteria because the PA documentation does not include a term that defines elevated heart rate as being due to a chronic condition.

· SIRS criteria should NOT be used if:

· Obtained in OR, interventional radiology, during active delivery, during cardiopulmonary arrest (code) or during procedural/conscious sedation

· Due to artificial intervention, e.g. ventilator rate set at 24

· Documentation indicates value is invalid, erroneous or questionable within 24 hours after the Severe Sepsis Presentation Time Suggested Data Sources: Physician/APN/PA or nursing documentation, entire ED record, nurses notes, vital signs record or flow sheet seporg1 seporgdt1 seporgtm1 seporg2 seporgdt2 seporgtm2 seporg3 seporgdt3 seporgtm3 seporg4 seporgdt4 seporgtm4 seporg5 seporgdt5 seporgtm5 seporg6 seporgdt6 seporgtm6 seporg7 seporgdt7 seporgtm7 seporg8 seporgdt8 seporgtm8 seporg9 seporgdt9 seporgtm9

Is there documentation of organ dysfunction in the medical record?

Indicate all that apply:

For each option found, enter the earliest date and time of documentation.

(If 1, enable date/time) Date

>= arrvdate and <= dcdt/dctm

Time (UMT)

4. Creatinine > 2.0 (see D/D rules)

1. Yes □ 2. No □

6. Total bilirubin > 2 mg/dL (34.2 mmol/L)

1. Yes □ 2. No □

7. Platelet count < 100,000

1. Yes □ 2. No □

8. INR > 1.5 or aPTT > 60 seconds(see D/D rules)

1. Yes □ 2. No □

9. Lactate > 18.0 mg/dL (>2 mmol/L)

1. Yes □ 2. No □

The intent of this question is to determine if there is documentation of at least one manifestation of organ dysfunction.

Date and Time: For each indication of organ dysfunction, enter the earliest date and time documentation of that indication of organ dysfunction was found in the medical record.

Organ dysfunction may be evidenced by any one of the following:

Value “1” SBP < 90 or MAP <65

· Mean arterial pressure (MAP) is the average arterial pressure throughout one cardiac cycle, systole, and diastole. To perfuse vital organs requires the maintenance of a minimum MAP. There are methods to calculate, but ONLY accept actual documentation of MAP <65.

· Do not use hypotensive BPs documented from an orthostatic BP evaluation.

· Do not use hypotensive BPs documented during a dialysis procedure.

Value “2” SBP decrease of more than 40 mmHg:

· Physician/APN/PA documentation must be present in the medical record indicating a >40 mmHg decrease in SBP has occurred and is related to infection, severe sepsis, septic shock, or severe sepsis with shock and not to other causes.

Value “3” acute respiratory failure as evidenced by a new need for invasive or non-invasive mechanical ventilation:

· Documentation the patient is on mechanical ventilation.

· Invasive mechanical ventilation requires an endotracheal tube (ET) or tracheostomy tube.

· Non-invasive mechanical ventilation may be referred to as BiPAP, CPAP, or AVAPS.

· New need for mechanical ventilation indicates that either the patient had a new need for mechanical ventilation or the patient had an increased need from intermittent to continuous mechanical ventilation.

· Use the date/time mechanical ventilation was started or the date/time the mechanical ventilation changed from intermittent to continuous.

Cont’d next page Organ dysfunction cont’d

· For example, Intubation flowsheet documents ET placement at 08:00; respiratory flowsheet documents vent settings/alarms at 08:15; and respiratory therapist note at 08:40 documents “Patient intubated and placed on mechanical ventilation at 08:30;” enter 08:30 as mechanical ventilation start time.

Value “4” Creatinine > 2.0:

· If physician/APN/PA documentation before or within 24 hours following presentation of severe sepsis states the patient has end stage renal disease (ESRD) and is on hemodialysis or peritoneal dialysis, do not use any reported creatinine levels as signs of organ dysfunction. The same physician/APN/PA documentation does not need to include both. ESRD (on hemodialysis or peritoneal dialysis) and reference the creatinine levels.

· If there is physician/APN/PA documentation before or within 24 hours following presentation of severe sepsis of chronic renal disease (e.g., CKD I, II, or III, or “chronic renal insufficiency”) and the baseline creatinine is documented, use creatinine values elevated >0.5 above baseline as organ dysfunction (e.g., baseline 2.30, creatinine now 2.81).

Value “5” urine output <0.5 mL/kg/hour for two consecutive hours:

· Only use urine output as a sign of organ dysfunction if documentation clearly indicates that urine output is being monitored hourly to be able to use this as organ dysfunction.

Value “8” INR >1.5 or aPTT >60 sec:

· If the medical record documentation before an elevated INR or aPTT value shows the patient received an anticoagulant medication in Appendix C Table 5.3, do not use the elevated INR or aPTT level as organ dysfunction. Physician/APN/PA documentation is not required.

Examples:

· Home Medication Record documents Coumadin 2.5 QD; Last dose 2/19/2021 at 0800; Lab Report 2/19/2021 at 1400 documents INR this AM 2.5 Cont’d next page

INR cont’d Do not use the INR of 2.5 to establish organ dysfunction because the documentation demonstrates the patient received an anticoagulant before the elevated INR result.

· Lab report 1/12/21 1500 INR 2.5, medication administration record has Coumadin 2.5 QD…