News: EHRs could help identify septic shock trends

Despite the fact that sepsis is one of the deadliest and costly medical conditions for hospitals, doctors frequently fail to properly document this immune system response to infection that kills more than 250,000 Americans each year, HealthData Management reported.

Tracking sepsis has traditionally been done using diagnosis codes. The lack of documentation in the electronic health record (EHR), however, makes it very difficult to paint an accurate picture of septic shock trends, Steven Simpson, MD, professor of medicine and interim director of the Division of Pulmonary and Critical Care Medicine at the University of Kansas, told HealthData Management.

As CDI specialists know, a coder cannot code a diagnosis unless the chart specifically documents that diagnosis. Therefore, if the physician does not document “septic shock” in the record, it could go unreported and untracked.

Recently, a study conducted published by CHEST Journal (the official publication of the American College of Chest Physicians) found that surveillance-based clinical data offered more reliable estimates of septic shock trends, compared with using coded records.

The study examined the annual septic shock incidence trends at 27 academic medical centers, focusing on hospitalizations of all adults from January 2005 through December 2014 with either a septic shock code or clinical criteria.

The CHEST study found that with clinical data, septic shock cases grew from 12.8 to 18.6 per 1,000 hospitalizations during the 10-year surveillance period, while mortality decreased from 54.9% to 50.7%. At the same time, the results from codes show a much larger jump, from 6.7 to 19.3 cases per 1,000 hospitalizations, while mortality dropped from 48.3% to 39.3%, HealthData Management reported.

“If you work in a hospital right now where you’re not seeing a rise in administrative claims for septic shock, you might be doing something wrong,” Simpson says. “If that’s not happening, you need to examine your system.”

Editor’s note: To read the complete coverage of the CHEST study by HealthData Management, click here. The full study published by CHEST can be found here.