News: Only 49% of hospitals comply with CMS’ sepsis bundle, data suggests

CDI Strategies - Volume 12, Issue 34

On average, more than half of hospitals fail to comply with the CMS sepsis treatment requirements, according to Modern Healthcare. Last week, CMS made the sepsis measure results public on Hospital Compare, and the data show that the national average compliance rate for the treatment measure was 49%.

Despite the low compliance percentage, it doesn’t necessarily mean that sepsis treatment is poor at hospitals, Modern Healthcare reported. Since the measure is a process measure, it doesn’t directly reflect outcomes for patients with sepsis. Plus, clinical nuance and trouble reporting the measure should be considered when looking at the data.

Since sepsis is a focus for many facilities, the low compliance rates may point to the elementary nature of its protocols, according to Modern Healthcare. For example, Rhode Island Hospital, according to the data, has a compliance rate of 21%, yet the hospital is deeply involved with the Surviving Sepsis Campaign and puts a focus on sepsis outcomes.

Documentation deficiencies may also be at play with the low compliance rates, Modern Healthcare reported. The measure must be manually entered by doctors within three-hour, and six-hour windows. If a physician documents too late, the coding professionals may be required to report that the measure wasn’t used.

While the data includes some unreliability, hospitals should still review it within context of their facility operations to identify areas for improvement.

Editor’s note: To read Modern Healthcare’s coverage of this story, click here. To visit the Hospital Compare website and download the data, click here. To read about the most recent Surviving Sepsis guidelines, click here. To download a tip card for sepsis documentation, click here. To download a presentation from the 2018 ACDIS Conference about sepsis, click here.

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