Note from the Instructor: Sepsis—stop looking at it as just one set of criteria
By Allen Frady, RN-BSN, CCDS, CCS, CRC
You hear it all the time: “We only use SIRS,” “I like sepsis-3 because that’s the way I learned it medical school,” “one of our commercial insurance companies only pays for sepsis-3,” “CMS tells us to use sep-1”. For some unexplainable reason, we appear to be in a battle of Tolkien proportions to discover the one sepsis to rule them all.
But, has it occurred to anyone that all three versions of sepsis have their place, each with its own merits and pitfalls. A truly astute physician would choose whatever clinical criteria best fit the presentation and the patient’s unique clinical scenario. What works for an immunocompromised 5-year-old may not be the best indicators for a healthy 25-year-old Olympic athlete. Patients come in all shapes, sizes, ages, and pre-existing disease states. A patient’s body does not review the cookie-cutter criteria prior to selecting how to respond to an infection or insult.
Let’s take a moment to review some of the benefits and drawbacks of each set of sepsis criteria.
Systemic Inflammatory Response Syndrome (SIRS) is perhaps still to this day the best early screening criteria for sepsis. It should, however, be looked at as just that: a screening test. I do not believe that the manifestations contained within SIRS should always be the only confirmatory evidence of sepsis. It’s completely appropriate that sepsis protocols be started based on positive findings of two or more SIRS criteria in the presence of infection. It is not, however, a requirement that sepsis must remain the diagnosis copied and pasted through the record after sepsis has apparently been ruled out.
Once you get past the initial bloodwork of the white blood cell count and lactate level, you start getting into the organ function assessment. Sepsis 2, which is not commonly discussed, is probably the most comprehensive sepsis workup you can give a patient. While it is hard to find a clear definition of sepsis 2, it’s generally accepted that sepsis-2 equals some SIRS criteria combined with findings from what is known as multi-organ dysfunction syndrome (MODS). Using this type of assessment, a patient with a known or suspected infection, one or more positive SIRS findings, and some level of organ dysfunction (if it’s thought to be subsequent to the infection) could be suspected of having sepsis.
Unfortunately, in a cost-conscious world, we won’t be ordering full screening bloodwork from head to toe on every patient with a suspected severe reaction to infection. Nonetheless, the evidence may still present itself in the course of the normal diagnostic workup and blood tests. This is a perfectly valid and acceptable way of diagnosing sepsis.
Of course, there are some situations (such as dealing with children’s illnesses) where spending efficiency will take a backseat to the patient’s safety and health. In such a circumstances, I would prefer my physician use this form of a sepsis workup (sepsis-2) to make sure no stone is left unturned. Unfortunately, medicine is an inexact science, requiring the use of predictions and probabilities: enter sepsis-3.
Sepsis-3 attempts to take all of the possible organ dysfunctions and select only the most statistically relevant. What we ended up with was the sequential organ failure assessment (SOFA) scoring table. The six particular body systems included in the assessment are thought to be, by at least some studies, the most statistically significant data points for predicting outcomes with regard to sepsis and mortality.
Since sepsis-3 requires a patient response beyond an inflammatory response, many more traditional physicians have embraced the idea that sepsis should be reserved for the more severe patients. CMS response to this, however, was that delaying identification could potentially delay the start of treatment and lead to undesirable outcomes.
We know that early treatment saves lives, prevents complication, and saves organs. So we now have the quick sepsis related organ failure assessment (qSOFA), which adds altered mental status and the labile blood pressure to our tool kit previously occupied by SIRS criteria. (I didn’t mention respiratory rate because that is already part of SIRS.) Be that as it may, positive early screening criteria do not always result in findings of sepsis in every single positive candidate.
Another problem with sepsis-3 is that it requires a knowledge of baseline functioning often not present in real world scenarios, which makes it difficult (if not impossible) to apply. I believe this is the reason why insurance companies quickly embraced sepsis-3, knowing that it would be easy to construct an argument that the patient failed to meet criteria.
Yet another criterion in the determination of the presence or absence of sepsis seems to be identifying the payer. While this is an obviously ridiculous situation at face value, it is nonetheless a real problem the facilities face.
At the end of the day, what we are left with is a couple of tools for early screening, a comprehensive body system review, and an accurate—if difficult to apply—prognostic tool. Choose what is appropriate for the clinical circumstance encountered or even use a combination of all of these. But please, stop insisting that only one set of criteria is correct or better or best.
Editor’s note: Frady presented the “Mastering Clinical Concepts in CDI” special two-day pre-conference event May 20 & 21 during which he addressed clinical criteria and assessment of documentation regarding sepsis. A CDI education specialist for HCPro in Middleton, Massachusetts, he teaches a variety of CDI-related Boot Camps for ACDIS. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.
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