1. Sepsis Core Measure
August 25, 2015

2. Background:
The new Sepsis Core Measure (SEP-1) will impact patients, providers and services across the hospital
Reporting on compliance with the measure begins October 1, 2015
Complex, timed, all or none measure
Potentially much larger denominator population than for other measures
Components of the measure will cross EDs, Inpatient floors and ICUs
Handoffs across clinical areas
Handoffs across clinical shifts

3. Measure Specifications
Denominator:
Inpatients age 18 and over with an ICD- 10-CM Principal or Other Diagnosis Code of Sepsis, Severe Sepsis, or Septic Shock
Specifications Manual for National Hospital Inpatient Quality Measures V5.0

4. Defining Severe Sepsis:
Clinical Documentation
Data from Medical Record

5. Defining Septic Shock:
In the Hour after crystalloid administration:
SBP < 90 or
MAP < 65 or
Decrease in SBP > 40 points or
Initial Lactate > 4 mmol/L

6. Measure Specifications
Numerator:
Within 3 hours of presentation of Severe Sepsis
Initial lactate level measurement
Broad spectrum or other antibiotics administered
Blood cultures drawn prior to antibiotics
6 hour requirements if initial lactate level is elevated
Repeat lactate level measurements
Specifications Manual for National Hospital Inpatient Quality Measures V5.0

7. Measure Specifications
Septic shock requirements:
Within 3 hours or presentation:
Resuscitation with 30 ml/kg crystalloid fluids
Within 6 hours if hypotension persists after fluid administration
Vasopressors
Volume status and tissue perfusion assessment
Specifications Manual for National Hospital Inpatient Quality Measures V5.0

8. Volume Status/Perfusion Assessment:
Must be documented by physician, PA, APN

9. Excluded Populations:
Administrative contraindication to care
Comfort care within 3 hours of presentation of Severe Sepsis
Comfort care within 6 hours of septic shock
Length of Stay > 120 days
Transfers from another acute care facility
Patients who expire within 3 hours of presentation of Severe Sepsis
Patients who expire with 6 hours of presentation of Septic Shock
Patients treated with Antibiotics for greater than 24 hours prior to presentation of Severe Sepsis/Septic Shock

10. Approach to measure:
Real-Time identification of patients at risk for Severe Sepsis/Septic Shock
Education and Training
Alerts in the EMR
Facilitate ordering and documentation of measure requirements
Identifying clinical resources
Creating order sets/alerts/documentation tools in the EMR
Ensuring accuracy and completeness of documentation
Concurrent CDI Queries
Retrospective Coding Queries

11. Identifying Patients in the ED
Vital Sign Screen
HR > 90
RR > 20
SBP < 90
O2 Sat < 90
Temp >38.3 or < 36.0
2/5 Criteria
1/3 Criteria
Alert Fires

12. Identifying Patients in the Hospital
Criteria met w/in 6 hours
Alert Fires
RN/CA Notified to Follow Sepsis Protocol
Physician/NP/PA/APN Notified to Follow Sepsis Protocol and provided Link to Sepsis SmartForm/Navigator

13. Approach to measure:
Facilitate ordering and documentation of measure requirements
Identifying clinical resources
Creating order sets/alerts/documentation tools in the EMR
Ensuring accuracy and completeness of documentation
Concurrent CDI Queries
Retrospective Coding Queries

14. Questions & Next Steps