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CDI Insights

Complying With the SEP-1 Bundle

How CDI can help hospitals comply with SCC guidelines for the management of severe sepsis.

Over the years, sepsis has received significant media attention due to under-documentation and over-documentation. CDI specialists are all too familiar with querying for sepsis to clarify clinical indicators, glean the source of the infection, determine whether the sepsis is present on admission, or ascertain whether a physician ruled out sepsis during the patient's hospitalization.

The Surviving Sepsis Campaign (SCC), a large international collaboration aimed to reduce sepsis-related deaths, eliminated some of the confusion when it published updated guidelines for the treatment and management of sepsis in 2012. The SCC continues to address sepsis-related process improvement. Most recently, the SCC published the Surviving Sepsis Bundle, a set of guidelines with which hospitals must comply beginning with October 1, 2015 discharges.

The bundle, which incorporates elements of three important evidence-based studies, requires hospitals to meet certain parameters for patients with severe sepsis and septic shock within three and six hours of the time of presentation. Hospitals must comply with the guidelines to receive the full IPPS update amount in FY 2017.

Following is a discussion of CDI implications of the sepsis bundle and how specialists should approach this topic as they increasingly venture into the world of quality.

Q: What's the goal of the severe sepsis/septic shock bundle?

Fee: The goal of the bundle is to ultimately improve patient care. Through its requirements, the bundle will hopefully reduce variability in severe sepsis and septic shock treatment, cost, and outcomes.  However, it's important to remember that the original SSC initiative included population cohorts with statistically similar characteristics (i.e., as defined by the 2001 consensus sepsis definition). With any prospective study, attempting to apply the same set of guidelines to a different population (i.e., as defined by the 2012 consensus sepsis definition) could affect the reliability of the results.

Q: How have facilities reacted to the severe sepsis/septic shock bundle thus far?

Fee: Many facilities have been highly reactive to the bundle. That's because the bundle (SEP-1) is also one of many Inpatient Quality Reporting (IQR) measures required for the full IPPS update amount. Although the SEP-1 bundle is currently part of the IQR, which is a pay-for-reporting initiative, many in the industry fear it will eventually become part of Hospital Value-Based Purchasing (HVBP). If this occurs, organizations could potentially be evaluated (and paid) according to their performance reflective of the quality of care they provide. Historically, IQR measures have laid the foundation for HVBP.

Q: Are these fears grounded in any reality?

Fee: Not necessarily from a financial impact. SEP-1 is currently an IQR clinical process measure-not an outcome claims-based measure. For FY 2013-2016, clinical process measures dwindled from 70% to 10% within the HVBP. In FY 2017, there is a potential HVBP cumulative penalty of 2%. In addition, process of care measures will be reassigned to a new domain-clinical care-and decrease to 5% of the HVBP composite. So there could be very little financial impact regarding a penalty even despite the fact that compliance with the bundle may require significant time and resources on the part of clinical abstractors and CDI specialists. However, with the display of public outcomes data in media, non-compliant providers may face the repercussions of a tarnished reputation.

Q: What specific role can CDI specialists play in all of this?

Fee: CDI specialists can-and should-continue to educate physicians about the proper definitions of sepsis, severe sepsis, and septic shock as specified by the SCC. Reiterate that early recognition and early treatment of sepsis is paramount. Documentation of sepsis helps account for nursing, monitoring, and other related costs.

Unfortunately, some facilities are redefining sepsis based on the bundle criteria. In these facilities, physicians follow the treatment protocols simply in fear of meeting the bundle requirements rather than do what's clinically appropriate. For example, some physicians order a lactate on every patient with an infection. Other facilities were inserting a central line in every patient who is potentially septic, prior to the recent bundle update.

This wasn't the intent of the bundle. The bundle was instituted to improve sepsis outcomes in a population that is reflective of the cohorts in the referenced prospective trials.  The bundle is not meant to define the severe sepsis and septic shock population. Instead, it should be used in the populations that have predictability shown better outcomes with use of these interventions.

Q: The severe sepsis/septic shock bundle requires strict attention to a timeline post-presentation. What are the challenges associated with this?

Fee: The challenge is that although some EHRs include sepsis alerts, many of these alerts are based on structured data only. This becomes problematic when a triage nurse documents potential urinary tract infection-and the triage vital signs support severe sepsis-but the physician doesn't document severe sepsis until hours later.  Once criteria for severe sepsis are present in the record, the bundle clock starts ticking. That's because the bundle defines onset as the time at which all clinical criteria are met or the time at which the physician/APN/PA document severe sepsis in the record-whichever comes first.

Bonney: Several clients have approached us to assist with this. Currently, we use NLP to identify cases of unconfirmed sepsis (i.e., instances in which a sepsis code is listed in the H&P, ER consult, or progress notes). When we identify a sepsis code, we alert nursing staff immediately. Our technology also includes a workflow that assigns a score to each sepsis diagnosis so nurses can prioritize their efforts. Sepsis diagnoses that have been confirmed, meaning a CDI specialist has reviewed the documentation and selected a sepsis diagnosis as principal or secondary, receive a higher score than an unconfirmed sepsis diagnosis.

Q: Can the technology incorporate clinical indicators rather than specific sepsis codes?

Bonney: Yes, we do have the opportunity to incorporate clinical indicators such as lactate level. We're already using the technology to assist CDI in identifying cases of sepsis or severe sepsis that are under-documented. It would be relatively easy to move this concept into the quality realm.

Q: In what other ways can technology help with the bundle?

Bonney: Aside from using NLP to identify clinical indicators of sepsis, it would be great if the technology could eventually help facilities determine how many cases fell into and then out of the bundle for whatever reason, such as the patient didn't meet the criteria or the patient ultimately didn't really have severe sepsis.

Fee: I agree. It would also be helpful to create something that would alert the physicians that he or she is on the hook for the bundle. For example, some physicians might not realize that the bundle uses lactate greater than four as a defining value for septic shock even though this was never an intent of the original evidence-based studies. Unless the physician specifies that the patient doesn't have septic shock (e.g., he or she has lactate elevated secondary to ketoacidosis), the patient will fall into the bundle, and the physician will be on the hook.

Q: Do you think the bundle will ultimately improve care and outcomes?

Fee: The intent of the bundle is good; however, instead of strictly applying it to a specific subset within the total sepsis population, the bundle is being used to redefine sepsis.  Also, some aspects of the bundle were applicable to a study population from years ago, and ongoing advancements have altered clinical practices. Hospitals run the risk of simply reacting to meet reporting specifications rather than truly focusing on improving care delivery. It will be interesting to see whether the current bundle actually affects outcomes. I suspect that at the end of this fiscal year, the bundle will be removed from the IQR or revamped completely.

Steve Bonney is responsible for business development and product strategy at RecordsOne. He is a national author and speaker on the use of natural language processing technology in healthcare. He works hand in hand with hospitals to identify new and innovative uses for NLP within coding, clinical documentation improvement, quality reporting and reimbursement. Bonney is an active member of AHIMA, ACDIS, HIMSS and WEDI.

James P. Fee, MD, CCS, CCDS, is vice president of Enjoin. He is board certified in Internal Medicine and Pediatrics and maintains a clinical practice in hospital medicine. Dr. Fee is an AHIMA-approved ICD-10-CM/PCS trainer and serves in a consultative role regarding clinical documentation integrity and its impact on financial accuracy, physician and hospital profiling, and quality metrics.

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