Cms sepsis core measure set 2017

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1 content=" Cms sepsis core measure set 2017 Testing for acute Hepatitis A (IgM HAV) should occur in patients presenting with acute hepatitis and possible fecal-oral exposure. Testing for acute hepatitis E (IgM HEV) should also be considered in those returning from endemic areas and whose tests for acute hepatitis A, B, and C are negative. (Strong recommendation, very low level of evidence). Clinicians are required to assess abnormal liver chemistries on a daily basis. The most common liver chemistries ordered are serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase and bilirubin. These tests should be termed liver chemistries or liver tests. Hepatocellular injury is defined as disproportionate elevation of AST and ALT levels compared with alkaline phosphatase levels. Cholestatic injury is defined as disproportionate elevation of alkaline phosphatase level as compared with AST and ALT levels. The majority of bilirubin circulates as unconjugated bilirubin and an elevated conjugated bilirubin implies hepatocellular disease or cholestasis. Multiple studies have demonstrated that the presence of an elevated ALT has been associated with increased liver-related mortality. A true healthy normal ALT level ranges from 29 to 33 IU/l for males, 19 to 25 IU/l for females and levels above this should be assessed. The degree of elevation of ALT and or AST in the clinical setting helps guide the evaluation. The evaluation of hepatocellular injury includes testing for viral hepatitis A, B, and C, assessment for nonalcoholic fatty liver disease and alcoholic liver disease, screening for hereditary hemochromatosis, autoimmune hepatitis, Wilson's disease, and alpha-1 antitrypsin deficiency. In addition, a history of prescribed and over-the-counter medicines should be sought. For the evaluation of an alkaline phosphatase elevation determined to be of hepatic origin, testing for primary biliary cholangitis and primary sclerosing cholangitis should be undertaken. Total bilirubin elevation can occur in either cholestatic or hepatocellular diseases. Elevated total serum bilirubin levels should be fractionated to direct and indirect bilirubin fractions and an elevated serum conjugated bilirubin implies hepatocellular disease or biliary obstruction in most settings. A liver biopsy may be considered when serologic testing and imaging fails to elucidate a diagnosis, to stage a condition,. Before initiation of evaluation of abnormal liver chemistries, one should repeat the lab panel and/or perform a clarifying test (e.g., GGT if serum alkaline phosphate is elevated) to confirm that the liver chemistry is actually abnormal. (Strong recommendation, very low level of evidence). Entrustable Professional Activities (EPAs) for GI Fellowship Training. Testing for chronic hepatitis B is conducted with HBsAg testing. Testing for acute hepatitis B is with HBsAg and IgM anti-hbc. The following groups are at highest risk: persons born in endemic or hyperendemic areas (HBsAg prevalence >2%), men who have sex with men, persons who have ever

2 used injection drugs, dialysis patients, HIV-infected individuals, pregnant women, and family members, household members, and sexual contacts of HBV-infected persons. (Strong recommendation, very low level of evidence). Testing for chronic hepatitis C is conducted with anti-hcv and confirmation is performed with HCV-RNA by nucleic acid testing. Risk factors for hepatitis C include history of intranasal or intravenous drug use, tattoos, body piercings, blood transfusions, high risk sexual conduct, and those born between 1945 and Testing for acute hepatitis C is with anti-hcv and HCV RNA by nucleic acid testing. (Strong recommendation, very low level of evidence). Albumin, bilirubin, and prothrombin time are markers of hepatocellular function that can be influenced by extrahepatic factors. An elevated alkaline phosphatase level of hepatic origin may be confirmed by elevation of gamma-glutamyl transferase (GGT) or fractionation of alkaline phosphatase. Policies and Procedures for Identifying and Resolving Conflicts of Interest. Patients with elevated BMI and other features of metabolic syndrome including diabetes mellitus, overweight or obesity, hyperlipidemia, or hypertension with mild elevations of ALT should undergo screening for NAFLD with ultrasound. (Strong recommendation, very low level of evidence). Paul Y. Kwo, MD, FACG, FAASLD 1, Stanley M. Cohen, MD, FACG, FAASLD 2 and Joseph K. Lim, MD, FACG, FAASLD 3. Received 11 February 2016; accepted 15 September Liver chemistries that are commonly ordered in comprehensive metabolic profiles are indirect markers of hepatobiliary disease. They are not true measures of hepatic function and thus are best referred to as liver chemistries or liver tests, and should not be referred to as liver function tests. True tests of liver function are not commonly performed but include measurement of hepatic substrates that are cleared by hepatic uptake, metabolism, or both processes (2). Because of the widespread use of the comprehensive metabolic profile testing that is done in routine practice to screen those who present for routine evaluation as well as those who are symptomatic and/or referred for elevation of abnormal liver chemistries, such abnormalities require a rational approach to interpretation. To date, there are no controlled trials that have been performed to determine the optimal approach to evaluate abnormal liver chemistries. This guideline has been developed to assist gastroenterologists and primary care providers in the interpretation of normal and abnormal liver chemistries as well as an approach to prioritize and evaluate those who present with abnormal liver chemistries. More than 14,000 GI professionals worldwide call themselves an ACG Member. Join the community of clinical gastroenterologists committed to providing quality in patient care. Members access a wide variety of resources and benefit from ACG's ongoing educational and legislative initiatives to ensure quality in care. ACG Home / Guideline / Evaluation of Abnormal Liver Chemistries. Please call the Communications Team at or . Patients with abnormal AST and ALT levels, particularly patients with other autoimmune conditions, should undergo testing for autoimmune liver disease including ANA, ASMA, and globulin level. (Strong recommendation, very low level of evidence). Journalists access information on digestive health, including the latest ACG news and up-to-date information about

3 ACG's Annual Scientific Meeting and the latest clinical science. Latest Findings from The American Journal of Gastroenterology. Am J Gastroenterol 2017;112:18-35; doi: /ajg ; published online 20 December Applying to GI Fellowship Programs: What You Need to Know. Authored by a talented group of GI experts, the College is devoted to the development of new ACG guidelines on gastrointestinal and liver diseases. Our guidelines reflect the current state-of-the-art scientific work and are based on the principles of evidence-based medicine. Dr. Dorrah is co-chair of the sepsis floor workgroup, which was charged with crafting one process that all seven hospitals in her system can follow to treat patients who develop sepsis on the floor. Rolled out this fall, the initiative includes a combination of nursing and provider education, nursing protocols, alerts in the Epic EHR and standard template documentation. In any given week that he works the hospitalist service, Dr. Odden in St. Louis may see no sepsis or severe sepsis cases, or he may see five or six. COMPLICATING MATTERS for hospitalists trying to deliver the new sepsis treatment bundle is the fact that groups of sepsis experts are publicly fighting over how to define sepsis. In its Feb. 23, 2016, issue, just four months after hospitals began reporting compliance with the sepsis bundle to the CMS, the Journal of the American Medical Association published an international consensus statement redefining sepsis and septic shock. Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto. "Our average antibiotics time was four hours the last time we looked," Dr. Simpson says. That's due to delays in recognizing sepsis, in ordering tests and drugs, in pharmacy procedures, in transporting the medications from the pharmacy to the floor, in nurses realizing the meds are available, and, finally, in nurses administering the dose to the patient. Last year, the agency adopted a bundle of sepsis interventions as a core measure in its inpatient quality reporting program. As a result, hospitalists say, the challenges of treating sepsis have become much tougher. Part of Dr. Simpson's solution is outreach throughout Kansas, educating clinicians in hospitals state-wide about sepsis to help them get a jump on the diagnosis. According to Andrew Young, DO, the service chief of medicine at LAC+USC Medical Center and a co-author of that study, more recent preliminary data from his hospital show a 23% compliance rate with the CMS sepsis bundle. "The most challenging bundle elements to accomplish seem to be the repeat lactate, documenting the fluid infusion rate and having a stop time for the infusion.". For Dr. LaRosa in Newark, consistent bundle documentation can be frustrating. That's because the required focused exam within six hours of the Code SMART call is highly specific as to what elements must be contained in the note and, of course, in the patient evaluation to meet the standard. The CMS began requiring hospitals to submit sepsis-related data in October Eventually, those data may be publicly reported and affect hospital reimbursement. As for problems with documentation, "we are used to writing '2 liters IV bolus,' but our abstractors are saying that doesn't meet the core measure," Dr. Young explains. "Either the nurse needs to document when the bolus is done or we need to put in the infusion rate. We need to figure out how to tackle that.". "Unlike in an emergency department or an ICU, where you see a lot of

4 severe sepsis, you don't see it frequently on the med-surg units," Cooper's Dr. Dellinger points out. "On the floors, you have to train a lot of people and keep them poised for something that doesn't happen frequently.". As for why, the study noted that clinicians have fewer "distractions" at night and on weekends, allowing them to "focus on meeting the parameters necessary." (A study. abstract was presented at SHM's 2016 annual meeting.) Interestingly, the study also found that an increased rate of bundle compliance didn't boost patients' rate of survival to discharge. "There are a lot of advantages to nurse-based screening because it's a moment when someone is looking at all the information, even if it is very quickly," says Dr. Odden in St. Louis. The aim of screening is in part to "prompt a conversation with the physician. The secret ingredient is engaging both the nurses and physicians to try to put this together.". "It's definitely the hardest core measure I've ever tried to meet.". At Baylor Scott & White in Round Rock, this year's SepsisPalooza led to the formation of various workgroups to address specific bundle items. "It's definitely the hardest core measure I've ever tried to meet because it has a lot of components, and you have only three or six hours to complete them," Dr. Dorrah says. "As physicians, we often don't realize that 'Time Zero' has even been met because we're so busy trying to take care of the patient, not watch the clock.". Published in the December 2016 issue of Today's Hospitalist. The CMS bundle, which reflects Surviving Sepsis Campaign recommendations, requires hospitals to complete several interventions within three hours of a patient presenting with sepsis, then several more within six hours. (See " What's in the CMS sepsis bundle?") To get credit for meeting the measure, hospitals must achieve 100% compliance with all bundle elements, an "all-or-nothing" requirement that many hospitals struggle with. Some clinicians also either disagree with or are leery of some bundle elements, such as the call for large fluid boluses for nearly all patients with severe sepsis, even those with heart failure or end-stage renal disease. And even when people stay current, they may not be able to meet the measure, given the complicated institutions they work in. caring for patients with severe sepsis on the floor has always been a challenge. But now, the Centers for Medicare and Medicaid Services (CMS) has upped that ante. Opera 9.0 and up, and Google Chrome. Supported browsers for Macintosh include Safari, understand the reasons behind lack of compliance with guidelines and to develop strategies. In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by:. be prevented by minimal infection control efforts and 32% by "well organized and highly. Discuss the standards of professional conduct associated with infection control in the healthcare setting. Outline the infectious disease process. Describe various practices that can result in exposure to bloodborne pathogens. Identify effective strategies to prevent or control infection, including precautions, isolation techniques, hand hygiene, standards for cleaning, and safe injection practices. Describe the role of surveillance and reporting in an effective infection control program. Discuss the impact of communicable diseases in healthcare professionals, including the necessity for preplacement evaluations, periodic health assessments, education, and postexposure prophylaxis. Evaluate the impact and

5 appropriate response to sepsis. hospital costs related to three categories of HAIs it considers "reasonably preventable:". were the cause of approximately 75,000 deaths and add approximately $28.4 to $33.8 billion in. has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. CSS 2.0 may work, but are not supported. Supported browsers must utilize the TLS encryption. Other operating systems and browsers that include complete implementations of ECMAScript edition 3 and. Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 5 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. direct medical costs annually [4, 5, 95]. The most common types of HAIs were pneumonia (22%), surgical site. previously been estimated at a high of 1 in 10 [1, 4, 94, 95]. There were an estimated 722,000 HAIs in 648,000 adults and TEENren in. Your date of completion will be the date (Pacific Time) the course was electronically. Pass the mandatory test and/or evaluation and receive immediate feedback. Review the course material online or in print. (CDC) Study of Efficacy of Nosocomial Infection Control suggested that 6% of all HAIs could. pneumonia and K. oxytoca (10%), and Escherichia coli (9.5%). As HAIs have become a cause for increasing concern, many national organizations, state departments of health, and professional organizations have taken additional steps to prevent or control infection in the healthcare environment. that target those reasons. In addition, there are professional conseq averaged only 30% to 50% [3, 31, 44, 56, 57, 58]. Decreasing the number of HAIs will require research to better. In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.