UW MEDICINE PATIENTS ARE FIRST SEP-1 CHALLENGING CASES WITH DR. TOWNSEND AMADAE AREVALO RN, MSN, CCRN KATIE MEHRING RN, BSN, CCDS AMANDA SIGALA, RN, BSN, MPH, CPHQ JUNE 12, 2018
OBJECTIVES 1. Summarize the discussions with Dr. Townsend regarding challenging cases for SEP-1. 2. Recognize role of Clinical Documentation Specialists in improving documentation and efforts in insurance denials 3. Apply new and enhanced knowledge to their respective areas (abstraction, Sepsis committees & working groups, leadership) in regards to SEP-1 Specs Version 5.4 (discharge 2
DISCLOSURES WE DO NOT have any financial relationship with industry or commercial supporters to disclose. 3
NORTHWEST HOSPITAL & MEDICAL CENTER Not-for-Profit Community Hospital 281 Licensed Beds 1775 Employees 679 Medical Staff, mostly independent Level 4 Trauma Designation Level 2 Special Care Nursery Level 1 Stroke Categorization (WA-DOH) Level 1 Cardiac Categorization (WA-DOH) 4
HARBORVIEW MEDICAL CENTER Academic Medical Center UW Medicine includes Northwest Hospital & Medical Center, Valley Medical Center, Harborview Medical Center, UW Medical Center, UW Neighborhood Clinics, UW Physicians, UW School of Medicine and Airlift Northwest 413 Licensed beds 5200 Employees Level 1 adult and pediatric trauma and burn center and regional referral center serving Washington, Wyoming,Alaska, Montana and Idaho. Emergency Medicine and Disaster Management Comprehensive Stroke Center Specialty Care including neurosciences, HIV/AIDS, psychiatric, substance abuse, eye care, vascular surgery, rehabilitation, sleep medicine and spine care 5
NORTHWEST HOSPITAL SEP-1 2017 2017 SEP-1 Overall Compliance % Reasons for Failure % 17.5 17.5 17.5 15 10 7.5 7.5 58% 42% Failed Passed 6
HARBORVIEW MEDICAL CENTER SEP-1 2017 2017 SEP-1 Overall Compliance % Reasons for Failure % 31 18.9 19.8 14.6 12 52% 48% Passed Failed 1.7 1.7 7
CRYSTALLOID FLUID ADMINISTRATION HMC Case Study #1 8
CMS V. 5.4 (DISCHARGE PERIOD 7/1/18 12/31/18) Crystalloid Fluids: For the presence of Initial Hypotension, only abstract crystalloid fluids that were started in the timeframe of 6 hrs. prior through 3 hrs. after the initial hypotension. A single order for the target volume initiated within 6 hrs. prior through 3 hrs. after initial hypotension is acceptable. If crystalloid fluids are initiated via multiple physician/apn/pa orders, only abstract crystalloid fluids initiated within 6 hrs. prior to 3 hrs. after. Initial Hypotension: Use the earliest date of the second hypotensive blood pressure documented within the time period of 6 hrs. prior to or within 6 hrs. following Severe Sepsis Presentation date and time 9
TIME FRAME FOR FLUID ADMINISTRATION 49F had acute apneic event & PEA arrest in the field while being evaluated by paramedics for SOB. Intubated in the field. 19:30 Arrived at ED, CPR ongoing. 19:34 Triage Vitals HR 154, BP 140/109 20:24 Initial lactate (13.3) 21:40 Time Zero in Admit Note: Septic shock, Highest suspicion would be pulmonary process, anticipate aspiration event in the setting of arrest. Ground glass opacities on imaging raise concern for atypical infection, viral infection. 21:51 WBC 17.83 Initial Hypotension 22:30 SBP 83 02:00 SBP 80 10
TIME FRAME FOR FLUID ADMINISTRATION Fluid requirement 1890-2100 ml (Pt. weight = 70 kg x 30 ml/kg = 2100) (within 6 hrs. prior & 3 hrs. after Initial Hypotension @ 02:00, between 20:00 to 05:00) 18:58 in ambulance 500mL LR 22:36 in ED 500mL NS 23:34 in ED 100 ml diluent c/ abx. 02:30 in ICU 500 ml LR 04:55 in ICU 500mL LR 05:58 in ICU 1000 ml LR 11
MD REVIEW Received 1600 ml within appropriate time frame (20:00 to 05:00 ). Needed 1890-2100 ml. Patient care improvement opportunity as the ICU faculty mention volume resuscitation for her shock, but the patient only got a small portion within appropriate time frame. Fails measure in both V. 5.3 and 5.4 Avoid this fallout by ordering fluid as one order instead of multiple orders. 12
ROLE OF THE CLINICAL DOCUMENTATION SPECIALIST RN (CDS) Concurrently reviews the medical record to ensure accurate reporting of medical diagnoses. Notifies the QI sepsis abstractor of current sepsis admissions. Concurrently requests documentation clarification and/or clinical validation as needed. 13
CDS REVIEW Consider the diagnostic criteria used for the diagnosis of Septic Shock Consider the entire clinical picture Potentially conflicting documentation Seek clarification 14
CRYSTALLOID FLUID ADMINISTRATION NWH Case Study #1 15
BP POST BOLUS ADMINISTRATION 56M admitted for Severe Sepsis with Septic Shock; documentation by ED MD @ 1804 Weight: 81.7kg 30mL/kg= 2206-2451 IVF orders: 1. IV LR 250mL Administered 1600-1631 2. IV NS 1000mL Administered @ 1644-1740 & again 1740-1830 16
VITALS 1830-1930 1830 1838 1845 1855 1903 1925 1930 Systolic 70 68 71 109 77 102 80 Diastolic 50 49 54 73 51 78 42 MAP 57 55 60 85 60 86 54 17
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Calculated 10% of 30mL/k required volume = 2206mL Calculated the rate of which the volume infused as well as when 2206mL would have finished infusing. Finished @ 1827 20
VITALS 1830-1930 1830 1838 1845 1855 1903 1925 1930 Systolic 70 68 71 109 77 102 80 Diastolic 50 49 54 73 51 78 42 MAP 57 55 60 85 60 86 54 21
QUESTIONS? 22
SEVERE SEPSIS PRESENTATION Documentation Challenges 23
IMMEDIATE FEEDBACK & CONCURRENT REVIEWS 1. Cases from Clinical Documentation Specialists (CDS) 2. Manual Abstraction 3. Immediate Feedback sent to Providers 24
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SEVERE SEPSIS DOCUMENTATION NWH Case Study #2 26
SEVERE SEPSIS DOCUMENTATION 100F in ED dx & treated for UTI + Influenza on 2/5 H&P states pt did not met sepsis criteria - VS normal. First documentation of Severe Sepsis was on 2/6 1300 in progress note. No initial lactate within 6h of presentation. 27
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CRITICAL CARE MD REVIEW: So far as I can tell, this is in the category of "chart hygiene" failure. Docs should be encouraged to document sepsis after admission if they deem something to be "missed sepsis" based on the data for purposes of improving care, but should be discouraged from using the "s" word in any other circumstance in subsequent follow up notes (unless new sepsis develops). Similarly, coders should not leave notes eliciting sepsis documentation for same reason. Can't tell which was the case here. 30
INPATIENT MD REVIEW Agree with [Critical Care MD above] that "chart hygiene" is important. I think the MD who picked this patient up felt that patient did meet severe sepsis on admission given WBC of 15 and lactic acid of 2.6 and clear source of infection. However, all vitals signs were stable. 31
CDS REVIEW This chart was not concurrently reviewed by a CDS. There was not a coder query on this chart Clinical Validation Needed Provide vital signs, lab values, documentation for provider review Clinical Validation Clarification: Please provide documentation of how/why this clinical presentation is out of proportion to what would be expected for a localized infection alone 32
SEVERE SEPSIS DOCUMENTATION HMC Case Study #2 33
SEVERE SEPSIS PRESENT 50M with 1 day of acute onset LUQ abdominal pain which started abruptly this morning. 18:55 Triage Vitals HR 120, RR 24, BP 140/74 19:27 Initial Lactate (3.0) 19:27 WBC 34.71 20:40 ED Note @ "Intra-abdominal free air, concern for bowel perforation, Acute CHF 20:40 Met Severe Sepsis Criteria No BC obtained, went urgently to OR for ex lap & got abx. in OR. Hypotensive in OR, but vitals in OR should not be used per CMS. 34
SEVERE SEPSIS PRESENT V. 5.4 SPECS 35
ED NOTE @ 20:40: DOCUMENTATION OF SUSPECTED INFECTION 36
SEVERE SEPSIS PRESENT V. 5.4 37
ADMIT NOTE 01:35:?NEGATION OF SUSPECTED INFECTION 38
MD REVIEW The perforated ulcer is a source for infection. After repair, the clinician felt that continued instability was due to heart failure, but the initial concern for infection was accurate. 39
CDS REVIEW Complicated clinical case Possible potential for documentation clarification of appropriate diagnosis at time of presentation vs. postoperatively. Reminder of necessity for providers to understand the role of the CDS and the background of why documentation clarification is being requested 40
QUESTIONS? 41
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Amadae Arevalo Catherine Mehring 206-668-1367 Amadae.arevalo@ nwhsea.org Phone Email URL Amanda Sigala 206-744-9433 afrye@uw.edu Sean Townsend Phone Email URL