Cite this post as:
Scott Weingart, MD FCCM. We are Complicit – A glimpse into the current state of Severe Sepsis/Septic Shock Quality Measures. EMCrit Blog. Published on June 11, 2015. Accessed on October 4th 2023. Available at [https://emcrit.org/emcrit/current-state-of-severe-sepsis-quality-measures/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: June 11, 2015
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
You finished the 'cast,
Now Join EMCrit!
As a member, you can...
- Get CME hours
- Get the On Deeper Reflection Podcast
- Support the show
- Write it off on your taxes or get reimbursed by your department
.
Get the EMCrit Newsletter
If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the Resuscitation and Critical Care goodness.
This Post was by the EMCrit Crew, published 8 years ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.
Hi Scott, I am a Nurse Practitioner in the ER, but have long background in EMS and ER nursing…worked in corporate quality for exactly as long as I could stand it…worked on Primary care side with CMS measures and understand the reasons for leaving out important stuff…They leave out what is not easily measurable data, whether or not it is vital…How can they measure “suspected infection” when they get most of their flagged cases from insurance claims data…ICD codes. They can collect lab data, diagnosis and procedure codes, but they cannot quantify and collect clinical judgement. It is a flaw… Read more »
Absolutely!!!
CMS and NQF both have public stakeholder comment periods. Your/our input is essential.
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallforPublicComment.html
tee hee hee hee hee hee
In some obscure corner of the detailed core measure explanation it appears that the CMS definition of a balanced crystalloid is either LR or NS. Our providers are moving steadily toward fluid resuscitation using balanced crystalloid solutions like Normosol-R. Does anyone know if there is a caveat for use of any isotonic crystalloid? Or are they really going to penalize us for using these better products?
I can’t imagine that being a problem, but that will up to your coders
Metabolic Theory of Septic Shock
Please do a search for the above
This is an incredibly important and depressing post. What has our world come to!
Cochran review Early vs late antibiotics in severe sepsis pre-Itu admission.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007081.pub2/full
No RCTs found
Something similar developing in the UK, will likely become a performance indicator, driven by the “sepsis trust”. It’s the policy management of severe sepsis in my hospital. Not sure how well validated the bundle is outside of my hospital. I’m told it has been repeated in other hospitals, but I have not found any published data. Some aspects of the bundle make sense. Some do not. The argument for early antibiotics is extrapolation from septic shock. Cochran could not find any RCTs in severe sepsis.
http://m.emj.bmj.com/content/28/6/507
Scot Nice review of the current Sepsis measure. Hospitals will be/ are struggling with this measure. To answer your request to be more participatory I have included the following lnk from CMS. Remember this is a huge volume IQR call but they do have opportunity to ask and more importantly submit questions. I would suggest any one who has some thoughts on this topic to attend and submit questions and concerns. You may register for the webinar at the following link: https://cc.readytalk.com/r/wzscq465sz0&eom. This IQR webinar, titled “Early Management Bundle, Severe Sepsis/Septic Shock” will be presented and will provide the basis,… Read more »
the docs running this webinar are the complicit docs
Excellent post! This is the most eloquent breakdown of this terrible Core Measure I’ve seen. Thank you! The irony, of course (as with most stupid CMS measures) is that this will increase costs in the long run (without benefiting care), when we start treating CHF/COPD exacerbation’s, pancreatitis, PE’s, SBO’s, and AKI’s like they are all sepsis (last time I checked, there is more than one kind of shock). Kindey failure…here’s some Zosyn and Vanc! Pulmonary edema with elevated WBC…here’s 2 L of fluids! Frail elderly patient who is normotensive w/ MAP of 70..here’s a line in your neck! This is… Read more »
yes!
The worst part is, if we give all the antibiotics so that we don’t fail the measure, which we are ALL already pressured to do…along comes the next measure!! Somebody is already typing somewhere… Numerator: Number of patients presenting with sepsis who are found to be resistant to any antibiotic given during any previous admission…:) http://www.qualityforum.org/News_And_Resources/Press_Releases/2015/NQF_Statement_on_the_White_House_Effort_to_Combat_Antibiotic_Resistance.aspx Seriously though, I have seen a few comments in here saying you can make a difference through public comment period…but the rule is listed as “finalized” and the meeting that is posted above is not for the purpose of commenting, it is for the… Read more »
nowhere in this discussion is there a discussion about bacteria unless you include “we all like antibiotics for bacterial infection” the problem with the sepsis debacle is that none of it is focused on microbiology or the early pathologic identification of the microbe causing the infection in real time. this recent paper hit a great nail on the head of our numbskulls when it decried the lack of a pathologic diagnosis in emergency department. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4307726/ the answer my fine friends as told by Semmelweis, Koch, Lister, Pasteur et al is to be found in the laboratory and not on the… Read more »
Absolutely right Dr.Weingart.. There has been tremendous public health value derived in the efforts of delivering enhanced sepsis awarenes in the ER, EMS, and on the wards and the need for early fluids and antibiotics. For example I recently sent a e coli urosepsis case to the ER and they managed the case like we would have in the ICU. Within a few hours he received 4 liters of NS. His HR fell from 130 to 96. His Lactate fell from 2.2 to 1.5 and by the next day his creat. had fallen from 2 to 1.5. The bringing of… Read more »
Sorry that was the wrong link. Here is the link which tells the almost unbelievable history of 25 years of pathological, dead end, Sepsis Science. Read this and you will understand why the clinical docs are beginning to push back. Read this again if you read it in the past. You will note that all that it predicted when it was written, has come true. Remember the hope for all those randomized trials. PROCESS, ARISE, PROMISE. If the linked article was right …. they never had a chance. Of course, in the end, that was exactly the case. It is… Read more »
There are a variety of incorrectly positioned assumptions in this critique. The most prominent is that any of the 4 trials on septic shock somehow included a definition of severe sepsis. This is simple false. The trials defined shock and were silent ion the definition of severe sepsis. The next faulty assumption is that “Somehow, septic shock now includes a lactate >4. The lactate >=4 was supposed to be the severe sepsis that went into the phrase that EGDT built: Severe Sepsis and Septic Shock.” This is again simply a misstatement of the facts. Lactate >= 4 is a part… Read more »
This is a illustrative example of the collision of medical threshold science (also called thresold decision making) which originated in the 1970s and 80s with concepts of ROC and the work of Paulker, et al. and the clinicians who have learned to their sorrow the personalized consequences of utilitarian, “one size fits all” threshold rules based medicine for complex heterogenous dynamic group of phenotypes of severe infection which we call sepsis. The application of threshold based rules (as one might for ACS or acute carotid occlusion) to the broad range of sepsis phenotypes with no known time of onset is… Read more »
Lawrence, this is an elegant theory and the letter you cite explains much of it well, but it’s a prescription to nowhere. Just as much as threshold science has been used to built this monster, threshold science is being used to deconstruct it. Is there another science we should be applying? And how do we know it has better results or is a better fit? Essentially it comes down to this: never has a public health campaign endured more head-on and sideways at tacks and criticism as the Surviving Sepsis Campaign. Often these criticisms come as critiques of our methods,… Read more »
Sean I support the SSC and never argued that it was not a good idea. I am not sure that the entire claimed reduction in death is supported by solid science given the fluidity of the criteria defined denominator over the past decade, However, the culture in the ER relavant timely intervention has been greatly improved by SSC. A major achievement in the interest of public health My problem is with the present science of sepsis. In particular, the collection, analysis and reliance uoon preselected gilded thresholds. These are data fragments upon which scientists and clinicians have anchored. This has… Read more »
I have been asked to explain my comments in simpler terms. Let me summarize. The acheivements of SSC thought leaders rank with other great medical leaders. We are thankful for their brilliance, hard work. and dedication to public heath. However now, in 2025, it is important to understand that: “There are no thresholds of sepsis, thats a 1980s myth. There are only the dynamic relational patterns of the different phenotypes of sepsis.” ER docs are faced with these complex patterns while regulators are listening to those well meaning thought leaders who, for 25 years have been convinced they could define… Read more »
One might ask why are we, as clinical sepsis researchers, so desperate that we resort to SOME in an intellectual challenge to the sepsis dogma? To explain how our problems mirror those of the ER physcian, here is the pivotal statement from Scott in this blog. “I am still fairly desperate to know the evidence for this new definition, but I haven’t found it yet. Pretty unacceptable to hold every hospital in the US accountable to an arbitrary definition that has not been tested in large-scale trials.” That is what sepsis researchers working outside the dogma have faced for over… Read more »
Thank you for sharing the story Sherrie! It kind of weaves in so much well with our storyline and suite of cloud based Sepsis solutions and software that primarily assist nurses and physicians in the sepsis care process. As a nurse you are aware of the time delays that do happen unintentionally, in the care process. Added to it is the gaps i the care transition process when nurses and physicians change their shifts and handover care to the next set of care providers, In all this chaos, hospitals fails to adhere to the sepsis bundle protocols mandated by the… Read more »
Great discussion and comments. However, my issue with all of this is more unsophisticated… Where the statement exists above “after crystaloid fluid administration”, does that mean after a 30 ml/kg fluid bolus, or some “reasonable amount of fluid”? ..and does CMS clarify how rapidly this fluid bolus should go in? That is very difficult for me to clarify, as I’m involved peripherally with our hospital’s attempt to make sense of all of this. In addition, the IS department is trying to build a module in Epic to help with the abstract recording times. They have similar questions regarding the fluid… Read more »
How much fluid is too much for these patients? Say young, showing early signs of DIC, renal failure, and with a mild trop elevation? Recent contextual invasive strep A exposure.
Many thanks from Canada,
who are the people on the committee? someone with a website that has a large following of healthcare providers (for example Scott Weingart) should start a web petition to remove the inane parts of the guidelines. that’s about the only way docs in the trenches will have a voice.