Pearls and Pitfalls: CMS and Sepsis

Pitfall/ Misconception #1: The government reviews every sepsis case at my hospital. They are watching me right now!

No, CMS is not spying on every sepsis patient in the hospital, and it doesn’t even review most cases. Usually one of several private entities pairs up with a hospital (examples include Premier and Vizient), and they select 20% of all cases at random with discharge diagnoses consistent with “sepsis, severe sepsis, or septic shock.” Those cases are then reviewed by a hospital committee for compliance with the 2012 Surviving Sepsis Campaign SEP-1 bundle recommendations (2). 

Pearl #1: Bundled care according to the SSC is time-sensitive, but CMS calculates “time zero” for sepsis in a very specific way. I guarantee it’s not how you would do it. 

Nearly every piece of big data (prospective or otherwise) has shown that bundled care delivered in a timely fashion really does save lives (3). Even the folks who hold up PROMISE or ARISE as “disproving” EGDT as a valid practice (a topic for a different day) should be ready to admit that delays in antibiotics and early identification of septic patients are important (4). Broadly speaking, CMS states that timely sepsis care involves the satisfaction of the 3 and 6 hour bundle after the start of sepsis or “time zero” (Table 1). However, CMS doesn’t “start the clock” the same way you probably do (5).  Here’s how it happens:

Step 1: Once a case is selected for review, it goes to a chart abstractor in your hospital to comb through the notes, vitals, and labs. Who abstracts this chart and how thorough they are really matters. They will be looking for a discrete “time zero” for sepsis.

Step 2: An abstractor will look for 3 things to overlap within a window of 6 hours:

• 2 or more SIRS criteria (Table 2)
• A dated and timed note from a physician or mid-level provider that states the patient may have an infection/ sepsis
• Lab or physical exam evidence of organ failure (Table 3)

The order in which these three things occur does not matter. 

Step 3: The abstractor will look for clarifying statements in provider notes. This includes:

• Any note that specifically states the patient has “severe sepsis” or “septic shock”
• Any note that specifically addresses reasons for organ failure NOT being from sepsis

Step 4: The abstractor will take the latest occurring criteria (from step 2) as sepsis “time zero.” There are several exceptions to this when certain phrases are found in the chart, however:

• If a provider (MD/DO/APP) states that the patient “had sepsis on arrival,” then time zero auto-defaults to the exact time the patient arrives on the inpatient unit. 
• If a provider states the patient had sepsis “upon triage,” then time zero auto-defaults to the time of ED arrival/ triage. 
• If a provider note states that the patient has septic shock or severe sepsis, the abstractor will take the timestamp on the note as time zero. 

Example 1:

11:30- patient arrives in ED triage

11:40- patient’s HR =105 and RR is 25 (2 SIRS criteria)

12:00- patient is roomed in the ED

12:20- ED provider examines patient and starts a note (timestamp = 12:20)

13:30- CXR reveals infiltrate

15:45- Lactic acid returns at 2.5 mmol/dL (organ failure)

16:00- ED physician orders blood cultures, CTX, and admit order

19:00- ED physician signs note, with her Assessment and Plan stating that the patient had “severe sepsis”

When was time zero?

According to CMS, the physician note states that the patient has “severe sepsis” at 12:20, which becomes time-zero. To be compliant with the 3-hour bundle, the patient must receive blood cultures, have a lactic acid measured and receive abx within 3 hours of time-zero. 

Since time-zero = 12:20, but the patient did not actually get abx until, after 16:00, the case would fail arbitration and be ruled as “non-compliant.” The case would be ruled as inappropriate care. 

Example 2:

11:30- patient arrives in ED triage

11:40- patient’s HR =105 and RR is 25 (2 SIRS criteria)

12:00- patient is roomed in the ED

12:20- ED provider examines patient and starts a note (timestamp = 12:20)

13:30- CXR reveals infiltrate

15:45- Lactic acid returns at 2.5 mmol/dL (organ failure)

16:00- ED physician orders blood cultures, CTX, and admit order

19:00- ED physician signs note, with her Assessment and Plan stating that the patient had “community-acquired pneumonia.”

When was time zero?

According to CMS, the physician note specifies infection at 12:20 and 2 SIRS criteria are present at 11:40. However, it’s not until 15:45 that a lactic acid results at 2.5 mmol/dL. Since these 3 things occur within 6 hours of each other, the onset of sepsis time-zero defaults to the latest of these three things: lactic acid elevation at 15:45. Given that the patient got cultures, lactic acid, and abx 30 minutes after time-zero, the case would be ruled “compliant.”

Unfortunately, the CMS SEP-1 Core measure is an “all or none” pass/fail system. Example 1 gets no credit at all for managing the case appropriately whereas Example 2 gets all the glory of being “compliant.”