Clinical and Coding


What ICD-9/DRG codes are to be included to identify patients? Is this primary discharge diagnosis or any diagnosis?
The Department is not specifying which codes would be included. Any patient diagnosed with severe sepsis or septic shock discharged within the reporting quarter should be reported regardless of coding/DRG assignment. 

Determining the difference between severe sepsis and septic shock in pediatric patients is not always possible. 
Pediatric patients should be categorized as having septic shock when you are unable to differentiate between the two.

What is the expectation for the receiving hospital for reporting on patients transferred with sepsis 'present on admission', from both another ED or as a direct inpatient hospital transfer?
Both the transferring and receiving hospitals are responsible for collecting and reporting the variables, including demographics, adherence, severity adjustment and co-morbidity variables. Data from both institutions will eventually be linked for outcomes and adherence measures reporting. It is understood that the hospital may not have data on all elements but is expected to report on the data that is available for each hospital.

Can lactate be reported in mEq/L units?
No, data will be reported using one of the specified units in the data dictionary.

Do we need to report out of state transfers?
Yes. Instructions on reporting out of state transfers are contained within the data dictionary.

What source of admission is Assisted Living?

Non-Health Facility Point of Origin

When DOH states "all cases are to be reported on", are they referring to all cases coded on discharge as sepsis/severe sepsis OR cases with an admission working diagnosis of sepsis?
The hospital is responsible for reporting all diagnosed cases of severe sepsis or septic shock.

For the bandemia data element within the severity adjustment variables, can you please confirm why the bandemia is 5% and provide reference to the relevant literature for our hospital?
The bandemia element is one component of the Mortality in Emergency Department Sepsis (MEDS) score and has been used in various studies for the creation of risk adjusted mortality associated with sepsis. Shapiro NI, et al. Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule. Critical Care Medicine 2003; 31(3): 670-675.

Why are we collecting data on obvious answers such as low platelets associated with sepsis?
Several data elements are captured to determine severity adjustment values.

What if the protocol was never ordered but elements were addressed i.e., fluids, antibiotics but not lactate? Would I answer No for the protocol and enter the variables?
Correct, you would enter "NO" for the protocol and would report data elements which were addressed.

Does their need to be clinical documentation supporting why the protocol was not initiated? 

If protocol was started in the ED and following day, patient was made comfort care, do we answer "patient excluded from the protocol"?
No. Exclusion criteria need to be in place at the time the protocol would have been initiated.

Is Altered Mental Status the 1st assessment or after the protocol initiated?
The variable reports a difference in mental status at time the protocol is initiated, as compared to the patient's baseline.

In reference to the "Site of Infection" variable, if there are more than one suspected or diagnosed sites of infection, should code 7 be selected?

No, the most likely source of infection should be chosen. If the site of infection cannot be determined then choose 7=Unknown.

Does mechanical ventilation include NPPV or only invasive mechanical ventilation? What if patient arrives on a vent or has a history of mechanical ventilation?
Include all types of assisted ventilation except CPAP or BiPAP for sleep apnea.

If the patient is from a nursing home, is the severe sepsis/septic shock categorized as "hospital acquired" consistent with pneumonia measures?
If a patient arrives at a hospital with severe sepsis or septic shock then the condition was not hospital acquired.

How do we report steroids as dosage/type can vary for acute or chronic conditions?
Clinical judgment should be used.

Is Hepatitis B or C without liver failure included in the liver co-morbidities? What about acute vs. chronic liver failure?
Chronic liver disease as a co-morbidity is detailed in the data element 'Chronic Liver Disease'.

If a severe sepsis diagnoses was made intra-op, how do we submit this?
The severe sepsis or septic shock protocol should still be initiated and all variables reported. Any specific concerns can be addressed through Help Desk support.

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