Sepsis Audit FAQ

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Q: What does “15 th Percentile based on statewide distribution” mean?

A: This represents the minimum value in order for that variable to pass validation, and it’s based on the statewide performance for each individual variable (e.g. Protocol Datetime, Blood Cultures Obtained, Bandemia, etc.). A variable then passes validation if the Percent Valid is equal to or greater than the “15 th Percentile” value.

Q: How can Fluids Completed Datetime be determined? Can we use the IV rate and the administration time to calculate this?

A: The Fluids Completed Datetime is determined by several factors:

  • First, the weight of the patient (in kg) is located in the medical records. Using the required rate of 30ml/kg, the total fluid volume necessary for infusion is calculated (or the pediatric required volume is calculated).
  • Then, the clear documentation of start AND completion times for that amount of fluids is needed to answer that “At least 30ml/kg crystalloid were given” (or the pediatric required amount).
  • Using only the IV rate and administration time (i.e. start time) to “guesstimate” fluids completed is not appropriate.
  • If start times are documented for what would have been a sufficient number of fluid bags and if stop times are lacking for some or all, then the correct response would be "Volume of fluids given is unknown."
  • Documentation such as “2 liters of NS given” or “3000ml administered” are not considered appropriate documentation for fluids given. The start and completion times for those fluid bags are required.


Q: Can you clarify Lactate Reported Datetime and Lactate Re-ordered Datetime?

A: Lactate Reported Datetime – This is the date and time that the lab result is reported for the first lactate level associated with the severe sepsis or septic shock episode. This is not when the sample is drawn, collected, sent to the lab, etc. Lactate Re-ordered Datetime – This is the date and time that the second lactate is re-ordered.

Q: How did the reviewers determine the validity of Protocol Datetime?

A: Each hospital submitted a sepsis protocol for approval, and that approved protocol outlined how each facility would initiate their protocol. Based on what was said in the hospital’s protocol, the reviewers then examined the medical records to see if a matching clear date and time of protocol initiation was be found in the documentation.

Q: In the absence of clear documentation of sepsis protocol initiation, how do we determine a sepsis protocol start time?

A: The protocol is reported as not initiated if there isn’t clear documentation that aligns with your hospital protocol start time.

Q: If I see elements of the protocol (lactate, antibiotics) being started but the sepsis protocol order set is not initiated, can I just use the date and time of one element as protocol initiation?

A: The start of a protocol is designated within the individual hospital’s sepsis protocol. In the absence of clear documentation that supports what the hospital's sepsis protocol states, then the protocol is reported as not initiated. However, the data for those individual patient care elements should still be reported.

Q: I reviewed our audit results, and I can’t address any issue unless I know what the auditors found and why items were marked invalid. Can I get a list of what the auditors found? Can we discuss these findings?

A: Individual case results will not be discussed, and auditor findings will not be provided. The purpose of these audits was to help facilities identify areas where data abstraction and reporting may need to be addressed.

Q: We have items that were submitted and found in the audit to have failed. However, we can find in our EMR where those items are valid. Do we have to change anything if we disagree?

A: If you find that your data is correct according to your records, you would not resubmit the data. Be sure when medical records are requested for audit that the complete medical record is submitted AND, is legible and documented well. If you have data to correct, you will need to request that the entire file which contains the case(s) is deleted and then resubmitted with corrections also resubmitting the correct cases. Please see FAQs on file correction if you are uncertain of the process

Q: Can I use the intubation time for Mechanical Ventilation Datetime?

A: Yes. The intubation datetime must be that which is specifically associated with the initiation of mechanical ventilation for the patient. Any type of mechanical ventilation (invasive or noninvasive) is acceptable, except CPAP or BIPAP that is used specifically for sleep apnea. An order date/time for mechanical ventilation is not acceptable.

Q: What if the patient arrives in the ED and is already receiving and continues to receive ventilation support?

A: The arrival date and time would be used for Mechanical Ventilation Datetime.

Q: Does the route of administration matter for broad spectrum antibiotics?

A: No. The Data Dictionary does not specify a required route of administration.

Q: I can see clearly in the order history the dates and times for blood cultures, antibiotics, etc. However, these items were marked as invalid. Why is that?

A: It is not the order datetimes that are to be reported.

  • For blood cultures, the datetime that the blood culture was drawn or collected is to be submitted. If cultures are ordered as a set, then the first datetime for blood culture collection is reported.
  • For broad spectrum antibiotics, the date and time that the antibiotic was administered is to be submitted and not the time that the order was verified. Please bear in mind that other words may be equivalent to “administered,” such as “given, started, or performed.”
  • The order history alone would not be sufficient to provide such data.


Q: From what I understand, the earliest and triage times were only to be filled out for patients with sepsis protocols initiated in the ED. Otherwise, these fields could be left blank. That’s what we did, but on our audit report, we have numerous invalids for earliest and triage. Why is that?

A: As discussed in the WebEx presentation, the Earliest and Triage Datetimes could be left blank if no protocol was initiated in the ED. However, those fields were abstracted, and that would explain those invalids. As such, attention and resources should be directed at any other variables that did not perform well.

Q: Is the triage time asking for when the triage is started or completed?

A: The Triage Datetime is referring to the start or initiation of the triage assessment process in the ED.

Q: We receive severe sepsis/septic shock patients as transfers from another facility. If the sepsis protocol was initiated at the other facility, we may not repeat elements of the protocol when clinically not necessary. This may result in adherence variables not being completed on our end. How do we handle this?

A: The treatment that is provided at your facility is what you would report and not what was done at the other facility. For transfer patients, make sure to label those cases as such in the admission or discharge status and transfer status variables.

Q: Will the audit results change our data for public reporting?

A: No, the audit and validation process did not change what was reported by the hospitals. The results of the audit were to aid each facility in identifying areas for correction and improvement. It is up to each facility to take the audit results and assess how to address process improvements, if needed.

Q: What section or portion of the medical records did the auditors examine in validating the variables?

A: The entire medical record that was submitted by each hospital was reviewed during the audit.

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