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About half of U.S. hospitals do not follow CMS' recommended sepsis and septic shock treatment guidelines, according to Hospital Compare data released Wednesday.
Wednesday marked the first time CMS publicly released such data since it introduced the Severe Sepsis and Septic Shock Early Management Bundle measure about three years ago.
There has been some debate over the specific definition of sepsis, but generally, it refers to the body's inflammatory response to an infection that leads to organ systems shutting down and, in some cases, mental confusion. Sepsis can be fatal, and prompt treatment can be the difference between life and death. Signs of sepsis include extreme pain or general discomfort, sleepiness, shortness of breath, and a shiver or a fever.
CMS in July 2015 adopted the Severe Sepsis and Septic Shock Early Management Bundle measure to show the share of patients with severe sepsis or septic shock for which a hospital provided appropriate care. CMS designed the measure to improve the identification and treatment of sepsis.
The measure focuses on a hospital's process for effectively and quickly treating sepsis, which means does not directly reflect the outcomes of patients with sepsis. The measure does not examine the rates of sepsis or sepsis deaths.
The measure evaluates whether hospitals follow several time-sensitive guidelines for treating sepsis using data on a pool of patients experiencing organ failure and an algorithm to determine compliance. When a patient has severe sepsis, hospitals under the guidelines are supposed to measure the patient's serum lactate levels, collect blood cultures, and provide antibiotics within three hours of diagnosis. When a patient has septic shock, hospitals under the guidelines are supposed to follow that protocol and take several other steps within six hours.
The data released Wednesday are based on how 3,005 hospitals treated adults with sepsis during the first nine months of 2017, Modern Healthcare reports.
The Hospital Compare data showed that, nationally, 49% of hospitals on average followed sepsis treatment guidelines in the first nine months of 2017. Rates for following the treatment guidelines ranged throughout the United States, as well as within health care systems. Rhode Island and Delaware had some of the lowest compliance rates, according to Modern Healthcare.
Several experts have said it's important not to take the data out of its context as a measure of whether hospitals are following a specific process.
David Mayer, vice president of quality and safety at MedStar Health and board member of the Patient Safety Movement, said the compliance data does not take into account clinical judgement. Mayer said clinicians can decide whether moving forward with a preventive treatment is appropriate for a patient, noting that just because an electronic health record (EHR) alerts a clinician that a patient might have signs of sepsis, it does not mean the patient has sepsis. "We still want good clinical judgment, and we don't want to be over-treating those who we feel pretty confidently don't have sepsis," Mayer said.
Further, documentation errors might skew compliance results, Modern Healthcare reports. Clinicians must manually enter data on the measure within three or six hours of the treatment, but some physicians provide the documentation too late, which means staff later have to report that the measure had not been used. He said, "Many times when we go back in the charts we are compliant with many of these bundles, be it sepsis or ventilator-associated pneumonia, but someone didn't document it correctly or they documented later in the day."
According to Mayer, the measure on sepsis care provides less information than a measure on sepsis mortality, which he said offers more insight on clinical care and improvement opportunities. "What CMS has done with sepsis has elevated everyone's game and made us all aware of the importance of compliance but I take these numbers with a grain of salt," he said.
James Shamiyeh, a pulmonary and critical-care physician and medical director of UT Medical Center's Heart Lung Vascular Institute, said, "While 45% to 50% compliance, to the lay person, may seem low, that range is not a bad place to have landed, relative to the complexity of the measure." However, he added, "There's still more work to do. This is not an easy thing to tackle." According to Shamiyeh, sepsis-related complications, length of stay, and mortality at UT Medical Center decreased since the medical center overhauled its sepsis program and developed specific procedures for quickly treating suspected cases of sepsis in 2015-2016. Shamiyeh said hospitals receive sepsis cases of varying complexity, and standard guidelines might not always provide the best treatment (Castellucci, Modern Healthcare, 7/27; Knowles, Becker's Clinical Leadership & Infection Control, 7/27; Nelson , Knoxville News Sentinel, 7/27; Nelson , Knoxville News Sentinel, 7/27).
By Veena Lanka, MD, Senior Director
At first glance, the 49% SEP-1 compliance figure appears shocking and absolutely unacceptable for a developed nation such as the United States. The report may rightfully spark outrage and fear among readers, especially those who are currently in a hospital, have close ones in a hospital, or are suffering from chronic conditions that could bring them into hospitals.
However despite the shocking headline, this performance report is not cause for alarm for patients or providers. When you begin to deconstruct the 49% result, it quickly becomes clear that the sepsis definitions used by CMS don't quite line up with the latest evidence. Here are 4 reasons why you shouldn't panic:
Therefore, the SEP-1 measure as it exists today is not a definitive indicator of a hospital's clinical outcomes for sepsis. Until the limitations are iterated upon by CMS, providers should:
For a more detailed analysis of this news and information about what providers can do to improve their sepsis quality keep an eye out for my upcoming blog post on the topic.
In the meantime, make sure you read our research report on 10 imperatives to reduce sepsis mortality. Not a Physician Executive Council member? View our infographic on the how to improve sepsis outcomes.
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