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Sepsis CMS Core Measure (SEP-1) Highlights

Jamie Santistevan, MD

JamieSantistevanThe Sepsis CMS Core (SEP-1) Measure has been receiving a lot of recent attention for its complexity. Here are four key points that are important to understand and remember:
  

1. Lactate >2 or organ dysfunction defines severe sepsis. The definition for sepsis is unchanged: two SIRS criteria plus suspected infection. Severe sepsis is defined as sepsis plus one or more variable of organ dysfunction, which includes a lactate >2. See the below table for other “signs” of organ dysfunction.

SIRS Criteria Organ Dysfunction Variables
Temp >101 SBP < 90
Temp < 96.8 MAP < 70
HR > 90 SBP decrease > 40 from known baseline
RR > 20 Cr > 2.0
WBC > 12,000 UOP < 0.5 ml/kg/hr for > 2 hours
WBC < 4000 Bilirubin > 2.0
> 10% Bandemia Platelets < 100,000
  INR > 1.5 or PTT > 60 secs
  Altered Mental Status
  Lactate > 2


Septic shock is defined by CMS as severe sepsis with hypoperfusion despite adequate fluid resuscitation or a lactate > 4.

2. It’s all or nothing.
In order to be compliant, you need to meet all the measures. For severe sepsis, this includes:

Within 3 hours of presentation:
             Measure serum lactate
             Obtain blood cultures prior to antibiotics
             Administer antibiotics
Within 6 hours of presentation:
             Repeat serum lactate if initial lactate is >2

For septic shock:

Within 3 hours of presentation:
             Measure serum lactate
             Obtain blood cultures prior to antibiotics
             Administer antibiotics
             Resuscitation with 30mL/kg crystalloid fluids
Within 6 hours of presentation:
             Repeat volume status and tissue perfusion assessment
             Vasopressor administration
             (If hypotension persists after fluid)


3. A repeat assessment of volume status and tissue perfusion is required for patients with septic shock. This is required when a patient has persistent hypotension after fluid resuscitation. The volume assessment can be done using either a focused physical exam or using some physiologic parameters.

Focused physical exam must include:
      Vital signs
      Cardiopulmonary exam
      Capillary refill
      Peripheral pulse evaluation
      Skin exam
OR any two of the following:
       Central venous pressure
       Central venous oxygen
       Bedside cardiovascular ultrasound
       Passive leg raise or fluid challenge


4. Patients who are transferred from another acute-care facility are not included in this measure. Patients included are those who are older than 18 years of age who present with severe sepsis or septic shock. Other patients excluded are those placed on comfort care or those who die within 3 hours of severe sepsis presentation or within 6 hours of septic shock presentation.


Take-Home Points:

1. Severe sepsis is defined as sepsis plus a lactate > 2 or evidence of organ dysfunction.

2. You need to meet ALL the measures in order to be compliant with this core measure.

3. Patients with septic shock require an assessment of volume status and tissue perfusion within 6 hours of presentation.

4. Patients NOT included are those transferred from another facility or those placed on comfort cares.

 

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