Portal de Periódicos da CAPES

Accountability for Sepsis Treatment

2017; Elsevier BV; Volume: 151; Issue: 5 Linguagem: Inglês

10.1016/j.chest.2017.01.011

1931-3543

Christine Motzkus, Craig M. Lilly,

Cardiac, Anesthesia and Surgical Outcomes

Improving care and outcomes for patients with sepsis is an increasingly achievable goal. The United States Centers for Medicare and Medicaid Services (CMS) and the Joint Commission (JC) have joined forces to provide new publicly reported measures that aim to reduce preventable sepsis-related mortality.1Rhee C. Gohil S. Klompas M. Regulatory mandates for sepsis care—reasons for caution.N Engl J Med. 2014; 370: 1673-1676Crossref PubMed Scopus (155) Google Scholar The Centers for Disease Control has long recognized the importance of expeditious and effective treatment of infections and has implemented creative programs that urge patient and family advocacy by having them ask their providers “Do you think this might be sepsis?”2Centers for Disease Control and Prevention. Sepsis questions and answers. https://www.cdc.gov/sepsis/basic/qa.html. Accessed December 20, 2016.Google Scholar The SEP-1 sepsis core measure is supported by increasingly clear reproducible high-quality evidence from clinical trials that defines the timing of specific treatments and assessments for patients recognized as having sepsis.3Lilly C.M. Protocol-based care for early septic shock.N Engl J Med. 2014; 371: 386-387PubMed Google Scholar Translation of key clinical trial interventions into improved patient outcomes has been a major focus of professional society and philanthropic efforts.4Dellinger R.P. Levy M.M. Rhodes A. et al.Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.Crit Care Med. 2013; 41: 580-637Crossref PubMed Scopus (4514) Google Scholar One of our most successful governmental programs for translating advances of clinical science into better patient outcomes is the Quality Initiative of the Department of Health and Human Services (HHS). This initiative was introduced by HHS Secretary Tommy Thompson in 2001 and was expanded in 2003 to include the Hospital Quality Initiative (HQI). The harmonization of the initial CMS and JC measure sets has led to improved outcomes for patients.5Chassin M.R. Loeb J.M. Schmaltz S.P. Wachter R.M. Accountability measures—using measurement to promote quality improvement.N Engl J Med. 2010; 363: 683-688Crossref PubMed Scopus (383) Google Scholar Hospital Quality Initiative reporting requirements were defined by the Deficit Reduction Act of 2005 and augmented in 2007 by final regulation CMS-1488-F. During 2010, the JC classified each core performance measure as either accountability or nonaccountability and in 2012 introduced a standards-based expectation for minimum performance using ORYX accountability measures. The programs of this initiative that combine public reporting with CMS financial incentive programs have made high-quality care available to more Americans.6Cohen R.I. Jaffrey F. Reitzner J.B. Baumann M.H. Quality improvement and pay for performance.Chest. 2013; 143: 1542-1547Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Measures for acute coronary syndromes, venous thromboembolism, and stroke have fostered local programs that have reduced preventable complications of these conditions. These programs have gained public support because both their aims and implementation are perceived as being patient focused. Responding to reports of adverse outcomes from sepsis, including the heart-wrenching death of Rory Staunton, a 12-year-old New York boy, advocacy groups, including the Sepsis Alliance, and physician groups, including the Surviving Sepsis Campaign,4Dellinger R.P. Levy M.M. Rhodes A. et al.Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.Crit Care Med. 2013; 41: 580-637Crossref PubMed Scopus (4514) Google Scholar have advocated change. To improve sepsis care, CMS and the JC leveraged the National Quality Forum and resources including the Agency for Healthcare Research and Quality National Quality Measures Clearinghouse to create a new measure intended to encourage prompt responses when sepsis is recognized.1Rhee C. Gohil S. Klompas M. Regulatory mandates for sepsis care—reasons for caution.N Engl J Med. 2014; 370: 1673-1676Crossref PubMed Scopus (155) Google Scholar The new sepsis CMS core measure is designated SEP-1.7Centers for Medicare and Medicaid Services, The Joint Commission. Specifications manual for national hospital inpatient quality measures discharges 10-01-15 (4Q15) through 06-30-16 (2Q16).http://www.jointcommission.org/assets/1/6/IQRManualReleaseNotes_V5_01.pdf. Accessed January 30, 2017.Google Scholar The SEP-1 measure is new territory for the programs of the Quality Initiative because it is more complex than its predecessors, and measurement has proved to be substantially more burdensome. There are increasing concerns that its impact may be limited, because the initial results of local measures designed to achieve high levels of adherence have been disappointing. It is also concerning that the laudable focus of the SEP-1 measure on timely responses when sepsis organ dysfunction is recognized could institutionalize incentives that in effect delay the diagnosis of evolving sepsis. The SEP-1 measure is a ratio. SEP-1 is reported as the fraction of sepsis patients who receive all sepsis care elements during measure-specified time frames, as detailed in Table 1. The complexity of the measure is evident from the many clarifications and versions of the metric that have been posted since its public release. Clarifications like the one that allows assessment of the adequacy of resuscitation using catheters that are often placed in large peripheral veins rather than central veins is problematic because it is neither evidence-based nor considered acceptable critical care practice. To the extent that modifications of this complex measure deviate from evidence-based sepsis management strategies, they risk loss of support for the measure itself.8Marik P.E. Early management of severe sepsis.Chest. 2014; 145: 1407-1418Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar One important aspect of the SEP-1 measure is that it does not strictly define how the time that sepsis first started is to be identified. This time is central, because it serves as the anchor for the SEP-1 time frames. This difficulty has led to subjectivity, variability of reported rates, and requests for SEP-1 clarifications. Unfortunately, it also has the potential to provide incentives that could delay the reporting of sepsis recognition and the initiation of lifesaving treatments. The unscheduled nature of the need for sepsis care and narrow time lines of the SEP-1 measure have made implementation complex. This is due, in part, to the requirement for 3-hour and 6-hour physician assessments that mandate labor-intensive workflows during a time frame in which transitions of responsibility for care often occur. Unlike the management of stroke and acute coronary syndromes, which also require unscheduled high-acuity interventions during narrow time windows, the activities of the SEP-1 measure are not similarly well reimbursed.9Goeschel C.A. Wachter R.M. Pronovost P.J. Responsibility for quality improvement and patient safety.Chest. 2010; 138: 171-178Abstract Full Text Full Text PDF PubMed Scopus (53) Google ScholarTable 1Data and Time Elements of the SEP-1 MeasureTimeNumeratorSevere SepsisSeptic Shock3-h bundle elements1.Initial lactate level measurement2.Broad-spectrum or other antibiotic administered3.Blood cultures drawn prior to antibiotics and received within 6 h of severe sepsis presentation1.All severe sepsis 3-h bundle elementsand2.Resuscitation with 30 mL/kg crystalloid fluids6-h bundle elements1.Repeat lactate level measurement only if initial lactate level is elevated1.Vasopressor agents only if hypotension persists after fluid administration2.only if hypotension persists after fluid administration or initial lactate level ≥ 4 mmol/L (within 6 h of presentation of septic shock), then repeat volume status and tissue perfusion assessment consisting of either:a.Focused examination including: vital signs and cardiopulmonary examination and capillary refill evaluation and peripheral pulse evaluation and skin examinationorb.Any two of the following four measurements:•Central venous pressure measurement•Central venous oxygen measurement•Bedside cardiovascular ultrasonography•Passive leg raise or fluid challengeDenominatorIncluded:1.Age ≥ 18 y2.Inpatient3.ICD-10-CM principal or other diagnosis code of sepsis, severe sepsis, or septic shockExcluded:1.Directive for comfort care or palliative care within 3 h of presentation of severe sepsis2.Directive for comfort care or palliative care within 6 h of presentation of septic shock3.Administrative contraindication to care within 6 h of presentation of severe sepsis4.Administrative contraindication to care within 6 h of presentation of septic shock5.Length of stay > 120 d6.Transfer from another acute-care facility7.Patients with severe sepsis who die within 3 h of presentation8.Patients with septic shock who die within 6 h of presentation9.Patients receiving IV antibiotics for more than 24 h prior to presentation of severe sepsisICD-10-CM = International Classification of Diseases, Tenth Revision, Clinical Modification. Open table in a new tab ICD-10-CM = International Classification of Diseases, Tenth Revision, Clinical Modification. Improving sepsis outcomes is an aim worthy of universal support and the SEP-1 measure is an important next step in the fight for patients with sepsis. SEP-1 needs to be buttressed with measures and programs that encourage the early recognition of infections that are evolving into sepsis. Programs like that of the Centers for Disease Control that encourage patients and their caregivers to engage providers in early sepsis recognition represent a particularly promising approach. The development of processes for more complex measures like SEP-1 is of interest both to institutions and to the practicing physicians who will have their electronic personas affected by public reporting.10Borbas C. Morris N. McLaughlin B. Asinger R. Gobel F. The role of clinical opinion leaders in guideline implementation and quality improvement.Chest. 2000; 118: 24S-32SAbstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar The importance of having accurate, fair, effective, and transparent measures that are free of manipulation is difficult to understate. The substantial number of revisions, clarifications, new details, changes, and updates of the SEP-1 measure are a clear indication that to a greater extent than its predecessor measures, SEP-1 remains a “work in progress.” In accordance with their responsiveness to input from clinical professionals, health-care provider organizations, state hospital associations, health-care consumers, performance measurement experts, and others who fostered the creation and development of the initial CMS/JC core measure set, HHS needs to encourage broad participation in a robust review process that continues to improve the SEP-1 measure. The success of the SEP-1 program has the potential to lead to successor programs that encourage better early sepsis recognition. Successor programs that integrate information from the electronic medical record with emerging diagnostics that identify the presence of sepsis causing pathogens hold great promise for expediting sepsis recognition. Inaction or frustration that leads to marginalization of the SEP-1 program risks the loss of its large potential benefits for our patients with sepsis.