February 29, 2016

Diagnosing Sepsis: A Gradual Farewell to SIRS

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The third international consensus definitions for sepsis and septic shock were published on Feb. 22 in the Journal of the American Medical Association (JAMA), and the Internet went wild with discussion.

Granted, the part of the Internet interested in sepsis and healthcare news is somewhat limited, so the news may not yet be on the radar of many clinical documentation specialist (CDS) and coding professionals. 

In a study of 148,907 out of 1.3 million U.S. encounters and 700,000 non-U.S. encounters (encompassing acute inpatient, community, and tertiary facilities), systemic inflammatory response syndrome (SIRS) criteria failed in both convergent validity as well as discriminant validity as a measure to accurately predict sepsis. In other words, SIRS criteria are present in patients who never develop infection and never incur adverse outcomes (making for poor discriminate validity). Additionally, SIRS criteria are often absent in patients who have protracted courses with significant morbidity and mortality (making for poor concurrent validity).

Perhaps the final nail in the coffin for the long-maligned and hotly debated relationship of SIRS criteria and sepsis – a task force of experts in sepsis pathophysiology, clinical trials, and epidemiology convened by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine – concluded unanimously that SIRS criteria are unhelpful. 

The search for statically significant screening criteria for sepsis yielded a rapid assessment approach known as qSOFA (quick sepsis-related organ failure assessment), which was found to identify patients likely to have a prolonged ICU stay or die in the hospital.

qSOFA:

Respiratory rate > or equal to 22/min

Altered mentation

Systolic blood pressure < or equal to 100mm Hg

qSOFA does not require lab exams and can be applied in settings outside of the acute-care facility to identify patients in need of treatment escalation. A confirmatory diagnosis of sepsis should be guided by additional clinical testing to validate that sepsis-related organ stress is occurring in the presence of an infection.  

The Full SOFA criteria (which will require a host of laboratory tests)  include measurements of respiratory status, coagulation profiles, liver stress, cardiovascular functioning, central nervous system response, and renal function. While neither qSOFA nor SOFA are standalone diagnostics of sepsis, they represent a statistically significant starting point. A SOFA score of two or greater is associated with an in-hospital mortality rate of greater than 10 percent. Physicians are being encouraged to continue to utilize SIRS criteria as an indicator of the initial infection, as well as using  expanded SIRS criteria  (such as elevated glucose in the absence of diabetes, elevated procalcitonin, ileus, and blood cultures) in their full workup of a suspected septic patient.

Shock also was addressed in the consensus paper, being defined sharply as fluid resuscitation resistant hypotension with a mean arterial pressure less than or equal to 65 requiring vasopressor support and a serum lactate level of greater than or equal to 2 mmol/L. The combination of SOFA  > or equal to two and the above criteria for septic shock is associated with a greater than 40-percent mortality rate.

According to the JAMA report, the task force has effectively declassified non-severe sepsis as a statistically significant reportable condition, redefining it as what ICD-10 guidelines refer to as “severe sepsis.” The report suggests that the term “severe sepsis” is redundant. Obviously, Coding Clinic and coding guidelines will take some time to catch up with this new definition, and of course, ICD-10 itself is only updated annually.

This raises some concerns. Non-severe sepsis has been removed as a clinically viable diagnosis while the coding rules still will carry on with the old definitions. For this reason, we will probably see the continuation of the application of SIRS and non-severe sepsis for the foreseeable future. Every clinical documentation improvement (CDI) program should begin consulting with their physician advisors and champions to develop a strategy for bridging the discrepancy during the immediate period while this is being addressed.     

The task force recommendation that any patient meeting criteria for SOFA automatically should be reported with the ICD-10 codes for severe sepsis (R65.20) is less problematic, given that sepsis with organ failure has long been the criteria for severe sepsis.

The task force recommends additional clinical trials before the full application of these criteria, so don’t expect SIRS/sepsis to vanish overnight. In spite of that, many physicians no doubt will welcome the change of definition and probably will began adopting the new practice guidelines while slowly ushering SIRS out of the mainstream.

The good news is that this also may put an end to the days of documentation improvement specialists living in a perpetual state of having to endure criticisms of criteria they neither advocated for nor created.

I welcome the new definition, which physicians hopefully will support and adopt; if only I was as hopeful for a quick resolution by the American Hospital Association (AHA) and the Centers for Medicare & Medicaid Services (CMS) to address the matter in Coding Clinic and/or next year’s edition of ICD-10.

Allen R. Frady, RN, BSN, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

With 20 years in healthcare, Allen R. Frady provides clients assistance in the areas of documentation, program implementation and compliance. His background includes critical care nursing, coding, auditing, utilization review, and documentation improvement.

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