June 27, 2016

Is Sepsis Now Severe Sepsis?

EDITOR’S NOTE: The late Robert S. Gold, MD tackled the issue of sepsis even before the advent of the 1992 SIRS criteria. He made certain that healthcare professionals should be aware that capturing the true clinical picture should be first and foremost on the agenda. This is the second in a series of articles on the subject of sepsis. Dedicated to Dr. Gold’s memory, this series has been written by Cesar M. Limjoco, MD, vice president of clinical services for DCBA, Inc., a consulting firm co-founded by Dr. Gold.

Sepsis-3 definition: "Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection."

"So now sepsis is now classified as severe sepsis! What has happened to sepsis? Or is there no sepsis, just severe sepsis?" Brian Cui asked in his Facebook page, The CDI network. Interestingly, Jean Louis Vincent, MD, the current “father of sepsis,” stated in an editorial in “Critical Care” magazine way back in 2012: “The confusion related to sepsis definitions and terminology was amplified some 20 years ago when

participants at a North American consensus conference confused signs of infection, such as fever and altered white blood cell count, with signs of sepsis, so that sepsis

became severe sepsis, and so on and so forth. But that debate is now part of history and we must move on.”

Did sepsis really disappear? In order to get it straight in our minds, we have to get back to what is really happening inside a patient who is in sepsis. What is a "dysregulated" host’s response to infection? An immune system that has gone awry is what it really is, ending up in organ failure(s). There is a small window of time when the patient is not yet in full organ failure. Depending on the organ, there are certain parameters that need to be met before you can say that the organ is in failure. Let's take one system—circulatory. Circulatory failure (in particular, septic shock) develops when the blood pressure is so low that the circulatory system is not able to perfuse the rest of the organs and tissues. In addition to its direct signs and symptoms, this perfusion deficit usually happens with around half an hour of significant hypotension. So there is a time wherein the blood pressure is significantly low, but the tissues have not yet suffered immensely. You can call this a state of dysfunction that has not fully evolved into failure. (In children, it is the peripheral vasodilatation that can lead to the diagnosis of septic shock well before blood pressure drops.)

What about respiratory dysfunction? A patient can have a hard time breathing and is in respiratory or ventilatory difficulties with hypoxia or hypercapnia. When the respiratory "dysfunction" gets serious enough that gaseous exchange is fully compromised (i.e., significant hypoxia or hypercapnia, or both), the patient is now in respiratory "failure" which can become so severe that ARDS (Acute Respiratory Distress Syndrome) develops.

Thus, there is cardiac dysfunction that is not yet failure and there is dysfunction that is true cardiac failure. The same goes for the rest of the vital organs—renal, brain (metabolic encephalopathy), hepatic, bone marrow, etc. To reiterate, there is dysfunction that is not yet failure and then there is dysfunction that is now in full failure. In short, the term dysfunction can mean with or without failure! It’s all semantics, but it infers a range in severity of illness.

The current ICD-10-CM coding system is based on previous writings about sepsis. There was a well-defined continuum from infection to sepsis (SIRS) to severe sepsis to septic shock. ICD10 is using the term “organ dysfunction” to mean organ failure (because many providers use them synonymously, e.g., LV dysfunction with ≤40% EF as synonymous with systolic heart failure), but the sepsis-3 definition's usage of the term dysfunction is inclusive of both with and without failure. The future will show some modifications of advice on how to adapt the existing system to the new definitions.

Regarding the Present On Admission (POA) issue, the patient is either admitted with sepsis with organ failure (severe sepsis) or patient was admitted with sepsis and develops organ failure after admission. In both cases, sepsis was POA. In the latter case, the organ failure(s) was (or were) not POA. Or, the patient was not septic on admission at all and it developed in the course of hospitalization—not POA at all!

Now that we understand what goes on behind the pathophysiology of sepsis, we then need to represent them with ICD codes. And this is where the conundrum lies! There are codes for sepsis with and without ORGAN DYSFUNCTION, but not with or without failure! The narrative description of the codes need to be corrected, because the issue is whether the patient has organ dysfunction WITHOUT FAILURE or organ dysfunction WITH FAILURE. To put it more simply, the descriptions should say, SEPSIS WITHOUT ORGAN FAILURE and SEPSIS WITH ORGAN FAILURE (i.e., SEVERE SEPSIS). In the meantime, while they undertake the process of changing the narrative, we still need to impart a difference in severity between sepsis (~10% mortality rate) and severe sepsis (~50-60% mortality rate). With sepsis, one way to do it is to use the current ICD code for sepsis without organ dysfunction. For severe sepsis, use the current code for sepsis with organ dysfunction; and then code the identified organ failure(s). For now, that should work! Severity of illness will be redeemed.
Cesar M Limjoco, MD

Dr. Limjoco has more than 25 years of experience as a consultant with significant expertise in the capture of severity of illness in clinical documentation.  He serves as vice president of clinical services of DCBA, Inc. a position he has held since 2005. Dr. Limjoco is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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