The Sepsis Conundrum

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Original story posted on: December 2, 2020

Sepsis can be masked by unrelated or related conditions.

In any quality or utilization review committee meeting, it is rare for the word “sepsis” to fail to appear. Sepsis hits health systems on all levels, from physician documentation to utilization management, discharge planning, documentation integrity, and the inevitable denials from payors. From a review of cost per case, the treatment and management is indeed costly, whether getting a patient vital testing or managing the likely ICU stay. For Accountable Care Organizations (ACOs) and Clinically Integrated Networks (CINs), this diagnosis signifies unpredictability and extensive utilization of resources, as patients discharge to post-acute facilities and have the highest risk for readmission back to the hospital. Despite extensive efforts, health systems continue to struggle to manage the associated complex and often competing priorities, which present when attempting to meet patient and organizational needs.

Sepsis remains a condition that can be complicated to identify and can be masked by unrelated or related conditions. The difficulty is that sepsis is the body's response to an underlying infection or inflammatory response – and therefore, it lacks a consistent presentation and/or linear course. Treatment is centered upon the hunt for source removal, in addition to organ function support. Success is then determined by how quickly the medical team can identify, treat, and obtain a healing response from the patient. Depending on the diagnosis and treatment course, patients can expect a length of stay anywhere between 5 to 12 days, with a likely tour through the emergency department, medical surgery, and intensive care units. At discharge, this course is not over, as the body is exhausted and needs more time to recover, so many patients will be sent to a Skilled Nursing Facility (SNF) for more rehab. At its core, sepsis is a systemic response to an infection; however, depending on the provider, health system, or payor, it can be clarified and defined further by varying criteria.

The lack of consensus surrounding the diagnosis is the crux of the sepsis conundrum. Effective identification, management, and reporting of sepsis hinges on accurate and consistent diagnostic criteria. However, diagnostic consistency is difficult to attain, as clinicians look for clusters of symptoms in often complicated patients. The publication of Sepsis-3 further muddied the waters, as some providers quickly adopted it, while others responded with hesitancy due to a lack of confidence in the methodology, even three years later. This has resulted in practitioners, even those within the same practice, often relying on criteria unique from their peers; some prefer systemic inflammatory response syndrome (SIRS) criteria, others Sepsis-2, while still others have moved to Sepsis-3. The Centers for Medicare & Medicaid Services (CMS) continues to utilize Sepsis-2 for the sepsis bundle and “severe sepsis” (terminology not in Sepsis-3) as an exclusion for the pneumonia readmission cohort, which has performance and financial implications under the Hospital Value-Based Purchasing Program. However, many commercial payers quickly adopted Sepsis-3, recognizing that this publication provided the perfect argument to deny costly claims.

With all these differing priorities, sepsis often feels like a moving target for all parties involved.

Faced with the need to balance various guidelines, organizations have attempted to achieve consistency by establishing organizational definitions, adopting one of the sets of published criteria or using a combination of clinical indicators from both. However, this has not been the easy fix they hoped for, as every potential positive outcome is met with opposing negative limitations. Select Sepsis-2, and denials spike. Select Sepsis-3, and case mix index (CMI) decreases. Use a mix, and frustrate clinicians with inconsistencies. It is virtually impossible to find a common solution that will meet the goals of medical staff, the quality department, the health information management (HIM) department, clinical documentation integrity (CDI), the finance department, and payors.

In February 2020, the U.S. Department of Health and Human Services (HHS) sent out a press release that identified the significant burden sepsis is creating for Medicare. They identified that despite a shorter length of stay, the cost of care for these patients has increased. In 2018, “Medicare spent more than $41.5 billion,” and in 2019, the estimate is expected to reach $62 billion. The expenses come from the initial hospitalization and the likely skilled nursing care that is delivered post-discharge. If you are part of an ACO or CIN, you can add the pre-hospitalization emergency room visit, as HHS reported that CMS found that two-thirds of sepsis patients had a medical encounter within a week prior to the hospitalization. Of the likely hospital readmission, approximately 7 percent of patients were readmitted within seven days after discharge from an index hospitalization for sepsis. Within 90 days of an index hospitalization, over 30 percent of patients were readmitted.

There is no easy answer to the sepsis conundrum that every hospital is faced with, and unfortunately, this article does not offer hospitals or providers the golden nugget of truth. However, maybe there is solace in knowing that you are not alone, and that this condition hits all levels in the care continuum. Despite incongruence in definitions, we know that a sepsis diagnosis means “pay attention” for all providers involved.

Intervention starts in the emergency room to determine underlying needs and successful opportunities for recovery. At discharge, the fight is not over, and care management teams should include this population as being of high risk, in need of continued monitoring to avoid a very likely return to the hospital. 

Tiffany Ferguson, LMSW, ACM, and Katy Good, RN, BSN, MHA, CCS, CCDS

Tiffany Ferguson is an accredited case manager by the American Case Management Association (ACMA), member of the Case Management Society of America (CMSA), and has more than 14 years of direct social work, leadership, and healthcare care management experience.  Tiffany is a licensed social worker who obtained her master’s degree from UCLA. Tiffany currently serves as a consultant for Phoenix Medical Management.

Katy Good is a registered nurse with a clinical background in Emergency Medicine and Intensive Care. She made her way into the field of Clinical Documentation Integrity in 2011 and quickly achieved certification as a Certified Coding Specialist and Clinical Documentation Specialist. She served on the board for the Association of Clinical Documentation Integrity Specialists from 2017-2020. Katy is currently the manager of education at Enjoin.

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