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MD Documentation Tips for Septic Patients 1) Sepsis: Patient with actual or possible infection and at least two (2) infection related Systemic Inflammatory Response Syndrome (SIRS) criteria 2) Severe Sepsis: Patients with Sepsis and at least one (1) infection related Organ Dysfunction 3) Septic Shock: Patients with Severe Sepsis with refractory Hypotension (after administration of IV crystalloid fluid bolus of 30mL/kg) and/or Initial Lactate ≥4.0 v All patients with at least Severe Sepsis require documentation of specific Organ Dysfunction associated with Sepsis in the same sentence. v Correct documentation: Organ dysfunction Due TO sepsis. € Correct: “Respiratory failure DUE TO sepsis. “ “ Acidosis DUE TO sepsis” € Wrong: “Acute Kidney Injury. Sepsis.” Separating the organ dysfunction will prevent coding as Severe Sepsis. SIRS criteria · Hyperthermia >100.9F/38.3C · Hypothermia <96.8F/36.0C · Leukocytosis >12,000 · Leukopenia <4,000 · Tachycardia >90/minute · Tachypnea >20/ minute · Bandemia >10% with normal WBC Organ Dysfunction criteria · Bilirubin >2mg/dl · INR >1.5 or PTT >6 sec without medications · Creatinine >2 mg/dl · Decreased UO <0.5ml/kg/hour for 2 hours · Lactic >2 (Lactic ≥4 = septic shock) · Platelet <100,000 · SBP <90 or MAP < 65 · SBP decrease 40 from baseline · Respiratory Failure with new need for mechanical ventilation or Bipap Time Zero for Severe Sepsis & Septic Shock is based on MD Documentation or Criteria met Ø If the bundle has been completed in ED it is best to capture documentation for the diagnosis of Severe Sepsis, in case the patient does not meet criteria until later. If criteria is met later, then the bundle already completed does not count!!!! Orders and Documentation · Please use the Sepsis Multi-phase Powerplan or ED Sepsis Powerplan · If the patient is hypotensive following fluid bolus Start Vasopressors. If we give more fluid for hypotension and the patient has already received the target fluid bolus we fallout for initiation of vasopressors in the presence of Septic Shock. · Target fluid bolus for hypotension related to Severe Sepsis is 30ml/kg unless BOTH Obesity and Ideal Body Weight is documented. · If the hypotension is related to NON-INFECTIOUS source it has to be documented to not count toward time zero. · If organ dysfunction is related to NON-INFECTIOUS source it has to be documented to not count toward time zero. · Document tissue perfusion after a fluid bolus by including: vital signs, capillary refill, cardiopulmonary evaluation, peripheral pulse, and skin examination.



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