270,000 Americans die of sepsis each year.
But we can't agree on how to diagnose it.
The problem is more complex than you think...
A thread π§΅
But we can't agree on how to diagnose it.
The problem is more complex than you think...
A thread π§΅
The problem?
πΆ Doctors are taught Systemic inflammation (SIRS) + source of infection = Sepsis
πΆ A different definition has been created.
πΆ This has significant financial, and potentially deadly, consequences
Let's dig in ‡οΈ
πΆ Doctors are taught Systemic inflammation (SIRS) + source of infection = Sepsis
πΆ A different definition has been created.
πΆ This has significant financial, and potentially deadly, consequences
Let's dig in ‡οΈ
1 / WHAT DOCTORS LEARN
1οΈβ£ 2 SIRS + source of infection = Sepsis
2οΈβ£ Add organ dysfunction = Severe sepsis
3οΈβ£ Add unresponsive hypotension = Septic shock
This is "Sepsis-2".
So what's the new definition?
1οΈβ£ 2 SIRS + source of infection = Sepsis
2οΈβ£ Add organ dysfunction = Severe sepsis
3οΈβ£ Add unresponsive hypotension = Septic shock
This is "Sepsis-2".
So what's the new definition?
2 / SEPSIS-3
Sepsis-3 was created in a February 2016 JAMA article.
It defines sepsis as:
"Life threatening organ failure due to dysregulated host response to infection."
It does not identify sepsis until organ damage has already occurred.
It uses SOFA criteria...
Sepsis-3 was created in a February 2016 JAMA article.
It defines sepsis as:
"Life threatening organ failure due to dysregulated host response to infection."
It does not identify sepsis until organ damage has already occurred.
It uses SOFA criteria...
SOFA (Sequential organ failure assessment) is a list from 6 organ systems
πΆ Respiratory
πΆ Coagulation
πΆ Cardiovascular
πΆ Liver
πΆ Renal
πΆ CNS
You need 2 to meet criteria. I will not include them all here.
πΆ Respiratory
πΆ Coagulation
πΆ Cardiovascular
πΆ Liver
πΆ Renal
πΆ CNS
You need 2 to meet criteria. I will not include them all here.
For sepsis-3, you either have sepsis or septic shock.
There is NO "severe sepsis".
This will be important laterβ¦
There is NO "severe sepsis".
This will be important laterβ¦
3 / PROBLEMS WITH SEPSIS-3
Problem #1.
SOFA is outdated. It has not been updated since 1994.
Example: It still uses dopamine dosing as criteria.
Dopamine is not used as much anymore.
Problem #1.
SOFA is outdated. It has not been updated since 1994.
Example: It still uses dopamine dosing as criteria.
Dopamine is not used as much anymore.
Problem #2:
CMS (Medicare/Medicaid) does NOT use Sepsis-3.
Hospitals get paid by CMS on how well they treat sepsis.
Their requirements are based on a diagnosis of
...
severe sepsis (or septic shock)
So, is CMS going to change its definition?
CMS (Medicare/Medicaid) does NOT use Sepsis-3.
Hospitals get paid by CMS on how well they treat sepsis.
Their requirements are based on a diagnosis of
...
severe sepsis (or septic shock)
So, is CMS going to change its definition?
NOPE
They double-downed in 2016 and just did AGAIN...
"The Value of SEP-1" was published in Feb 2022 in CHEST.
(SEP-1 = Their bundle of how to IDENTIFY sepsis + treat it)
They double-downed in 2016 and just did AGAIN...
"The Value of SEP-1" was published in Feb 2022 in CHEST.
(SEP-1 = Their bundle of how to IDENTIFY sepsis + treat it)
CMS is NOT just arguing semantics.
They believe that SIRS criteria (which is sensitive, but not specific) and the CMS sepsis bundle are saving lives.
It is the inclusion criteria, not just what we call it, that is important.
This leads us to problem #3β¦
They believe that SIRS criteria (which is sensitive, but not specific) and the CMS sepsis bundle are saving lives.
It is the inclusion criteria, not just what we call it, that is important.
This leads us to problem #3β¦
Problem #3:
Sepsis-3 defines sepsis AFTER organ dysfunction has occurred.
Early identification, and thus treatment, is to PREVENT organ dysfunction.
Sepsis-2 criteria identifies sepsis earlier and, in 2016, was associated with a 15 year trend of improving mortality.
Sepsis-3 defines sepsis AFTER organ dysfunction has occurred.
Early identification, and thus treatment, is to PREVENT organ dysfunction.
Sepsis-2 criteria identifies sepsis earlier and, in 2016, was associated with a 15 year trend of improving mortality.
4/ WHY DOES ALL OF THIS MATTER?
Patients with true sepsis are expensive to treat.
So, insurances pay hospitals based off that. But sepsis-2 over-calls sepsis.
Insurances feel they are overpaying so they prefer Sepsis-3 criteria.
(but remember CMS prefers Sepsis-2).
Patients with true sepsis are expensive to treat.
So, insurances pay hospitals based off that. But sepsis-2 over-calls sepsis.
Insurances feel they are overpaying so they prefer Sepsis-3 criteria.
(but remember CMS prefers Sepsis-2).
This puts hospitals in a tough spot.
If you continue to use sepsis-2, many insurances will deny it.
Denials take time and resources.
Is it worth it to simply tell your doctors to only use sepsis-3?
But what if you miss some patients with sepsis?
And what about CMS?
If you continue to use sepsis-2, many insurances will deny it.
Denials take time and resources.
Is it worth it to simply tell your doctors to only use sepsis-3?
But what if you miss some patients with sepsis?
And what about CMS?
This is an on-going debate. I'd love to hear your thoughts.
What are you hearing from your hospital?
Have you ever heard of Sepsis-2 vs Sepsis-3?
What are residencies teaching? Sepsis-3 is more than just qSOFA.
@On_Diversion (here's your sepsis thread)
What are you hearing from your hospital?
Have you ever heard of Sepsis-2 vs Sepsis-3?
What are residencies teaching? Sepsis-3 is more than just qSOFA.
@On_Diversion (here's your sepsis thread)
@On_Diversion In summary:
1οΈβ£ Doctors learn criteria to identify sepsis EARLY (but does over-call)
2οΈβ£ A new definition (sepsis-3) defines sepsis only AFTER organ dysfunction
3οΈβ£ The new definition relies on outdated criteria
4οΈβ£ Commercial insurers and CMS (Medicare/medicaid) don't agree.
1οΈβ£ Doctors learn criteria to identify sepsis EARLY (but does over-call)
2οΈβ£ A new definition (sepsis-3) defines sepsis only AFTER organ dysfunction
3οΈβ£ The new definition relies on outdated criteria
4οΈβ£ Commercial insurers and CMS (Medicare/medicaid) don't agree.
@On_Diversion That's a wrap!
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2. RT the tweet below to share this thread with your audience
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