Lawsuit Cites Trauma Alerts And Sepsis Alerts

[2021Doctor]

Doctors allege non-physicians activate codes
In the North Carolina whistleblower complaint, the doctors said unnecessary trauma codes were typically activated by a non-physician, often a physician’s assistant, who was given little time to make an actual assessment.
After April 15, 2020, when TeamHealth started delivering contracted services to Mission Hospital’s Emergency Department, the number of trauma activations surged, according to the lawsuit.
On one busy ER shift in May 2022, Ramming witnessed many medically ill patients getting trauma designations, yet many ending up going home, according to the complaint. When he commented on this to the physician’s assistant who was on duty, the response was “trauma overcalls aren’t a problem for corporate medicine,” according to the complaint.
Ramming described a case of an 85-year-old woman who came to Mission’s Highlands hospital emergency room with cat scratches and was given a sepsis alert. He canceled the tests, which were “not needed for cat scratches, needless to say,” he said.
Mid-level practitioners in the emergency department were incentivized to order numerous unneeded or redundant lab tests, including blood samples, urinalysis, laboratory analyses, metabolic panels, CT scans and X-rays, according to the lawsuit.
He also noted that it was common to over-code patients as sepsis cases because it not only pads the bill for extra testing, but also pools non-septic patients with truly sick ones, lowering the overall mortality rate.
Doctors’ lawsuit: HCA Healthcare and TeamHealth overcharged patients

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[RustedFox]

That's an HCA thing, not a TeamHealth thing.

The sepsis circus needs to die.
I fight this battle every day; fortunately it's an easy one with my canned phrases.

 

[WilcoWorld]

On my last shift I was saying that I think Stroke Center certification has probably harmed far more patients than it has helped. The momentum created when we activate these protocols out of a desire to avoid a metrics fallout, rather than because we actually think the patient needs it, can really get in the way of good care.

 

[VA Hopeful Dr]

The Feds declined to get involved, good chance this isn't going anywhere.

 

[Pudortu]

That's an HCA thing, not a TeamHealth thing.

The sepsis circus needs to die.
I fight this battle every day; fortunately it's an easy one with my canned phrases.

Please share

 

[ScepticSkeksis]

The code sepsis is egregious. Not every febrile, tachy, 21-year old with flu has sepsis. I see midlevels active sepsis on nearly every patient with a fever, even though there's an obvious source and the patient is clearly not septic. How common is random sepsis in healthy people under 40?

 

[RustedFox]

Please share

Exactly what Skeksis said above. RLPs put in sepsis orders on every single patient they see.

To "stop the nonsense", if there's a SIRS criteria present and I don't want a lactic, ALL the saline, and a dose of Ceftriaxone... RIGHT UNDER the vital signs, I put in my disclaimer. I work tonight, so I'll go copy-paste it here.

 

[JacobMcCandles]

The code sepsis is egregious. Not every febrile, tachy, 21-year old with flu has sepsis. I see midlevels active sepsis on nearly every patient with a fever, even though there's an obvious source and the patient is clearly not septic. How common is random sepsis in healthy people under 40?

More white coat nurse clinical admins (who will lose their jobs once the government moves on to something other than sepsis) who haven't worked bedside this millenia and can't even get meds out of the pixis, etc. who come down and stand around in the ED in the way is the last thing we need.

 

[wareagle726]

A travel nurse came up to me last night acting like somebody was actively dying..."bed 14 meets sepsis criteria! please put in the sepsis bundle and abx." I told her they didn't have an infection so they don't need abx/sepsis protocol. I saw her note later "Dr. WE notified about positive sepsis screen, he declined to act on this information." What did the patient present for you may ask? Young guy isolated gsw to the foot positive for cocaine.

 

[EMhawkeye]

A travel nurse came up to me last night acting like somebody was actively dying..."bed 14 meets sepsis criteria! please put in the sepsis bundle and abx." I told her they didn't have an infection so they don't need abx/sepsis protocol. I saw her note later "Dr. WE notified about positive sepsis screen, he declined to act on this information." What did the patient present for you may ask? Young guy isolated gsw to the foot positive for cocaine.

I would chart a free text note

“Nurse so and so informed me patient met sirs criteria. Rn jenny mcjennerson educated on sepsis criteria”

 

[EMhawkeye]

A travel nurse came up to me last night acting like somebody was actively dying..."bed 14 meets sepsis criteria! please put in the sepsis bundle and abx." I told her they didn't have an infection so they don't need abx/sepsis protocol. I saw her note later "Dr. WE notified about positive sepsis screen, he declined to act on this information." What did the patient present for you may ask? Young guy isolated gsw to the foot positive for cocaine.

Love the screenname btw. War eagle!

 

[DocEspana]

Exactly what Skeksis said above. RLPs put in sepsis orders on every single patient they see.

To "stop the nonsense", if there's a SIRS criteria present and I don't want a lactic, ALL the saline, and a dose of Ceftriaxone... RIGHT UNDER the vital signs, I put in my disclaimer. I work tonight, so I'll go copy-paste it here.

here for the macro

 

[ScepticSkeksis]

I want a macro that's like a "Patronum" against the clipboard dementors.

 

[BoardingDoc]

I am utterly lost in regards to this entire thing. The first shop I worked at had a sepsis orderset that would trigger based on vitals with all this annoying crap in it that was rarely necessary. I've never seen one since, and I have definitely never heard of a "code sepsis" though based on everyone chiming in, it seems this is a widespread thing?

 

[CajunMedic]

Previous job: Somehow waylaid on to the sepsis committee, getting the constant "Dr. Medic, don't forget to make sure the residents are putting in the sepsis bundle orders and using the canned text" from the clipboard nurses, dealing with "time zero" and all the extra sepsis paperwork.

Current job: Me to charge nurse:"Hey, I forgot to start antibiotics in time and we're probably gonna fall out. Is there a form to document time zero and the rest of the sepsis stuff?" Charge nurse: "Yeah, we don't do any of that here. Pretty sure no one cares or is keeping track of it." Not sure how it's getting done, but I'm not getting emails from admin about sepsis metrics...

 

[JacobMcCandles]

I am utterly lost in regards to this entire thing. The first shop I worked at had a sepsis orderset that would trigger based on vitals with all this annoying crap in it that was rarely necessary. I've never seen one since, and I have definitely never heard of a "code sepsis" though based on everyone chiming in, it seems this is a widespread thing?

Code Sepsis is something that gets tried every 2 or 3 years. What happens is that the sepsis committee leader (who is always some kind of non-clinical nurse) thinks that the only thing the ED ever sees is sepsis. They're focused on sepsis so they forget about all the other patients we see. This happens with strokes, MIs, anything with a committee, etc. They think it'll be easy to identify every septic patient, disregarding the fact that the majority of people who qualify for a Code Sepsis won't truly be septic. This leads to nurses feeling like they have to spend more time on these patients which leads to worse care for all the other patients...not to mention all the people who get unnecessary lactics, cultures, and antibiotics.

The number of people who 'fall out' of meeting the protocol never changes because many of these issues are unrelated such as the lactic, cultures, and antibiotics all get put in at the same time but then they're scanned wrong even though the lactic and cultures were drawn before the antibiotics. Or the patient has two documented blood pressures/MAPs that meet the criteria for 'septic shock' but the blood pressures were taken 15 seconds apart and then not pulled into the chart until the patient is out of the ED. Nonetheless, the mortality never changes because we're not doing anything that actually improves care and getting lactics that don't change management 30 seconds after an antibiotic is hung is a fall out but doesn't truly change mortality for the patient. While they try to change everything, nothing really changes except worse care for the patients and more frustration for the actual clinical nurses and physicians. They end up stopping the Code Sepsis responses and the sepsis nurse ends of losing their job and they hire another or just repeats the same thing over and over again. Admin doesn't understand that they'd save money and patients would get better care if they just fired the non-clinical nurses and disbanded the sepsis committee.

 

[bravotwozero]

Previous job: Somehow waylaid on to the sepsis committee, getting the constant "Dr. Medic, don't forget to make sure the residents are putting in the sepsis bundle orders and using the canned text" from the clipboard nurses, dealing with "time zero" and all the extra sepsis paperwork.

Current job: Me to charge nurse:"Hey, I forgot to start antibiotics in time and we're probably gonna fall out. Is there a form to document time zero and the rest of the sepsis stuff?" Charge nurse: "Yeah, we don't do any of that here. Pretty sure no one cares or is keeping track of it." Not sure how it's getting done, but I'm not getting emails from admin about sepsis metrics...

I think covid changed the stance on sepsis protocol for a lot of hospitals,
Especially when evidence emerged that goal directed therapy with the fluid boluses was doing more harm than good in Covid pneumonia.

Since then, although our hospital wants us to use the order set, they’re not coming down on people as much for fallouts. Particularly true if I just state in MDM my reason, saying I don’t think it’s sepsis etc.

 

[southerndoc]

FWIW I'm the sepsis committee chair for my health system. I argue against code sepsis when it's brought up.

I suspect that there will be a huge push nationwide for more SEP-1 compliance. I have heard a lot of discussion regarding CMS tying SEP-1 compliance to reimbursements. From what I'm hearing, this will affect ALL reimbursements for every CMS patient -- inpatient and ED visits -- whether related to sepsis or not. The rumor is that 2026 reimbursements will be tied to 2024's SEP-1 performance with the most compliant hospitals getting a bonus and the least compliant getting reductions in reimbursements.

Sepsis treatment does help, but there is a point where it all becomes non-sense. 30 mL/kg doesn't show as much benefit as antibiotics in reducing mortality. Instead of preaching cultures, lactates, and 30 mL/kg boluses, we should be preaching early antibiotics. Antibiotics within 1 hour have been shown to reduce mortality, but we often delay them in order to obtain blood cultures, lactate, and fill the checkboxes of SEP-1.

BTW, the SEP-1 measures are implemented by CMS without opening it to public comment. There are things about to become part of the bundle that I am in strong disagreement with.

 

[gutonc]

FWIW I'm the sepsis committee chair for my health system. I argue against code sepsis when it's brought up.

I suspect that there will be a huge push nationwide for more SEP-1 compliance. I have heard a lot of discussion regarding CMS tying SEP-1 compliance to reimbursements. From what I'm hearing, this will affect ALL reimbursements for every CMS patient -- inpatient and ED visits -- whether related to sepsis or not. The rumor is that 2026 reimbursements will be tied to 2024's SEP-1 performance with the most compliant hospitals getting a bonus and the least compliant getting reductions in reimbursements.

Sepsis treatment does help, but there is a point where it all becomes non-sense. 30 mL/kg doesn't show as much benefit as antibiotics in reducing mortality. Instead of preaching cultures, lactates, and 30 mL/kg boluses, we should be preaching early antibiotics. Antibiotics within 1 hour have been shown to reduce mortality, but we often delay them in order to obtain blood cultures, lactate, and fill the checkboxes of SEP-1.

BTW, the SEP-1 measures are implemented by CMS without opening it to public comment. There are things about to become part of the bundle that I am in strong disagreement with.

I have no dog in the sepsis fight (outside of working in a hospital based outpatient clinic that might get hammered if what you describe comes to pass in 3 years), but I want to thank you for sitting on that committee and fighting the good fight for your colleagues.

I think that a lot of physicians (here on SDN and in general) just like to b**ch and moan about all the outside influences on our practice of medicine, but when offered the opportunity to actually be part of the decision making process, say no, and then continue to complain. I spent 5 years as a medical director trying to get my partners to understand this and step up, and only when I quit (and walked away from a dozen or so such committees that I was on), did anybody stop for a second to realize how important physician representation is in these settings. T

he clipboard nurses don't get their marching orders out of thin air, they come from these committees. If you want to make the clipboard nurses do something useful, or (better yet), go away, get involved, and speak louder and with more conviction/data than the other people on the committee, who I assure you are mostly former clipboard nurses who got promoted, and the admin d-bags that promoted them.

TL;DR: Put up or shut up.

 

[RustedFox]

here for the macro

I forgot about this.
Worked at our new Freestanding ER that night, and slept from 11:30 - 6:30.

Here it is:

"One or more SIRS criteria are noted; but the sepsis bundle was NOT initiated, as the patient's presentation is felt to beat least as likely as not due to a non-infectious etiology (in this case, [ ]), and hasty administration of fluids and/or antibiotics is therefore felt to be detrimental to this patient's care given the associated risk of adverse effects such as fluid overload, C.difficile, cardiac conduction abnormalities, immune derangement (SJS/TEN), etc."

Inside the brackets, I put whatever it is that I suspect is actually going on with the patient (heat injury, alcohol intoxication/withdrawal, anxiety, primary tachydysrhythmia, etc.)

I never hear from the sepsis police anymore.

 

[JacobMcCandles]

Sepsis treatment does help, but there is a point where it all becomes non-sense. 30 mL/kg doesn't show as much benefit as antibiotics in reducing mortality. Instead of preaching cultures, lactates, and 30 mL/kg boluses, we should be preaching early antibiotics. Antibiotics within 1 hour have been shown to reduce mortality, but we often delay them in order to obtain blood cultures, lactate, and fill the checkboxes of SEP-1.

This is true for those with septic shock. This hasn’t truly been shown to be correct for those with regular old sepsis.

 

[RustedFox]

Code Sepsis is something that gets tried every 2 or 3 years. What happens is that the sepsis committee leader (who is always some kind of non-clinical nurse) thinks that the only thing the ED ever sees is sepsis. They're focused on sepsis so they forget about all the other patients we see. This happens with strokes, MIs, anything with a committee, etc. They think it'll be easy to identify every septic patient, disregarding the fact that the majority of people who qualify for a Code Sepsis won't truly be septic. This leads to nurses feeling like they have to spend more time on these patients which leads to worse care for all the other patients...not to mention all the people who get unnecessary lactics, cultures, and antibiotics.

The number of people who 'fall out' of meeting the protocol never changes because many of these issues are unrelated such as the lactic, cultures, and antibiotics all get put in at the same time but then they're scanned wrong even though the lactic and cultures were drawn before the antibiotics. Or the patient has two documented blood pressures/MAPs that meet the criteria for 'septic shock' but the blood pressures were taken 15 seconds apart and then not pulled into the chart until the patient is out of the ED. Nonetheless, the mortality never changes because we're not doing anything that actually improves care and getting lactics that don't change management 30 seconds after an antibiotic is hung is a fall out but doesn't truly change mortality for the patient. While they try to change everything, nothing really changes except worse care for the patients and more frustration for the actual clinical nurses and physicians. They end up stopping the Code Sepsis responses and the sepsis nurse ends of losing their job and they hire another or just repeats the same thing over and over again. Admin doesn't understand that they'd save money and patients would get better care if they just fired the non-clinical nurses and disbanded the sepsis committee.

We had a "sepsis fallout" on a STEMI once. I kid you not.

 

[PianoMedic]

To the brain trust here, honest question: in what instances is SEP-1 applied? Is the trigger the old severe sepsis, so lactic over 4.0 or hypotension with sepsis as suspected etiology? Or is it sirs positive with a source? Or is it some other method of application (ie sepsis becomes diagnosis somewhere down the line and then they back time it to start somewhere)?

 

[sloh]

He also noted that it was common to over-code patients as sepsis cases because it not only pads the bill for extra testing, but also pools non-septic patients with truly sick ones, lowering the overall mortality rate.

Will Rogers. It's interesting how prevalent this is in medicine. You also see it in cancer medicine.

The Will Rogers phenomenon refers to the “improved” survival of patients with cancer or other diseases by either reclassifying them into different prognostic groups, recognizing subtle disease manifestations, or by using diagnostic modalities that allow the disease to be diagnosed at an earlier stage.

"The 'Will Rogers phenomenon' is an apparent epidemiological paradox named after a remark made by the humorist Will Rogers about migration during the American economic depression of the 1930's: "When the Okies left Oklahoma and moved to California, they raised the average intelligence level in both states." In 1985, Alvan Feinstein proposed the name 'Will Rogers Phenomenon' to describe the 'stage migration' he observed in patients with cancer. Changes in the criteria for assigning patients to the various stages of a disease can produce spurious improvements in stage-specific prognosis, even though the outcome of individual patients has not changed. In oncology, new imaging tools allowed detection of cancer metastases before they became evident clinically. In consequence, more patients are classified into the more severe metastatic disease stage from the less severe single tumour stage. Such a 'stage migration' resulted in an improved survival of patients in both the less and the more severe disease stages. Multiple sclerosis is also subject to the Will Rogers phenomenon since the introduction of the imaging-assisted McDonald criteria. Given the sensitivity of magnetic resonance imaging for detecting disease activity, which is believed to be five to ten times greater than that of clinical assessment, the McDonald criteria are expected to allow earlier diagnosis, hence the 'stage migration' relative to the previous Poser diagnostic criteria. Because of the ethical problems associated with carrying out placebo-controlled trials in multiple sclerosis owing to the wider availability of therapeutic options, the use of historical controls groups remains an attractive option. However, the Will Rogers phenomenon, which is recognised as one of the most important biases limiting the use of historical controls groups in experimental treatment trials, compromises the interest of this approach. In this context, the use of different diagnostic criteria may generate spurious improvements in the medium-term prognosis of multiple sclerosis, which may be wrongly interpreted as treatment effects."

 

[Rekt]

I have no dog in the sepsis fight (outside of working in a hospital based outpatient clinic that might get hammered if what you describe comes to pass in 3 years), but I want to thank you for sitting on that committee and fighting the good fight for your colleagues.

I think that a lot of physicians (here on SDN and in general) just like to b**ch and moan about all the outside influences on our practice of medicine, but when offered the opportunity to actually be part of the decision making process, say no, and then continue to complain. I spent 5 years as a medical director trying to get my partners to understand this and step up, and only when I quit (and walked away from a dozen or so such committees that I was on), did anybody stop for a second to realize how important physician representation is in these settings. T

he clipboard nurses don't get their marching orders out of thin air, they come from these committees. If you want to make the clipboard nurses do something useful, or (better yet), go away, get involved, and speak louder and with more conviction/data than the other people on the committee, who I assure you are mostly former clipboard nurses who got promoted, and the admin d-bags that promoted them.

TL;DR: Put up or shut up.

Have you sat on any committees or just director? I’ve sat on multiple and am currently on several as my hospital providers incentive to do so.

I’d disagree and even go as far as to say committee’s are anti physician. They don’t exist to improve our life or even improve patient care. They exist because all the non clinical and former clinical clipboard warriors that work banker hours four days a week need a job and this is their big checkbox.

Maybe it’s because you’re a specialist, whereas with EM we’re usually just “extra”.

On one of my committees it took 18 months to remove a single order from an order set that hasn’t had clinical relevance for 20 years that was autoclicked and ordered. Committees are a joke.

 

[JacobMcCandles]

My committee experience has typically been that they know what they want to do but they just want to give the illusion that you get some say. They don’t want physicians who won’t roll over and go along with whatever absurd experiment they want to try. Remember, many of these committees exist to continue to try to justify their existence. My one exception was the P&T Committee. Maybe it was the pharmacy director but I felt he actually listened and worked to make things better for every department.

 

[Mount Asclepius]

To the brain trust here, honest question: in what instances is SEP-1 applied? Is the trigger the old severe sepsis, so lactic over 4.0 or hypotension with sepsis as suspected etiology? Or is it sirs positive with a source? Or is it some other method of application (ie sepsis becomes diagnosis somewhere down the line and then they back time it to start somewhere)?

Sepsis is generally defined as an infection plus organ damage.

For SEP-1:

• Sepsis is defined as infection + 2 SIRS criteria + organ damage.
• Organ damage is defined as SBP <90, MAP<65, SBP decrease >40, acute respiratory failure as evident by need of NIV (BiPAP or CPAP) or invasive ventilation, creatinine >2, UOP <0.5 ml/kg/hour over 2 hours, bilirubin >2, PLT <100K, INR >1.5, or lactate >2.
• Time of sepsis is the first point when infection, SIRS and organ damage are all present.

 

[PianoMedic]

Sepsis is generally defined as an infection plus organ damage.

For SEP-1:

• Sepsis is defined as infection + 2 SIRS criteria + organ damage.
• Organ damage is defined as SBP &lt;90, MAP &lt;65, SBp decrease &gt; 40, acute respiratory failure as evident by need of NIV (BiPAP or CPAP) or invasive ventilation, creatinine &gt;2, UOP kg/hour over 2 hours, bilirubin &gt;2, PLT &lt;100k, INR&gt;1.5, or lactate &gt;2.
• Time of sepsis is the first point when infection, SIRS and organ damage are all present.

Thanks for that, very clear and concise and about what I remembered, just some details were missing. I was hearing some QA people in the ED talking about lactics recently and I wanted to be more knowledgeable speaking about this crap.

 

[Siggy]

A travel nurse came up to me last night acting like somebody was actively dying..."bed 14 meets sepsis criteria! please put in the sepsis bundle and abx." I told her they didn't have an infection so they don't need abx/sepsis protocol. I saw her note later "Dr. WE notified about positive sepsis screen, he declined to act on this information." What did the patient present for you may ask? Young guy isolated gsw to the foot positive for cocaine.

I hate it when my wound cultures grow cocaine.

 

[Apollyon]

I forgot about this.
Worked at our new Freestanding ER that night, and slept from 11:30 - 6:30.

Here it is:

"One or more SIRS criteria are noted; but the sepsis bundle was NOT initiated, as the patient's presentation is felt to be at least as likely as not due to a non-infectious etiology (in this case, [ ]), and hasty administration of fluids and/or antibiotics is therefore felt to be detrimental to this patient's care given the associated risk of adverse effects such as fluid overload, C.difficile, cardiac conduction abnormalities, immune derangement (SJS/TEN), etc."

Inside the brackets, I put whatever it is that I suspect is actually going on with the patient (heat injury, alcohol intoxication/withdrawal, anxiety, primary tachydysrhythmia, etc.)

I never hear from the sepsis police anymore.

I see what you did there!

 

[Fox800]

Sepsis is generally defined as an infection plus organ damage.

For SEP-1:

• Sepsis is defined as infection + 2 SIRS criteria + organ damage.
• Organ damage is defined as SBP <90, MAP<65, SBP decrease >40, acute respiratory failure as evident by need of NIV (BiPAP or CPAP) or invasive ventilation, creatinine >2, UOP <0.5 ml/kg/hour over 2 hours, bilirubin >2, PLT <100K, INR >1.5, or lactate >2.
• Time of sepsis is the first point when infection, SIRS and organ damage are all present.

The 30 mL/kg crystalloid insanity is only indicated for septic shock, correct? Defined as SBP <90, SBP decrease >40, or lactate >4, yes?

 

[RustedFox]

The 30 mL/kg crystalloid insanity is only indicated for septic shock, correct? Defined as SBP <90, SBP decrease >40, or lactate >4, yes?

Correct

 

[EctopicFetus]

We go thru our ebbs and flows on this. So much of it is dumb and just gaming the system. I feel lucky that other than money my hospital doesnt care about much. (No its not an HCA hospital).

Perhaps we will feel the push once CMS ties $$ to this. During covid we were told that our mortality for sepsis was an outlier compared to other hospitals. This was across all of our EDs. I was dumbfounded cause i would say our docs are above avg, it is hard to get a job in my group and very engaged clinicians.

Welp turns out they didnt pull out all the covid deaths an voila we were doing an excellent job as we felt we were.

There is a lot of gamesmanship in these numbers, what gets counted and what doesnt (See the Will Rogers effect) has more to do with what happens than almost anything else.

 

[EctopicFetus]

Most Em trained docs will do a bang up job with sepsis. Medicine has made a push to protocolize everything. however, humans and their ailments arent as clear cut as the non doctors think.

As mentioned this holds true with other "code" problems. I was on a stroke committee for a while and the head stroke guy wanted them called right away for a pretty long list of complaints including AMS. I said if you want to understand how often you will be called just look at the board right now. I logged in and showed him the amount of psych, confused, intoxicated patients were in the ED. I said you may as well park the neurologist in the ED.

We were able to do away with the stupidity.

 

[Mount Asclepius]

The 30 mL/kg crystalloid insanity is only indicated for septic shock, correct? Defined as SBP <90, SBP decrease >40, or lactate >4, yes?

Correct, or MAP<65.

 

[RustedFox]

Have you sat on any committees or just director? I’ve sat on multiple and am currently on several as my hospital providers incentive to do so.

I’d disagree and even go as far as to say committee’s are anti physician. They don’t exist to improve our life or even improve patient care. They exist because all the non clinical and former clinical clipboard warriors that work banker hours four days a week need a job and this is their big checkbox.

Maybe it’s because you’re a specialist, whereas with EM we’re usually just “extra”.

On one of my committees it took 18 months to remove a single order from an order set that hasn’t had clinical relevance for 20 years that was autoclicked and ordered. Committees are a joke.

Bro. Let me tell you about my time on the "sepsis committee".

I agree with you en force.

 

[gutonc]

Have you sat on any committees or just director? I’ve sat on multiple and am currently on several as my hospital providers incentive to do so.

I’d disagree and even go as far as to say committee’s are anti physician. They don’t exist to improve our life or even improve patient care. They exist because all the non clinical and former clinical clipboard warriors that work banker hours four days a week need a job and this is their big checkbox.

Maybe it’s because you’re a specialist, whereas with EM we’re usually just “extra”.

On one of my committees it took 18 months to remove a single order from an order set that hasn’t had clinical relevance for 20 years that was autoclicked and ordered. Committees are a joke.

I have sat on a lot of different committees, I’d estimate more than a dozen over the past decade. Some were short term things intended to address a single issue, others were ongoing for years.

And I never said these committees were not anti-physician or created for our benefit. I said that, unless we’re at the table and speaking up, we get what we deserve.

Most of the committees I joined, I did in order to advocate for myself and my physician colleagues. And only a small handful of the committees were specialty specific.

 

[CoolDoc1729]

I forgot about this.
Worked at our new Freestanding ER that night, and slept from 11:30 - 6:30.

Here it is:

"One or more SIRS criteria are noted; but the sepsis bundle was NOT initiated, as the patient's presentation is felt to beat least as likely as not due to a non-infectious etiology (in this case, [ ]), and hasty administration of fluids and/or antibiotics is therefore felt to be detrimental to this patient's care given the associated risk of adverse effects such as fluid overload, C.difficile, cardiac conduction abnormalities, immune derangement (SJS/TEN), etc."

Inside the brackets, I put whatever it is that I suspect is actually going on with the patient (heat injury, alcohol intoxication/withdrawal, anxiety, primary tachydysrhythmia, etc.)

I never hear from the sepsis police anymore.

Love this! I think I will make it slightly snarkier and add to my dot phrases. It gives me enjoyment to write funny or snarky things in the chart. Exact quotes about patient cc: requesting a soda and some hospital socks, or what the patients were watching on TV during their episode of 10/10 abdominal pain. That way I get a laugh if I have to 🙄 review a chart from 6 weeks ago for some stupid reason 😂 also then I can usually remember which person it is since I’ve seen a few hundred other patients by then

 

[southerndoc]

To the brain trust here, honest question: in what instances is SEP-1 applied? Is the trigger the old severe sepsis, so lactic over 4.0 or hypotension with sepsis as suspected etiology? Or is it sirs positive with a source? Or is it some other method of application (ie sepsis becomes diagnosis somewhere down the line and then they back time it to start somewhere)?

The actual CMS measure? It's only abstracted by the chart abstractors if there is a sepsis diagnosis upon discharge (from the hospital; patients discharged from the ED aren't included). To add to what @Mount Asclepius mentioned, there is a very stupid CMS rule that your note open time will be used for sepsis time if you diagnose sepsis in the ED and don't document the time you treated it. There's a lot of quack stuff with nuances of SEP-1 -- note open time, "rule out sepsis" in your differential starts the clock, etc. We even submitted a question to CMS asking for explanation for why adding it to the differential starts the clock, and they basically replied with "we view it as the initiation of sepsis treatment." So if you put in your differential "rule out aortic dissection," then you should start treatment immediately by contacting the cardiovascular surgeon and prepping the patient to go to the OR before you do the CT. Ridiculous.

 

[southerndoc]

The 30 mL/kg crystalloid insanity is only indicated for septic shock, correct? Defined as SBP <90, SBP decrease >40, or lactate >4, yes?

Just a technicality, but a SBP <90 or MAP <65 doesn't mean septic shock. It qualifies for severe sepsis, but does still require the 30 mL/kg bolus unless you exclude it based on CHF, ESRD, LVAD, etc. A lactate >4 is septic shock even with a normal blood pressure unless you justify the lactate as coming from another source (hypoxemia, metformin, seizures, albuterol treatment, etc.). Septic shock from hypotension is when the patient is unresponsive to fluids.

 

[FutureInternist]

Doctors allege non-physicians activate codes
In the North Carolina whistleblower complaint, the doctors said unnecessary trauma codes were typically activated by a non-physician, often a physician’s assistant, who was given little time to make an actual assessment.
After April 15, 2020, when TeamHealth started delivering contracted services to Mission Hospital’s Emergency Department, the number of trauma activations surged, according to the lawsuit.
On one busy ER shift in May 2022, Ramming witnessed many medically ill patients getting trauma designations, yet many ending up going home, according to the complaint. When he commented on this to the physician’s assistant who was on duty, the response was “trauma overcalls aren’t a problem for corporate medicine,” according to the complaint.
Ramming described a case of an 85-year-old woman who came to Mission’s Highlands hospital emergency room with cat scratches and was given a sepsis alert. He canceled the tests, which were “not needed for cat scratches, needless to say,” he said.
Mid-level practitioners in the emergency department were incentivized to order numerous unneeded or redundant lab tests, including blood samples, urinalysis, laboratory analyses, metabolic panels, CT scans and X-rays, according to the lawsuit.
He also noted that it was common to over-code patients as sepsis cases because it not only pads the bill for extra testing, but also pools non-septic patients with truly sick ones, lowering the overall mortality rate.
Doctors’ lawsuit: HCA Healthcare and TeamHealth overcharged patients

Pa-

Ra-

Graphs.

😏

 

[Apollyon]

Septic shock from hypotension is when the patient is unresponsive to fluids.

And that's when the "time of death" clock starts. In other words, that's already when they're failing.

And, wouldn't it be the other way? "Hypotension from septic shock is when the patient is unresponsive to fluids"?

 

[FutureInternist]

On my last shift I was saying that I think Stroke Center certification has probably harmed far more patients than it has helped. The momentum created when we activate these protocols out of a desire to avoid a metrics fallout, rather than because we actually think the patient needs it, can really get in the way of good care.

Goodhart's law - Wikipedia

 

[southerndoc]

And that's when the "time of death" clock starts. In other words, that's already when they're failing.

And, wouldn't it be the other way? "Hypotension from septic shock is when the patient is unresponsive to fluids"?

No, the definition of septic shock is hypotension unresponsive to a 30 mL/kg bolus in the one hour after the bolus is complete (requiring 2 BPs to be documented) OR a lactate >4.

 

[DocEspana]

We had a "sepsis fallout" on a STEMI once. I kid you not.

I had a "sepsis fallout" on a cardiac arrest who developed pancreatitis 5 days into their stay and had 6(!!) negative cultures during their stay.... but the lactate drawn after the cardiac arrest was 15 and the ROSC vitals were tachy and I set the vent setting to >20.

I know its maybe unnecessary in this group to explain, but for the few med students floating around, lets enumerate:
Sepsis fallout only goes back 48 hours
Pancreatitis (especially in a ICU patient) is generally an aseptic phenomenon
That many negative blood cultures really cements there was never an infectious etiology
A temporarily dead person doesn't perform a lot of aerobic respiration, so lactate of *only* 15 was a miracle
and I basically induced the SIRS vital signs with my epinephrine/levo drip and vent settings.

yet I had to explain to the higher ups how insane this nasty-gram they sent me was.

 

[Mount Asclepius]

A code sepsis or sepsis alert is actually defined when EMS activates a stroke alert because they think the altered old person who fell down has a facial droop and seems weaker on one side. The fever then tips you off to deactivate the stroke alert and instead do the bundle. Unfortunately the inappropriate pre-hospital stroke activation has created a sepsis fallout. The hospitalist then requests a troponin for complete evaluation of AMS, which you solely obtain for them sillily so that they’ll accept the admission. Unfortunately you then also fall out from cardiac measures when the troponin is elevated and you forgot to do a HEART score. This completes the trifecta, triple double, 3-core measure fallout. High fives all around for good care, but nasty grams for not checking boxes. Luckily you work for a SDG with partners on all the key committees and a medical director who has your back. You never hear about any of it and carry on delivering good care.

 

[RoyBasch]

A code sepsis or sepsis alert is actually defined when EMS activates a stroke alert because they think the altered old person who fell down has a facial droop and seems weaker on one side. The fever then tips you off to deactivate the stroke alert and instead do the bundle. Unfortunately the inappropriate pre-hospital stroke activation has created a sepsis fallout. The hospitalist then requests a troponin for complete evaluation of AMS, which you solely obtain for them sillily so that they’ll accept the admission. Unfortunately you then also fall out from cardiac measures when the troponin is elevated and you forgot to do a HEART score. This completes the trifecta, triple double, 3-core measure fallout. High fives all already for good care, but nasty grams for not checking boxes. Luckily you work for a SDG with partners on all the key committees and a medical director who has your back. You never hear about any of it and carry on delivering good care.

You somehow simultaneously fall out on sepsis, stroke, and STEMI measures for a patient who is admitted for AMS due to polypharmacy that resolves with metabolism of the valium, oxycodone, gabapentin, and seroquel (in addition to 8 other medications) their primary care physician prescribed for them.

 

[RustedFox]

You somehow simultaneously fall out on sepsis, stroke, and STEMI measures for a patient who is admitted for AMS due to polypharmacy that resolves with metabolism of the valium, oxycodone, gabapentin, and seroquel (in addition to 8 other medications) their primary care physician prescribed for them.

Replace "primary care physician" with Jenny McJennyson, ABC-123-NP.

 

[miacomet]

Doctors allege non-physicians activate codes
In the North Carolina whistleblower complaint, the doctors said unnecessary trauma codes were typically activated by a non-physician, often a physician’s assistant, who was given little time to make an actual assessment.
After April 15, 2020, when TeamHealth started delivering contracted services to Mission Hospital’s Emergency Department, the number of trauma activations surged, according to the lawsuit.
On one busy ER shift in May 2022, Ramming witnessed many medically ill patients getting trauma designations, yet many ending up going home, according to the complaint. When he commented on this to the physician’s assistant who was on duty, the response was “trauma overcalls aren’t a problem for corporate medicine,” according to the complaint.
Ramming described a case of an 85-year-old woman who came to Mission’s Highlands hospital emergency room with cat scratches and was given a sepsis alert. He canceled the tests, which were “not needed for cat scratches, needless to say,” he said.
Mid-level practitioners in the emergency department were incentivized to order numerous unneeded or redundant lab tests, including blood samples, urinalysis, laboratory analyses, metabolic panels, CT scans and X-rays, according to the lawsuit.
He also noted that it was common to over-code patients as sepsis cases because it not only pads the bill for extra testing, but also pools non-septic patients with truly sick ones, lowering the overall mortality rate.
Doctors’ lawsuit: HCA Healthcare and TeamHealth overcharged patients

This is why corporate medicine loves midlevels- they bill a ton, they miss stuff so patients come back, and their ethics are lacking

 

[Birdstrike]

It’s about time ER docs fight these things in court. Sue them for anything, everything and for all the abuses they heap in the good men and women of EM.

All offense, all the time.