In the News: Sepsis-3: New clinical definitions cause dilemmas

Earlier this year, a group of clinicians from around the globe released new standards for diagnosing sepsis. The Journal of the American Medical Association published the third international consensus definitions, dubbed Sepsis-3, in February.

The new criteria define sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.” They define septic shock as “[s]epsis with circulatory and cellular/metabolic abnormalities profound enough to substantially increase mortality.”

Noting “inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria,” the new definitions discard the concept of sepsis as SIRS due to infection, which has been the diagnostic standard for the last 25 years, according to an article on the ACDIS website by Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting in Houston.

The new guidance uses the Sequential (sepsis-related) Organ Failure Assessment score (SOFA) to define organ dysfunction. With SOFA, the function of six organ systems—respiration, coagulation, liver, cardiovascular, central nervous system, and renal—is graded on a scale of 0 to 4, where 0 represents normal function. For each organ system, the baseline SOFA score is assumed to be 0 in patients who don’t have preexisting organ dysfunction. The SOFA requirement is met by a minimum of a one-point increase in at least two organ systems, or by a two-point increase, or more, in one organ system.

Quick SOFA (qSOFA) is a bedside clinical approach used to identify patients who are likely to have a prolonged stay or die in the hospital, but it does not substitute for SOFA for defining organ dysfunction, Pinson wrote. Under qSOFA, the patient must meet two or more of the following criteria: altered mentation, respiratory rate greater than 22, and/ or systolic blood pressure < 100 mmHg.

The criteria for septic shock involve “persistent hypotension requiring vasopressors to maintain MAP [mean arterial pressure] > 65 mmHg and having a serum lactate level > 2 mmol/L despite adequate volume resuscitation.”

These definitions may represent a clinical consensus from the participating parties, but they don’t change the ICD-10-CM coding rules, Official Guidelines for Coding and Reporting, or various quality-related measures for the condition.

In a letter written to the Sepsis-3 authors on behalf of the ACDIS Advisory Board, Sam Antonios, MD, FACP, FHM, CCDS, CDI physician advisor for Via Christi in Wichita, Kansas, also noted that “the updated definitions also create a direct conflict with the current CMS clinical quality measure for process, SEP-1, which is part of the Inpatient Quality Reporting Program (IQR).”

In his letter, Antonios poses several questions to the definition’s authors (click here to read the letter) and offers ACDIS’ assistance in further addressing inconsistencies.

The ACDIS Advisory Board also released a position paper on the matter, stating that while Sepsis-3 definitions “set forth compelling evidence that cannot be dismissed,” it remains to be seen “how the clinical community will be able to operationalize or change its understanding of sepsis and septic shock.”

ACDIS cautioned against adopting the new guidelines, recommending CDI programs work with leadership regarding next steps. “Avoid blindly following the … recommendations,” it states.