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Note from ACDIS Director: The changing tide of sepsis definitions

ACDIS Director, Brian Murphy

ACDIS Director, Brian Murphy

By Brian Murphy

These days it seems sepsis is constantly in the news. Hardly a day passes where the efficacy of some new life-saving drug is being advocated or disputed, a sepsis DRG downgraded, or Sepsis-2 versus Sepsis-3 definitions debated. We’ve also had some major recent news from the likes of the Surviving Sepsis Campaign.

CDI specialists inhabit a world in which they need to navigate three sets of reporting requirements: Sepsis-2, Sepsis-3, and SEP-1, the latter from the National Quality Forum measure for public reporting of sepsis.

How can CDI specialists make sense of it all? I recommend reading our most recent ACDIS White Paper, “Where are we now with sepsis?”

The paper covers in detail the multiple issues around this tricky diagnosis, from the problems inherent in administrative versus clinical data, to systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock prior to the new Sepsis-3 definitions in 2016, and the definitions post Sepsis-3. The article also includes a nice bulleted summary and takeaways for your CDI department and medical staff.

Special thanks for principal authorship go to ACDIS advisory board member Sam Antonios, MD, FACP, SFHM, CPE, CCDS. Though primary authorship goes to Antonios, the entire ACDIS advisory board reviewed the work prior to publication.

To download the new White Paper, click here.

I would also encourage any of our ACDIS members who haven’t been by our resource pages in a while to check out all our White Papers and Position Papers. We’ve been publishing some helpful guidance of late, and more is on the way.

I hope this paper proves helpful in your continued mission of clinical accuracy in the patient chart.

If you have suggestions for topics you’d like to see the advisory board address, please let me know via email at bmurphy@acdis.org.

Note from ACDIS Director: Your CDI civic duty—vote in the advisory board election

If you’ve ever read one of our Position Papers, White Papers, a Note from the Board in our bi-monthly CDI Journal, or listened to an ACDIS Quarterly Conference call, then you know what a crucial role the ACDIS advisory board plays in the leadership of our association.

That’s why we need you, our ACDIS members, to take a few minutes out of your day for a very important duty: Voting for our next group of board members.

ACDIS advisory board members serve a voluntary, three-year term. Members of the board write articles, answer member questions, review conference materials, set direction for our CDI Practice Guidelines committee, and more.

Read more about our board members and their responsibilities on the ACDIS website by clicking here.

This year, seven finalists have stepped up to run and volunteer their time and energy. They deserve to have our members make an informed choice and cast their votes. Out of the seven nominees, the four with the most votes will be elected by popular vote of the ACDIS membership, for terms effective April 2017 through April 2020.

This vote by our membership is an important responsibility and we hope you take a few minutes to fulfill it.

View our voting page (open to ACDIS members only) here.

How to vote

  1. First, log onto the website with your username and password. You must be an ACDIS member in good standing. If you have forgotten your username/password, please write or call our customer service team: customerservice@hcpro.com, or 1-800-650-6787.
  2. Go to our voting page by clicking here.
  3. Read through the candidates’ bios/qualifications and reasons they are running, and then write down your top four votes.
  4. Click the yellow “vote” button.
  5. Our voting tool requires you to rank the candidates. Your top choice should be ranked number one, your second choice number two, etc. on down through number seven. If you’d like, you can just rank your top four candidates.
  6. Click the gray “vote” button. It will ask you to you review your choices.
  7. Once you are satisfied, click “confirm” and you are done. Our website only allows you to vote once.

You have two weeks to cast your ballot; voting opens today, Thursday, March 16, and closes end of day Friday, March 31.

Thank you for your attention to this important matter!

Note from the Director: CDI success requires more than a credential

Which credential/certification/licensure makes for the best CDI specialist? RN? RHIA? MD?

If you answered all of the above—or none of the above—you’re on the right track, according to a new Position Paper written by the ACDIS Advisory Board published on the ACDIS website.

To be blunt, no licensure or credential can identify whether someone will succeed as a CDI specialist. Not even ACDIS’ own Certified Clinical Documentation Specialist (CCDS) certification can guarantee that. We do, however, require anyone who sits for the CCDS exam to have two years of experience as a CDI specialist, so we feel good about the competency of our CCDS-credentialed professionals. CCDS holders must understand the basic core competencies and have demonstrated their skills in the field already.

But is that person a guaranteed fit with your culture?

Is that person dependent on an encoder or other computer assisted coding/natural language processing (CAC/NLP) tool that your hospital does not have?

There are many other factors that make up a good CDI specialist. As the new Position Paper explains, these factors include:

  • Effective verbal and written communication
  • Self-directed with an ability to work independently to complete the work at hand
  • The ability to think critically
  • A commitment to lifelong learning

The new Position Paper also notes that a strong clinical foundation is a must for any CDI specialist, and hiring an RN, MD, or an RHIA with strong clinical acumen will certainly fulfill that requirement. But, it’s no guarantee of success as the paper states:

“Credentials do not guarantee whether one will succeed as a CDI professional. Credentials merely identify the body of knowledge in which that person was originally trained. Prior bodies of knowledge certainly assist one’s success, and credentials and/or licensure provide identification of one’s stated profession and their level of education or achievement, but they do not ensure CDI competence. There is a number of necessary skills that cannot be ensured or captured by a credential.

It always comes down to the person. Why should CDI be any different?

If you’re wondering whether a Position Paper represents ACDIS’ official stance on an issue, you can find the answer here. Our recently published “Hierarchy of Authority” explains the order of significance of our published articles. ACDIS Positon Papers are peer-reviewed and represent the consensus opinion of the advisory board. We hope you find “ACDIS’ ‘Hierarchy of Authority’ of published articles” helpful as you navigate our website.

Editor’s note: This article originally appeared in CDI Strategies. Brian Murphy is the director of the Association of Clinical Documentation Improvement Specialists. Contact him at bmurphy@acdis.org.

Advisory Board Voting set; cast your ballot today

January may not feel like election season; most of the pomp and star-spangled banners of the political season fluttered down months ago. Nevertheless, the ACDIS (electronic) ballot box has been primed and dusted, ready for the amazing new candidates who stepped forward this year.

More than 50 volunteers submitted their resumes to the nomination committee. The committee, made up of four members of the existing advisory board, administration, and an at-large ACDIS member, have reviewed the applications, interviewed candidates, and selected 12 individuals from various professional backgrounds as finalists for the ACDIS Advisory Board.

Now it is up the ACDIS membership to review the candidates’ information and choose the individuals you believe will best serve the association for the next three years.

Remember, voting is open only to ACDIS members. Voting instructions are included on the top of the voting page. You must cast four votes total: two votes in group one, and one vote in groups two and three. Once your vote is cast your access to the voting page will be closed to prevent any individual from voting twice.

Note, too, that we are grateful for every one of the individuals who took time to submit their nomination to serve on the advisory board.

Voting will close at the end of the day (11:59 p.m., Eastern) on Thursday, January 29. Please click on this link and login to your ACDIS account to vote. 

The candidates are:

  • Group 1 (RN background): Claudia E. Baker, Terri McCubbin Graves, Melinda Matthews, Karen Newhouser, Judy Schade, and Paula Tatum
  • Group 2 (MD background): James P. Fee, Thomas W. Huth, and Charles E. Pitzele
  • Group 3 (HIM/coding background): Krystal Haynes, Melissa K. McLeod, Anny Pang Yuen

Advisory Board nominations due today

We are currently seeking four new ACDIS members to join our advisory board in 2015. ACDIS advisors are important, volunteer positions that help shape the direction of the association and provide leadership and expertise for the membership. The term of service is a maximum of three years.

The deadline for returning completed applications is Monday, November 17, 2014. A nominating committee and the ACDIS membership will make final selections by January 2015.

The role and expectations of ACDIS advisory board members is described on the advisory board page.

Please fill out and submit the application form by clicking here.

Call for Advisory Board nominations open

Join ACDIS. Get the Journal. Get informed.

Consider volunteering for the ACDIS Advisory Board.

We are currently seeking four new ACDIS members to join our advisory board in 2015. ACDIS advisors are important, volunteer positions that help shape the direction of the association and provide leadership and expertise for the membership. The term of service is a maximum of three years.

The deadline for returning completed applications is Monday, November 17, 2014.

A nominating committee and the ACDIS membership will make final selections by January 2015. The role and expectations of ACDIS advisory board members is described on the advisory board page. If interested, please fill out and submit the application form. Thanks for your consideration of this important opportunity to serve our association.

Quarterly Conference Call for ACDIS members scheduled

Don't miss the November quarterly conference call for ACDIS members.

Don’t miss the November quarterly conference call for ACDIS members.

Our next quarterly conference call is scheduled for Thursday, November 21, from 1-2 p.m. ET. To access the call, please dial the toll-free number that was emailed to you.

If you did not receive the email dial-in information please email Penny Richards at prichards@cdiassociation.com at least one-day prior to the call.

Due to heavy call volume, please dial in 10 minutes prior to the start of the program. These calls are offered as a means for ACDIS members to network with one another and to discuss any clinical documentation improvement related issues.

We will have a few ACDIS Advisory Board members on the call as well. We encourage your comments, thoughts, and questions during the call. If you would like to submit a topic or question for discussion please email ACDIS Director Brian Murphy at bmurphy@cdiassociation.com

Reminder: Applications for advisory board openings due Friday

The application period for four new ACDIS advisory board members is now open. The deadline for returning completed applications is November 15, 2013. A nominating committee and the ACDIS membership will make final selections by January 2014.

ACDIS advisors are important, volunteer positions that help shape the direction of the association and provide leadership and expertise for the membership. The term of service is a maximum of three years. The role and expectations of ACDIS advisory board members is described on the advisory board page.

Please fill out and submit the application form here: http://www.keysurvey.com/f/557833/77cd/

Applications open for ACDIS advisory board positions

The application period for four new ACDIS advisory board members is now open. The deadline for returning completed applications is November 15, 2013. A nominating committee and the ACDIS membership will make final selections by January 2014.

ACDIS advisors are important, volunteer positions that help shape the direction of the association and provide leadership and expertise for the membership. The term of service is a maximum of three years. The role and expectations of ACDIS advisory board members is described on the advisory board page.

Please fill out and submit the application form here: http://www.keysurvey.com/f/557833/77cd/

Guest post: Getting physicians to document effectively

Tim Brundage

Timothy N. Brundage, MD

by Timothy N. Brundage, MD

Physicians resist change. They fear it. Although comfortable reading medical literature, and comfortable improving patient care with new techniques and medications, having CDI professionals “educate” physicians about improving their documentation habits makes them markedly uncomfortable. Physicians see such discussions and reviews as a threat to their autonomy. They view CDI efforts as the “evil administration” pushing them to document differently, which of course, adds to their discomfort.

Historically, physicians were not educated about proper documentation techniques. The entire CDI profession is relatively young and only recently a part of physicians’ daily practice. Addressing CDI queries certainly adds to the time required to care for a patient when CDI queries, along with pharmacy queries and core measure order sets, are all pushed into an already overloaded medical chart.
Professional scrutiny
Regardless of previous experiences with documentation efforts and regardless of the additional effort it may necessitate, physicians’ response and cooperation is required. Why? Because unfortunately, physician scrutiny is increasing.
Currently, CMS is collecting data points on physicians. Such data is directly linked to the diagnosis documented by the treating physician in the medical record. The physician’s quality metrics will be measured and compared to other doctors in their same field.
Such results are already being posted on public websites such as Healthgrades.com, which reports data collected about individual physicians and can be easily accessed by patients. Consumers can read and review quality and morbidity/mortality data of physicians and compare those metrics to other physicians’ in the community. Accurate and thorough documentation will create reliable data that will reflect the high quality of care physicians provide.
Whether physicians want to hear about it or not, they need to understand that poor documentation leads to reduced reimbursement, increased claims denials, greater audit risk, inaccurate patient severity levels and inflated complication rates: all of which leads back to poor public reporting results.
Physicians must recognize they should get credit for the great care they are providing, and credit comes only through proper and thorough documentation reflected in appropriate coding. Following are examples of situations where documentation is critical to the healthcare process:
I.            If a patient meets sepsis criteria, but is only diagnosed with a urinary tract infection (UTI), then the patient appears healthier than they really are. The patient with a UTI probably doesn’t even need hospitalization, but the patient who meets SIRS criteria and can therefore be diagnosed with sepsis is much more ill. This patient needs hospital admission and has a higher mortality than the ambulatory patient with a garden variety UTI. When documentation is lacking, the patient appears to have a lower mortality risk than is truly present. This can lead to physicians having inaccurate mortality rates when compared to their peers.
II.            Physicians must understand that sick patients require more resources for their medical care. These patients require more laboratory tests, more radiographic imaging and more nursing care. The physician needs to document correctly so the true severity of illness is captured. This will allow the patient to have higher relative weight through MS-DRG assignment. The hospital then has more assigned resources to care for this sick patient. The hospital will be correctly reimbursed for this increased utilization of resources if the physician documents the true severity of illness through diagnosis-based coding language.
III.            Proper assignment of MS-DRGs also increases the amount of time the patient is expected to stay in the hospital. What does this mean to physicians? It means they have more time to take care of patients in the hospital before the case manager begins to ask that dreaded question: “When is this patient leaving?” Proper documentation affords physicians one to two days longer to address the patient’s medical issues before their expected length of stay is reached.
IV.            Accurate documentation also allows the attending physician to aid the surgeon. The attending must carefully and accurately document in the peri-operative period as to not inadvertently classify an expected outcome as a complication. One example of this is postoperative anemia. This diagnosis can easily be incorrectly classified as a complication. If the attending physician and the surgeon both opine that the anemia is expected, then this should be explicitly documented in the medical record.
Suggestions to improve diagnosis capture
Presently, St. Petersburg General Hospital uses order sets to improve the capture of specific diagnoses. Sepsis order sets have the SIRS criteria with check boxes next to each vital sign and/or lab finding. If the patient meets the SIRS criteria and has a source of infection, then they meet the criteria for sepsis. If the patient has end-organ dysfunction, then they may meet criteria for severe sepsis. These criteria are listed below the SIRS criteria with check boxes next to each abnormal laboratory finding. Download the sample order form.
The order set then lists the criteria for septic shock. These check lists help physicians to comprehensively diagnose, document and order medical therapies, allowing for easy, thorough documentation as well as management. Physicians need to understand, however, that these order sets must be followed up with documentation supporting the diagnosis in the discharge summary.
Correspondingly, St. Petersburg General Hospital uses pneumonia order sets to help physicians correctly diagnose pneumonia without missing complex respiratory diseases. If the physician chooses zosyn, the order set includes the phrase “for suspected gram negative rods.” If the physician chooses vancomycin, then it reads “for suspected MRSA.” Finally, if they choose clindamycin or flagyl, it reads “for suspected aspiration pneumonia.”
Why? Because physicians don’t realize that documenting healthcare-associated pneumonia will code to simple pneumonia unless suspected GNR or MRSA is documented as the causative organism. Also, physicians do not realize that documenting “suspected” or “possible” or “probable” diagnoses in the hospital setting allows those conditions to be coded—as long as the discharge summary documents those diagnoses as well.
Proper coding techniques are not taught to physicians. They have to pick it up themselves in order to document effectively. That’s why CDI efforts are so valuable.
Furthermore, CDI professionals need to educate physicians that laboratory data and radiographic imaging diagnoses are not codeable unless the clinician brings the information into the medical progress note. The radiologist’s impression on an x-ray may read pneumonia, but this diagnosis cannot be coded unless the clinician documents the diagnosis in the medical record. Correspondingly, labs that note low potassium, for example, do not translate to the diagnosis of hypokalemia unless specifically written in the medical record by the clinician

In summary, physician documentation is critical for MS-DRG capture and assignment of a relative weight as well as an expected length of stay. Physician documentation begins with legible handwriting and moves to accurate diagnosis and effective management of patient care issues. Consider recommending physicians use a pocket CDI card for accurate diagnosis. Download a sample pocket CDI card here.

Convincing physicians to slow down and document effectively isn’t easy. CDI specialists may need to find individual answers for each of their physicians. Some physicians will respond to improvements in their reported quality data, some will respond to improved public reporting, and some may respond to longer length of stay and more time to effectively manage their patient in the hospital. CDI specialists need to listen closely to the doctor for clues as to which approach will lead to change.
All physicians should review their own data on Healthgrades.com. They should monitor their public data, document carefully and thoroughly, and consider reading the book titled, “Who Moved My Cheese?”  This little book discusses how to deal with change. Physician scrutiny is here to stay and physicians need to stay ahead of the game.

Editor’s Note: Brundage is an ACDIS Advisory Board member and physician champion for Kindred Hospital North Florida District in St. Petersburg, Fla. Contact him at DrBrundage@gmail.com. This article was originally published as the “Featured Article” on the ACDIS homepage, February 4, 2013.