Sepsis is a serious, potentially life-threatening, condition where the body reacts to a localized infection and causes systemic inflammation and organ damage. Sepsis can be caused by bacterial, viral ,fungal, or other organisms that cause infection. A diagnosis of sepsis cannot be assumed based on laboratory and/or clinical criteria. Sometimes certain localized infections can have the same signs and symptoms as sepsis, but sepsis is not present. The provider must document in the medical record that the patient has a diagnosis of sepsis. However, if there are substantial clinical indicators that suggest sepsis, a query may be sent to the provider to clarify if the diagnosis of sepsis is indeed present.
Sepsis is diagnosed based on clinical assessment, lab tests, and SOFA (Sequential Organ Failure Assessment) score. Clinical assessment indicators include fever, tachycardia, tachypnea, hypotension, potential localized sources of infection, and altered mental status. Laboratory tests that may indicate sepsis are elevated or low white blood cells, elevated lactate levels, abnormal liver or kidney function, low oxygen levels, and abnormal PT/INR. Blood cultures are also obtained to identify organisms responsible for causing sepsis. Facilities and payors often use Sepsis-3 criteria to determine the degree of organ dysfunction.
Organ dysfunction is determined by the SOFA (Sequential Organ Failure Assessment) score. The grading is based on a scale from 0-4, with 0 indicating no dysfunction. If the patient’s baseline is unknown in any of the system categories, it is assumed to be 0. The SOFA score must show a 2-point increase from the patient’s baseline values from the following categories:
Treatment for sepsis may include IV antibiotics, IV fluids, supplemental oxygen when respiratory organs are involved, and close monitoring, often in an intensive care unit.
When querying providers to clarify sepsis, leading questions must be avoided. A leading query asks the provider to document a specific diagnosis, or directing the provider to provide a diagnosis without taking into account medical decision making. When sending a query to clarify if the patient has sepsis, it should include at least two or more clinical indicators (provider assessment and lab values), treatment given, and some degree of organ dysfunction.
Examples of appropriate questions for sepsis querying:
References
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