Sepsis Decision Aid

In the U.S., the treatment of sepsis and septic shock is complicated by strict regulations used to measure hospital sepsis outcomes. The Center for Medicare & Medicaid Services (CMS) Sep-1 guidelines are complex and based on chart abstraction. These factors lead to confusion and difficulty in the real-time treatment of patients. This decision aid is meant to assist in the regulatory steps for the treatment of a patient with sepsis. It is important to be aware that CMS makes changes to these criteria on a quarterly basis. This tool will be updated as often as possible to maintain correctness.

Does the patient have sepsis?

CMS does not use Sepsis-3 criteria for the SEP-1 Hospital Core Measure, however many private insurers and CMS utilize the Sepsis-3 criteria for reimbursement. Therefore, both criteria are listed here. Some hospitals utilize a hybrid method screening with SEP-1 criteria in the ED and utilizing Sepsis-3 criteria in the inpatient setting.

CMS SEP-1 Core Measure Definition Of Sepsis

Requires a source of infection AND > 2 SIRS criteria

SIRS Criteria

• Temp >100.9 or <96.8
• HR >90
• RR >20
• WBC >12k or <4k or >10% bands

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Sepsis-3 Definition Of Sepsis

Requires a source of infection AND organ dysfunction (see qSOFA or SOFA below). Use statement: “Sepsis due to [infection] with acute sepsis-related organ dysfunction as evidenced by [specify organ dysfunction].”

qSOFA > 2

• Respiratory rate of > 22/min
• Altered Mental Status
• Systolic blood pressure < 100 mm Hg

MDCalc – qSOFA Calculator

SOFA > 2

MDCalc – Sofa Calculator

Three Hour Bundle (Items to be completed within 3 hrs)

• Administer Broad Spectrum Antibiotics
  • Do not delay broad spectrum abx while searching for source
• Obtain Blood Cultures x 2
  • If unable to obtain 2 blood cultures, document inability to do so
• Obtain initial lactic acid

If MAP<65 (SBP<90) –OR– Lactic Acid >4 mmol/L

Administer 30 ml/kg IVF bolus

• If 30 mL/kg not given both must be done
  1. Order a specific amount of IVF – either specific volume (i.e. 1L) or mL/kg (i.e. 10 mL/kg)
  2. Document the amount of fluid ordered AND the rationale for not giving the full 30 ml/kg in a narrative note. CMS will currently accept any rationale given by the provider as long as it is explicitly stated. For example: CHF, ESRD, concern for fluid overload, adequate response to a lesser volume, etc.
• If BMI>30, can use Ideal Body Weight (IBW)
  • “BMI>30; using IBW of _ kg for sepsis”
  • MDCalc – BMI Calculator
  • MDCalc – Ideal Body Weight Calculator
• EMS fluid is considered part of the 30 mL/kg bolus. Document amount given by EMS and time.

After completion of the fluid bolus, document a perfusion reassessment. Use phrase “I have performed the perfusion reassessment” or include the following elements in a focused exam

Focused Exam

Focused Exam must include 5 of the following:

• Oxygen Saturation
• Capillary Refill
• Cardiopulmonary assessment
  • HR, rhythm, lung auscultation
• Peripheral Pulses
• Shock Index (“I’ve reviewed the shock index”)
• Skin color or condition (“cool and clammy”)
• Urine Output: exact volume not required (“diminished urine output”)
• Vital Signs: HR, RR, temp, BP

OR any one of the following:

• Central venous pressure
• Central venous oxygen
• Bedside cardiovascular ultrasound
• Passive leg raise or fluid challenge

And may be documented by another physician or provider (ex. admitting team)

Six Hour Bundle (Items to be completed within 6 hrs)

• Repeat lactic acid if initial is > 2 mmol/L
• Vasopressor for refractory hypotension – MAP<65 (SBP<90)
• If not already completed, document perfusion reassessment for persistent or refractory hypotension within 1 hour of bolus completion, or initial lactic acid > 4. Use phrase “I have performed the reperfusion assessment”.

Important Notes

• Patients that are excluded:
  • Age < 18 yo
  • Transferred to you from other hospital
  • Diagnosis of COVID-19 (principal or other)
  • Sepsis or septic shock due to a viral, fungal, or parasitic infection
  • Admitted to comfort care / hospice / palliative care within 6 hours of meeting sepsis criteria
  • Enrolled in a clinical trial for sepsis or septic shock during this hospitalization
  • Patients or surrogate refusing care (blood draw, cultures, antibiotics, etc.)
• Lactic acid elevation due to a non-infectious etiology (ex. seizure) is disregarded, but must be documented by the physician or provider.
• Requirement to use broad spectrum antibiotic was removed beginning July, 2021. Appropriate IV antibiotic selection is deferred to the treating physician or provider.

Further Reading

Updates and Controversies in the Early Management of Sepsis and Septic Shock Date Release: Apr 2021 Sepsis and septic shock guidelines, requirements, criteria, and treatments have changed substantially in the last few years. This issue reviews the latest evidence and discusses the changes and current controversies in sepsis diagnosis and management.

Current Topics in Shock and Sepsis Management: Traumatic Hemorrhagic Shock and Septic Shock Date Release: Apr 2021 This course combines audio and digital components to review critical care management of traumatic hemorrhagic shock as well as sepsis and septic shock. 

References

• CMS Hospital Inpatient Specifications Manual
• ACEP Sepsis CMS Core Measure (SEP-1) Highlights
• Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–810. doi:10.1001/jama.2016.0287

Last Updated on January 25, 2023

Sam Ashoo, MD

Sam Ashoo, MD, FACEP,  is board certified in emergency medicine and clinical informatics. He serves as EB Medicine’s editor-in-chief of interactive clinical pathways and FOAMEd blog, and host of EB Medicine’s EMplify podcast. Follow him below for more…