Persistent Hypotension

Persistent Hypotension is determined by hypotension that persists in the hour after the conclusion of the 30 ml/kg Crystalloid Fluid Administration: The end time of the fluid administration must be determined. This may be clearly documented in the chart or may need to be calculated by the abstractor. Review the systolic blood pressure readings and mean arterial pressure readings (MAP) beginning at the end time of…

Posted on Oct. 21, 2016 in How Should I Code This?

Septic Shock Present Based on Lactate Level

As with Severe Sepsis, Septic Shock presentation can be determined based on provider documentation OR on clinical indicators. To determine the presentation of septic shock:  First you MUST have Severe Sepsis Second you MUST have EITHER An Initial Lactate Level >=4 {if the lactate level is the last indicator use result time} OR Hypotension prior to crystalloid fluid administration and hypotension that persists within one hour…

Posted on Oct. 12, 2016 in How Should I Code This?

EMS / Ambulance Documentation Q&As

Question 136:      Are we allowed to use fluids administered by Emergency Medical Services (EMS) in route to our facility? Answer 136:        Yes, depending on the rate at which they are administered and whether or not there is an order or protocol that serves as an order. Fluids must be given at a rate greater than 125 ml/hour (equivalent to 1000 ml…

Posted on Sep. 30, 2016 in How Should I Code This?

All About Lactate Draws

Among the confusing rules for sepsis abstractions, is the one regarding which lactate is the initial lactate collected when multiple lactates are drawn. Additionally, clarification has been received from Qnet regarding differences in wording between the related data elements. For abstraction, arterial and venous lactate levels may be used. Point of care lactate can be used. For purposes of the measure the initial lactate is not…

Posted on Sep. 21, 2016 in How Should I Code This?