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…

Identifying infections for the purpose of determining severe sepsis presents a variety of challenges. Whether you are a novice with abstracting severe sepsis case or have been doing it for several months, here are some guidelines: DO NOT USE: Terms on an X-ray that would have been used when abstracting an “abnormal x-ray” for a pneumonia core measure chart – such as infiltrates. Viral or fungal…

Recently cases with documentation of severe sepsis/septic shock “present on arrival”; “present on admission” have been generating questions on the correct way to abstract presentation time. Consider these scenarios: Patient arrives to the emergency room on 12/9/15 at 1503. The clinical indicators for severe sepsis are found with the last piece suggesting a presentation date/time of 12/9/15 at 1647. In the H&P the physician documents “Patient…

One of the common errors when determining severe sepsis presentation occurs when a lab value is used as the last of the indicators. Remember, when using a lab value to determine the presentation time for severe sepsis, you must use the RESULT time, not the collection or order time. The other challenge related to lab results is the question of chronic conditions. In the current data…