Sepsis for CMS

On Oct 1, 2015 CMS began requiring hospitals to report their data on how they meet certain metrics for patients with “severe sepsis” via Sepsis Bundle Project v 5.0a. As with everything CMS, the details are things we need to know.

The reality is that these definitions are here, so rather than debate whether the metrics and definitions make sense (particularly in light of newer sepsis data), this post provides the definitions OUR coders are currently looking for to see if a patient should be included in the reporting data, so we can adjust our practice accordingly.

1. SIRS (Systemic Inflammatory Response Syndrome)

ANY 2 of the below:

  • Temp >38.3, <36.0
  • HR >90
  • RR >20
  • WBC >12.0, <4.0, OR 10% Bands
  • Altered Mental Status

2. SEPSIS = SIRS + “a possible source of infection”

3. Severe Sepsis: SIRS plus evidence of organ failure. 

  • This is an area where I think the definition may be escaping us, because lots of these things are things that are less immediately clinically relevant, but make semi-sick folks meet the definition of severe sepsis.
  • These are the patients who NEED to get the “Three Hour Bundle”
  • SBP <90 or MAP <65 ONE TIME (yes the spurious accidentally entered values entered by the nurse count)
  • Lactate >2.0
  • Creatinine>2.0 (excluding ESRD patients)***
  • Platelets <100K
  • Bilirubin >2.0
  • INR > 1.5
*** If your patient chronically has a creatinine of 1.9, and comes in at 2.1, YES, they will qualify for severe sepsis, UNLESS you document in your note that this is essentially unchanged from prior values.  Remember our coders can’t make decision on what is “clinically significant” – you have to tell them whether it is.

4. The “3-Hour Bundle”

The three Hour bundle are things that need to be completed within 3 hours from the TIME SIRS is recognized (Usually the time of first vital signs).

a.  BOLUS of 30 cc/kg if SBP <90 OR Lactate >4.0 (regardless of history of renal failure, CHF, etc…) Remember, you think these folks are septic, not fluid overloaded, etc as a cause of their vital sign abnormalites.

b. Lactate must be drawn BEFORE bolus

c. Cultures of blood and urine before antibiotics

d. Appropriate antibiotics for the “suspected infection source” must be initiated

Posted in Critical Care | Tagged

EM ONE – September Update – Changing SUX to ROC

So this post is not about new data, but a new way of practicing emergency medicine.  Our EMS system will be switching from using Succinylcholine (SUX) to using Rocuronium (ROC) on selected intubated patients next month.

Below is the data behind the decision, which might make you reconsider using ROC preferentially for intubations, but at least should make you more comfortable with others using it.

Here is what is discussed this month and rationale for the change:

  1. SUX will NOT “wear off” to prevent surgical airway

  2. ROC gives you a longer safe apneic time ***

  3. Appropriate ROC dose provides equivalent intubation conditions to SUX

  4. SUX has contraindications, particularly in our patients

  5. SEDATION: ROC removes your cues to sedate a patient**

Posted in Uncategorized

Rocuronium vs Succinylcholine for Intubation

Practice Changer: I will be using ROC at 1.2mg/kg in my ED patients who do NOT require repeat neurological examination.  It has no contraindications, is equally effective to SUX, and will give me LONGER SAFE APNEIC TIME to secure the airway.  I will order a sedative medication up front with ROC.

***In this post Rocuronium is ROC and Succinylcholine is SUX


The big advantage cited for SUX is: “With the shorter duration of action, should you encounter a cannot intubate, cannot ventilate situation,  most patients will begin breathing spontaneously and you avoid the need for a surgical airway   This chart from Anesthesia 2010 shows that this assertion is WRONG.

September 3

While this may be true in a healthy OR population, it is NOT the case with ED patients. Looking at the curves above, your patients will have coded WELL before SUX wears off if you can not ventilate them in some manner.

However, if you ARE able to ventilate your patient, and your SUX does wear off, you still have a patient with an unsecured airway who is moving, rather than a paralyzed patient in whom you can attempt other airway maneuvers.

My Conclusion: The shorter duration of action of SUX is not an advantage in the ED.


Effect of [succinylcholine] vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction

Anaesthesia 2010

Study: Randomized trial of ROC and SUX in a controlled operating room setting.

Intervention: 3 groups of 20 patients, all preoxygenated on 8L FM x 8 minute

  • Patients preoxygenated with mask removed 50 seconds after medications given
  • Patients left apneic until oxygen saturations reached 95%

3 Groups

R – Pretreated Lidocaine, Fentanyl, Propofol (2mg/kg), and ROC (1mg/kg)

S – Pretreated as above, then with SUX (1.5mg/kg)

SO – Propofol and SUX  (Essentially RSI with Propofol)

Outcome: Time to Desaturation to 95% during apnea


ROC (with pretreatment) time: 378 sec (6 min 18 sec)

RSI with SUX time: 240 sec (4 min)


September 1

Why is this?

Well they also looked at hemodynamic parameters: Patients in the RSI group had stronger fasciculations, Longer fasciculations, elevated HR and BP at 2 minutes after administration… essentially THE FASCICULATIONS ARE USING MORE OXYGEN

Conclusions: In healthy patients, you can expect an extra 2 minutes of apneic time when using Rocuronium vs Succinylcholine

Desaturation following rapid sequence induction using succinylcholine vs. rocuronium in overweight patients.

Acta Anaesthesiol Scand 2011

Study Design: Prospective evaluation of desaturation time in patients with BMI of 25-30 with use of either Roc or SUX

Intervention: Patients intubated in OR with midazolam, fentanyl, propofol, and either SUCCINYLCHOLINE 1.5 mg/kg or ROCURONIUM 0.9 mg/kg.

  • Measured time to desaturation to 92%

Outcome: Time until oxygen saturation reached 92%


ROC: 329 seconds (5 min 29 sec)

SUX: 283 seconds (4 min 43 sec)

My Conclusions: SUX had a more rapid desaturation than ROC  in SLIGHTLY overweight patients.  (BMI of 30 is relatively fit in my ED population).

3. A good dose of ROC makes it equally effective to SUX

At a dose of 1.2 mg/kg ROC  there is essentially no difference to time of onset or intubating conditions, or intubation success compared with SUX.

Rapid tracheal intubation with large-dose rocuronium: a probability-based approach.

Anesth Analg 2000

Design: Prospective randomized study of varying doses of ROC in patients intubated in the OR

Intervention: 0.4 – 2.0 mg/kg ROC pushed and they looked at intubation conditions 40 seconds later.  Success was determined by being able to pass an ETT within 30 seconds.

Results: 60 patients

Probability of intubation at 40 seconds (Black = ideal, White = good, Grey = poor)

Sept 5

sept 6

Conclusions: Higher doses of ROC achieve ideal intubations essentially as fast as SUX.  1.2mg/kg seems like an idea dose.

Comparison of Succinylcholine and Rocuronium for First-attempt Intubation Success in the Emergency Department

Acad Emerg Med. 2011

Study: Retrospective Review of RSI intubations from ED in Arizona in 2007 and 2008

Comparison: All RSI was performed with Etomidate.

Analysis: 327 intubations were included, 113 with sux and 224 with Roc


No difference in intubating conditions or success rates. Average doses of Rocuronium at 1.19mg/kg and Sux at 1.65 mg/kg.

Conclusions: Appropriate (high) dosing of paralytics provide equivalent intubating conditions.

4. SUX has LOTS of contraindications, ROC has NONE


ROC: None

SUX: has a list of uncommon contraindications, primarily having to do with preexisting and inducible hyperkalemia (Anesthesia 2006).


The average person seems to have a rise of 0.5 to 1.0 mEQ of K. (BLUE Bar in Left chart)

With lower limb immobilization you may a greater response (RED Bar in Left Chart)


Even starting with a normal K, you can have significant K release resulting in arrhythmia.


My Conclusions: In an emergent setting where obtaining a history is not always possible, and with the population we serve with one of the highest rates of dialysis in the country, the possibility of encountering a patient with a contraindication is relatively higher than in most places.


Patients treated with ROC frequently have their sedation wear off before their paralytic

Effect of paralytic type on time to post-intubation sedative use in the emergency department

— Emerg Med J 2013

Study: Retrospective Cohort of intubated ED patients from tertiary care center in USA

Comparison: All patients sedated with Etomidate and use of either ROC or SUX

Outcome: Time until sedation or analgesia administered

Results: 200 patients (100 per group)

SUX = 15 Min

ROC = 27 MIN

My Conclusions: You lose the cues for sedation you are used to with SUX when you use ROC.  Patients are awake but can’t respond.  If you are going to use ROC, MAKE SURE SEDATION IS INTEGRATED AS PART OF YOUR PROTOCOL, so you don’t forget to use it.

Posted in Uncategorized | Tagged ,

EM ONE – August Update – Cardiology

Hey Everyone –

Our recently adopted HEART score has a new twist, the HEART Pathway, that may be perfect for US ED use.  While our cardiology colleagues may have fewer chest pain consults, the new AHA guidelines for out of hospital arrest should make sure they don’t get too bored!  See below for the updates!

  1. AHA Guidelines for out of hospital arrest without STEMI **
Posted in Uncategorized

PCI after Cardiac Arrest

Practice Change:  After an ECG, ABG, and beside electrolytes all comatose post-arrest patients with ROSC should be discussed with the cardiologist for emergency PCI – up to 25% may benefit. 

Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient

JACC – July 2015

The JACC published new guidelines for cardiac arrest patients.  Essentially it suggests you should consider treating all comatose arrest patients (both with and without STEMI on ECG) with PCI.  The data they present suggest that about 25% of patients with ROSC, but without STEMI on ECG, will have an occluded culprit vessel that can be opened with PCI.

Journal of the American College of Cardiology, 66 (2015) 62-73. doi:10.1016/j.jacc.2015.05.009

Journal of the American College of Cardiology, 66 (2015) 62-73. doi:10.1016/j.jacc.2015.05.009

While they do try to differentiate between NSTEMI and STEMI patients, you’ll notice that other than one side being red and the other blue, the algorithms are identical.

ED physicians will have to evaluate for poor prognostic signs in the ED, but as the cut off is “multiple unfavorable resuscitation features,” it sounds like this decision will be in the cardiologist’s court.

Posted in Uncategorized | Tagged ,

HEART PATHWAY for Cardiac Risk

Practice Changer: The HEART Pathway is a simple cardiac risk assessment tool that is designed for use in the ED.  It’s safe and effective at classifying patients as low risk for outpatient evaluation of cardiac disease while also decreasing length of stay and cardiac testing.  


The HEART score was described in the Netherlands in 2008  and retrospectively validated initially in a European Cohort, then in the United States at Wake Forest University where they retrospectively found the rates of MACE (Major Adverse Cardiac Events) ** at 6 weeks in patients with HEART scores of 0-3 to be 0.6% (5/904 pts).  A prospective validation study confirmed the HEART score’s utility (see below).

July 2

It was noted in the retrospective US study (above) that the addition of negative serial biomarkers to the HEART score decreased risk to 0% MACE at 6 weeks.  Subsequently a 0 and 3 hour troponin has been added to the HEART score and termed the “HEART Pathway.”  This pathway was found to have over 99% sensitivity for MACE as a secondary retrospective outcome of the 1000+ patients in the MIDAS trial (below).  Earlier this year a prospective trial to describe benefits of using HEART was performed (below) showing no missed MACE and decreased length of stay and use of stress testing.

August 1

Below are:

  1.  The Prospective HEART Score validation article
  2. The HEART Pathway Retrospective Analysis
  3. The Prospective HEART  trial

1. Prospective validation study of the HEART Score.

A prospective validation of the HEART score for chest pain patients at the emergency department

— International Journal of Cardiology 2013

Study Design: Prospective cohort study

Population: All Patients presenting to 10 EDs in the Netherlands with Chest Pain.

Inclusion Criterion: All Chest Pain Patients. No age restrictions. Dyspnea and Palpitations were excluded. STEMIs were generally taken directly to the cath lab, so mostly excluded from analysis.

Data: HEART score, TIMI, and GRACE score was calculated for each patient.

July 2

ECG is the one factor that probably needs definition

  • 1 point = bundle branch block, LVH, repolarisation abnormalities from digoxin or other repolarisation abnormalities.
  • 2 points = any ST elevation or ST depression without BBB or LVH.

Risk Factors:

  • 1 Risk Factor: Treated Diabetes, Smoking, Diagnosed Hypertension, Diagnosed Hyperlipidemia, Family History of CAD, and OBESITY
  • 2 points are given for category if there is a: history of CAD, revascularisation, stroke, peripheral vascular disease

Primary End Point: Major Adverse Cardiac Event (MACE) at 6 weeks.

        MACE =AMI, PCI, CABG, coronary angiography revealing procedurally correctable stenosis managed conservatively, and death due to any cause.

Follow Up: Hospital Records or if not available, patients or PCPs were contacted

Results: 2440 patients with Chest Pain of which 45 were lost to follow up.

  • 407 patients with MACE


Rates of MACE at 6 weeks for Low Risk scores:

  • HEART score 0-3 (36.4% of study population)  = 1.7%
  • TIMI 0 -1 (34% of study population) = 2.8%
  • GRACE 0-60 (14% of study population) = 2.9%

August 6

Conclusion: HEART score for chest pain patients at the emergency department provides the clinician with a quick and reliable predictor of outcome shortly after arrival of the patient, without computer-required calculating.

2. HEART PATHWAY – What about the addition of serial troponins?

Identifying Patients for Early Discharge: Performance of Decision Rules Among Patients with Acute Chest Pain

– Int J Cardiol 2014

Study Design: Re-analysis of Prospective Cohort acquired for MIDAS study

Population: 1005 Patients >21 years old presenting to 18 US EDs with symptoms of Acute Coronary Sydrome


  1. Unstructured Analysis  (Essentially Gestalt)
  2. HEART score
  3. NACPR score by itself and with troponins at 0 and 3 hours.


  1. % classified as low risk  and discharged from the ED
  2. ACS within 30 days (AMI and Unstable Angina shown on catheterization included)


% Low Risk Sensitivity for MACE
Gestalt + Trop 13.5% 98%
HEART Score + Trop 20%


NACPR + Trop 4.4% 100%

My Conclusions: The HEART score with 0 and 3 hour serial troponin identified more people for discharge and did a better job identifying high risk individuals than clinical gestalt.  It also decreases the miss rate to <1%.

3. Prospective Study of Usual Care vs HEART Pathway

The HEART Pathway Randomized Trial: Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge

Circ Cardiovasc Qual Outcomes

Study: Prospective Randomized controlled trial of ED patients at Wake Forest University Medical Center

Population: Patients >21 years old with a troponin and EKG to rule out ACS,

Exclusions: STEMIs, Hypotension, non-cardiac source of symptoms discovered in ED.

Intervention: HEART score with a troponin at 0 and 3 hours. If low risk, they were discharged to home with PCP follow up within 1 week.

August 1

Control: Usual Care by ACC/AHA guidelines.  Typically involving serial biomarkers  and objective cardiac testing before discharge.

Primary Outcome: Objective Cardiac Testing Rates within 30 days, Hospital Length of Stay

Secondary Outcome: MACE at 30 days

Results: 282 patients randomized to two groups, 96% follow up at 30 days, no deaths in social security registry

Primary Outcome:

Decreased Objective Cardiac Testing by 12.1% at 30 days

Secondary Outcome:

No MACE in either low risk group at 30 days

Early Discharge increased with HEART by 21%, (would have been 29% except for protocol violations)

HEART Pathway decreased average patient’s LOS by 12 hours

August 2

Conclusions: Compared to usual ACC/AHA care, use of the HEART Pathway decreases utilization of health care resources.

Posted in Uncategorized | Tagged ,

EM ONE – July Update – Shhhh… the baby’s sleeping!

To Clot or NOT to Clot?

July 2015 Articles Reviewed

  1. Age Adjusted D-dimer in PE evaluation **

  2. Tranexamic Acid in Trauma

    1. CRASH II – initial protocol**
    2. Timing is important!**
    3. Head Injury
    4. In a trauma system
    5. Military Data (less applicable, but supportive studies)

If you’re looking for some appropriate background reading music, here is a band I accidentally saw live in the back yard of a club in Seattle a few years ago…

I present for your enjoyment: The Blood Clots.  They call themselves “Political Punk Rock.”

Posted in Monthly THUMBNAIL | Leave a comment