Focus area name

Focus area version

Applicable from (discharge month)

Sepsis

9

October 2017

Changes made from previous version of CFA

All treatments (oxygen, blood cultures, IV antibiotics, serum lactate, urine output) are all analysed against sepsis diagnosis date and time rather than arrival date and time.

Measures are against patients >16 years of age.

All previous CQUIN measures have been retired and replaced with new CQUIN measure looking at antibiotics review within 24-72 hours of sepsis diagnosis.

Table of Contents

Data collection form

Word Version available to download

Measure questions

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title	Q1. Is there documentation within the clinical record that the patient received palliative care only?

Q1. Is there documentation within the clinical record that the patient received palliative care only?

Acceptable sources of information:

Admission notes
Medical/surgical ward notes
Accident and emergency notes
Medical assessment unit notes
Consultation notes
Hospital discharge summary
Care plans
Hospice notes
GP referral letter

Terminology related to this question:

Applicable

Not applicable

Care of the Dying (Pathway)
End of life care
Hospice
Hospice care
Last Days of Life
No Active Treatment
Palliative care
Terminal care
TLC (Tender Loving Care)

Chemical code only
Do not cardiovert
Do not defibrillate
Do not intubate (DNI)
Do Not Resuscitate (DNR)
Keep comfortable
Living will
No aggressive treatment
No antiarrhythmic therapy
No artificial respirations
No cardiac monitoring
No Cardiopulmonary Resuscitation (NCR)
No chest compressions
No code
No Code 99
No CPR
No heroic or aggressive measures
No intubation and/or ventilation
No invasive procedures
No other protocols associated with advanced cardiac life support
No resuscitative medications
No resuscitative measures (NRM)
No vasopressors
Supportive care

Additional Information:

Disregard documentation of palliative care written on the day of discharge in any source other than discharge summary OR when it is referring to care planned after discharge only.

Answer Options

Answer option

Answer assistance

Unanswered

This will show when no alternative answer has been selected for this question

Yes

Consultant (or working as part of the Consultant team) documentation of palliative care (hospice etc.) mentioned in the following contexts suffices:

Palliative care only recommendation
Order for consultation or evaluation by a hospice/palliative care service
Patient or family request for palliative care only
Plan for palliative care only
Referral to hospice/palliative care service
If patient has advanced care planning or advanced care plan in place.

No

If there is no evidence of a palliative care process being in place for this patient.

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title	Q2. Sepsis suspected or sepsis diagnosis date/time

Q2. Please enter the date & time sepsis suspected/diagnosed/triggered

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	No applicable
Query sepsis Suspected sepsis Sepsis considered Question sepsis Potential sepsis Likely sepsis Working diagnosis sepsis Sepsis query cause Sepsis triggered	Not sepsis Sepsis unlikely Sepsis excluded

Answer options

Answer option

Answer assistance

Unknown

If the date/time of sepsis diagnosis or ‘query sepsis’ is unable to be determined from medical record documentation, enter UTD.

The clinical record must be abstracted as documented (taken at “face value”). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select “UTD.”

Examples:

Documentation within the medical record indicates the diagnosis date was 12-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the diagnosis date is outside of the range listed in the Allowable Values for “Day”, it is not a valid date and the abstractor should select “UTD.”

Documentation within the medical record indicates the diagnosis time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the diagnosis time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”

Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the diagnosis date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the diagnosis date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select “UTD.”

Date

The earliest documented day, month, and year that the patient received a sepsis diagnosis or was considered ‘query sepsis’. If the patient was diagnosed with sepsis prior to arrival at the hospital, then the arrival date and time should be entered as the diagnosis date and time.

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that the patient received a sepsis diagnosis or was considered ‘query sepsis’. If the patient was diagnosed with sepsis prior to arrival at the hospital, then the arrival date and time should be entered as the diagnosis date and time.

24 hour clock – A 24-hour period from midnight to midnight using a 4-digit number of which the first two digits indicate the hour and the last two digits indicate the minute.

Examples:

Midnight - 00:00 Noon - 12:00

5:31 am - 05:31 5:31 pm - 17:31

11:59 am - 11:59 11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

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title	Q3. What was the severity of the suspected sepsis/sepsis diagnosis?

Q3. What was the severity of the suspected sepsis/sepsis diagnosis?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	No applicable
Infection Sepsis Red flag sepsis Septic shock

Answer options

Answer option	Answer assistance
Unanswered	This will show when no alternative answer has been selected for this question
Infection	There is documentation within the clinical record that the patient had an infection
Sepsis	There is documentation within the clinical record that the patient had suspected sepsis diagnosis.
Red flag sepsis	There is documentation within the clinical record that the patient had suspected red flag sepsis or a red flag sepsis diagnosis.
Septic shock	There is documentation within the clinical record that the patient had suspected septic shock or a septic shock diagnosis.

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title	Q4. If there was a diagnosis/suspicion of septic shock, please enter the date/time

Q4. If there was a diagnosis/suspicion of septic shock, please enter the date/time

Acceptable source of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
Ambulance service notes

Answer Options

Answer options

Answer assistance

Unknown

If the date/time of septic shock diagnosis or ‘query septic shock’ is unable to be determined from medical record documentation, enter UTD.

The medical record must be abstracted as documented (taken at “face value”). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select “UTD.”

Examples:

Documentation within the medical record indicates the diagnosis date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the diagnosis date is outside of the range listed in the Allowable Values for “Day”, it is not a valid date and the abstractor should select “UTD.”

Documentation within the medical record indicates the diagnosis time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the diagnosis time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”

Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the diagnosis date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the diagnosis date is after the Discharge Date (death).

Date

The earliest documented day, month, and year that the patient received a septic shock diagnosis or was considered ‘query septic shock’

DD	Day (01-31)
MM	Month (01 - 12)
YYYY	Year (2000 - 9999)

Time

The earliest documented time (24 hour clock) that the patient received a septic shock diagnosis or was considered ‘query septic shock’

Examples:

Midnight - 00:00 Noon - 12:00

5:31 am - 05:31 5:31 pm - 17:31

11:59 am - 11:59 11:59 pm - 23:59

HH	Hour (00-23)
MM	Minutes (00-59)

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title	Q5. Is there documentation within the clinical record that the patient was suffering from neutropenic sepsis?

Q5. Is there documentation within the clinical record that the patient was suffering from neutropenic sepsis?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	Not applicable
Neutropenic sepsis Pancytopenia related sepsis Marrow suppression causing sepsis Chemo related sepsis Sepsis, neutrophils 0.5 x 10 9 per litre or less	Low white count Possible sepsis and chemo

Answer options:

Answer options

Answer assistance

Unanswered

This will show when no alternative answer has been selected for this question

Yes

There is documentation within the clinical record that the patient was suffering from neutropenic sepsis.

If any of the following are documented

Neutropenic sepsis
Pancytopenia related sepsis
Marrow suppression causing sepsis
Chemo related sepsis
Sepsis, neutrophils 0.5 x 10 9 per litre or less

No

There is no documentation within the clinical record that the patient was suffering from neutropenic sepsis.

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title	Q6. Was a screening tool present in the discharge notes?

Q6. Was a screening tool present in the discharge notes?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicabale	No applicable
Screening Tool Sepsis

Answer options:

Answer option	Answer assistance
Not present	There is no documentation within the clinical record that a screening tool was completed.
Not complete	There is documentation within the clinical record that a screening tool was not completed. There should be documented evidence of a screening tool in the patient record. This will indicate that this person was screened for sepsis, whether this was appropriate to this person and also whether sepsis was confirmed or not
Partially complete	There is documentation within the clinical record that a screening tool was partially completed. There should be documented evidence of a screening tool in the patient record. This will indicate that this person was screened for sepsis, whether this was appropriate to this person and also whether sepsis was confirmed or not
Complete	There is documentation within the clincal record that a screening tool was completed. There should be documented evidence of a screening tool in the patient record. This will indicate that this person was screened for sepsis, whether this was appropriate to this person and also whether sepsis was confirmed or not

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title	Q7. Is there documentation within the clinical record that the patient was already receiving appropriate targeted oxygen at the time of sepsis diagnosis?

Q7. Is there documentation within the clinical record that the patient was already receiving appropriate targeted oxygen at the time of sepsis diagnosis?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
GP letter
Ambulance service notes

Terminology related to this question:

Applicable	Not applicable
Targeted oxygen, high-flow oxygen

Answer options:

Answer options	Answer assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that the patient was already received appropriate targeted oxygen at the time of sepsis diagnosis
No	There is no documentation within the clinical record that the patient was already receiving appropriate targeted oxygen at time of sepsis diagnosis

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title	Q8. Is there documentation within the clinical record that targeted oxygen was delivered?

Q8. Is there documentation within the clinical record that targeted oxygen was delivered?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
Ambulance service notes

Terminology related to this question:

Applicable	Not applicable
Targeted oxygen delivered High flow oxygen given 100% oxygen given Targeted oxygen given by venturi mask Oxygen titrated to sats Oxygen given as per protocol

Answer options:

Answer option	Answer assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that targeted oxygen was delivered. For some patients targeted oxygen will have been commenced in the GP surgery, in the ambulance, Emergency Department or Assessment Unit before a diagnosis of sepsis was made. If it is clear that delivery of oxygen in these patients was appropriate for this same episode of care then this should be accepted as “Yes” There is documentation within the medical record that targeted oxygen was delivered. An episode of care consists of all clinically related activities for a patient for a single diagnostic condition from the onset of symptoms until treatment is complete. For example, a patient has a cough and temperature, develops a chest infection, pneumonia, sepsis and then recovers. All treatment surrounding this patient journey is described as an episode of care.
No	There is no documentation within the clinical record that targeted oxygen was delivered or it is unable to be determined from the medical record documentation.
NCI	There is documentation within the clinical record that targeted oxygen was not clinically indicated. There may be patients for whom this measure will be not clinically indicated (NCI). These patients may have documentation in their notes indicating that the consultant or team member has made a decision that this particular measure was not appropriate for this patient. This should be clearly documented in the clinical record. Patients with oxygen saturation levels of 95% and above can also be marked as not clinically indicated to receive oxygen.

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title	Q9. Delivery of targeted oxygen date/time

Q9. Delivery of targeted oxygen date/time

Acceptable source of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
Ambulance service notes

Answer Options:

Answer option

Answer assistance

Unknown

If the date/time of delivery of oxygen is unable to be determined from medical record documentation, select 'Unknown'

The medical record must be abstracted as documented (taken at “face value”). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select “Unknown'

Examples:

Documentation within the medical record indicates the delivery of oxygen date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for “Day”, it is not a valid date and the abstractor should select “UTD.”

Documentation within the medical record indicates the delivery of oxygen time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”

Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the delivery of oxygen date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select “UTD.”

Date

The earliest documented day, month, and year that targeted oxygen was delivered

Some patients may have been given oxygen before a diagnosis of sepsis was made. If the delivery of targeted oxygen for these patients was given for this same episode of care, then the date and time for delivery of oxygen should be entered as the time of sepsis diagnosis in order that the patient correctly passes the measure.

An episode of care consists of all clinically related activities for a patient for a single diagnostic condition from the onset of symptoms until treatment is complete.

For example, a patient has a cough and temperature, develops a chest infection, pneumonia, sepsis and then recovers. All treatment surrounding this patient journey is described as an episode of care.

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

he earliest documented time (24 hour clock) that targeted oxygen was delivered.

Examples:

Midnight - 00:00 Noon - 12:00

5:31 am - 05:31 5:31 pm - 17:31

11:59 am - 11:59 11:59 pm - 23:59

Some patients may have been given oxygen before a diagnosis of sepsis was made. If the delivery of targeted oxygen for these patients was given for this same episode of care, then the date and time for delivery of oxygen should be entered as the time of sepsis diagnosis in order that the patient correctly passes the measure.

An episode of care consists of all clinically related activities for a patient for a single diagnostic condition from the onset of symptoms until treatment is complete.

For example, a patient has a cough and temperature, develops a chest infection, pneumonia, sepsis and then recovers. All treatment surrounding this patient journey is described as an episode of care.

HH	Hour (00 – 23)
MM	Minutes (00-59)

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title	Q10. Is there documentation within the clinical record that blood cultures were collected for another suspected source of infection within the last 24 hours?

Q10. Is there documentation within the clinical record that blood cultures were collected for another suspected source of infection within the last 24 hours?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Laboratory test results
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary

Terminology related to this question:

Applicable	Not applicable
	Query sepsis Suspected sepsis Sepsis considered Question sepsis Potential sepsis Likely sepsis Working diagnosis sepsis Sepsis query cause

Answer options:

Answer option	Answer assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that blood cultures were collected for another suspected source of infection within the last 24 hours.
No	There is no documentation within the clinical record that blood cultures were collected for another suspected source of infection within the last 24 hours.

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title	Q11. Is there documentation within the clinical record that blood cultures were taken?

Q11. Is there documentation within the clinical record that blood cultures were taken?

Acceptable source of information:

Accident and emergency notes
Admission notes
Laboratory test results
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary

Answer Options:

Answer option	Answer assistance
Unanswered	No answer has been provided for this question.
Yes	There is documentation within the clinical record that blood cultures were taken
No	There is no documentation within the clinical record that blood cultures were taken or it is unable to be determined from the medical record.
NCI	There is documentation within the clinical record that blood cultures were not clinically indicated. There may be patients for whom this measure will be not clinically indicated (NCI). These patients may have documentation in their notes indicating that the consultant or team member has made a decision that this particular measure was not appropriate for this patient. An example of a patient who may be NCI would be where a pathogen had been grown prior to the diagnosis/query sepsis of sepsis being made and clearly related to the onset of sepsis. This should be clearly documented in the clinical record.

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title	Q12. Blood cultures taken date/time

Q12. Blood cultures taken date/time

Acceptable sources of information:

Accident and emergency notes
Admission notes
Laboratory test results
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary

Terminology related to this question:

Applicable	Not applicable
Blood cultures taken, bloods taken for culture.

Answer options:

Answer option

Answer assistance

Unknown

If the date/time of blood cultures is unable to be determined from medical record documentation, select 'Unknown'.

The clinical record must be abstracted as documented (taken at “face value”). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select “Unknown”.

Examples:

Documentation within the medical record indicates the blood cultures date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for “Day”, it is not a valid date and the abstractor should select “Unknown”.

Documentation within the medical record indicates the blood cultures time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “Unknown”.

Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the blood cultures date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select “Unknown”.

Date

The earliest documented day, month, and year that blood cultures were taken

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that blood cultures were taken

Examples:

Midnight - 00:00 Noon - 12:00

5:31 am - 05:31 5:31 pm - 17:31

11:59 am - 11:59 11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

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title	Q13. Is there documentation within the clinical record that the patient was already on an appropriate antibiotic at the time of sepsis diagnosis?

Q13. Is there documentation within the clinical record that the patient was already on an appropriate antibiotic at the time of sepsis diagnosis?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
GP letter
Ambulance service notes

Terminology related to this question:

Applicable	Not applicable
Antibiotics given for UTI, on amoxicillin for LRTI

Answer options:

Answer option	Answer assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that the patient was already on an appropriate course of antibiotics at the time of sepsis diagnosis
No	There is no documentation within the clinical record that the patient was already on an appropriate course of antibiotics at time of sepsis diagnosis

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title	Q14. Is there documentation within the clinical record that empiric intravenous antibiotics were administered?

Q14. Is there documentation within the clinical record that empiric intravenous antibiotics were administered?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
GP letter
Ambulance service summary

Answer Options

Answer option	Answer assistance
Unanswered	No answer has been provided for this question
Yes	Following diagnosis/query sepsis antibiotics should be initiated rapidly to treat the underlying infection. Antibiotic choice should be guided by local protocols. For some patients intravenous antibiotics will have been commenced in the Emergency Department, Assessment Unit or ward before a diagnosis of sepsis was made. If it is clear that administration of intravenous antibiotics in these patients was appropriate for this same episode of care then this should be accepted as “Yes” There is documentation within the clinicall record that empiric intravenous antibiotics were administered. An episode of care consists of all clinically related activities for a patient for a single diagnostic condition from the onset of symptoms until treatment is complete. For example, a patient has a cough and temperature, develops a chest infection, pneumonia, sepsis and then recovers. All treatment surrounding this patient journey is described as an episode of care.
No	There is no documentation within the clinical record that empiric intravenous antibiotics were administered or it is unable to be determined from the medical record.
NCI	There may be patients for whom this measure will be not clinically indicated (NCI). These patients may have documentation in their notes indicating that the consultant or team member has made a decision that this particular measure was not appropriate for this patient. An example of a patient who was NCI for this measure would be where antibiotics were already being administered at the time of diagnosis/query sepsis. This should be clearly documented in the medical record.

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title	Q15. Empiric intravenous antibiotics administered date/time

Q15. Empiric intravenous antibiotics administered date/time

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
GP letter
Ambulance service notes

Answer Options:

Answer option

Answer assistance

Unknown

If the date/time of antibiotic administration is unable to be determined from medical record documentation, enter UTD.

The medical record must be abstracted as documented (taken at “face value”). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select “UTD.”

Examples:

Documentation within the medical record indicates the antibiotic administration date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for “Day”, it is not a valid date and the abstractor should select “UTD.”

Documentation within the medical record indicates the antibiotic administration time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”

Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the antibiotic administration date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select “UTD.”

Date

The earliest documented day, month, and year that empiric antibiotics were administered

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that empiric antibiotics were administered.

Examples:

Midnight - 00:00 Noon - 12:00

5:31 am - 05:31 5:31 pm - 17:31

11:59 am - 11:59 11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

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title	Q16. Did the patient have an empiric review within 24 to 72 hours of sepsis diagnosis?

Q16. Did the patient have an empiric review within 24 to 72 hours of sepsis diagnosis?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary

Terminology related to this question:

Applicable	Not applicable
Antibiotics reviewed. Continue IV antibiotics Reviewed antibiotics Change to oral from IV antibiotics Change from one antibiotic to another, for example ‘stop clarithromycin start metronidazole and doxycycline.

Answer Options:

Answer option	Answer assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that an empiric review was carried out by day three of antibiotics being prescribed. There should be documented evidence in the medical record that a review of antibiotics prescribed to treat sepsis has been recorded within three days of their initiation. This evidence can be provided at any point in the three days from the beginning of the course of antibiotics given to treat sepsis.
No	There is no documentation within the clinical record that an empiric review was carried out or it was outside of the allowable time frame.
NCI	If the patient dies during the three day time period, then ‘NCI’ should be selected
Patient Discharged	If the patient was discharged within 72 hours of the sepsis diagnosis select this answer
UTD	If it not possible to determine from the clinical record whether a review of antibiotics took place, select this answer

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title	Q17. Is there documentation within the clinical record that the patient was already receiving appropriate fluid resuscitation at the time of sepsis diagnosis?

Q17. Is there documentation within the clinical record that the patient was already receiving appropriate fluid resuscitation at the time of sepsis diagnosis?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
GP letter
Ambulance service notes

Answer options:

Answer option	Answer assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that the patient was already receiving appropriate fluid resuscitation at the time of sepsis diagnosis
No	There is no documentation within the clinical record that the patient was already receiving appropriate fluid resuscitation at the time of sepsis diagnosis

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title	Q18. Is there documentation within the clinical record that intravenous fluid resuscitation was initiated?

Q18. Is there documentation within the clinical record that intravenous fluid resuscitation was initiated?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
Laboratory test results
High dependency unit notes
Hospital discharge summary
GP letter
Ambulance service notes
Fluid balance sheets

Terminology related to this question:

Applicable	Not applicable
Crystalloid fluid – normal saline 0.9% saline, Ringer’s solution, Ringer’s lactate, glucose 0.5% Colloid fluid – synonyms, albumin, dextran 40, dextran 70, gelatin, HES (hydroxyethyl starches), tetrastarch, gelofusine, plasmagel, plasmion, polygeline, haemacel, gelifundol, hespan, hextend, hetastarch, pentastarch

Answer options:

Answer option	Answer assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that the appropriate volumes of fluid resuscitation were initiated. For some patients intravenous fluid resuscitation will have been commenced in the Emergency Department, Assessment Unit or ward before a diagnosis of sepsis was made. If it is clear that administration of intravenous fluid in these patients was appropriate for this same episode of care then this should be accepted as “Yes” There is documentation within the medical record that empiric intravenous fluid resuscitation was administered. An episode of care consists of all clinically related activities for a patient for a single diagnostic condition from the onset of symptoms until treatment is complete. For example, a patient has a cough and temperature, develops a chest infection, pneumonia, sepsis and then recovers. All treatment surrounding this patient journey is described as an episode of care.
No	There is no documentation within the clinical record that fluid resuscitation was initiated or it is unable to be determined from the clinical record.
NCI	There is documentation within the clinical record that fluid resuscitation was not clinically indicated. There may be patients for whom this measure will be not clinically indicated (NCI). These patients may have documentation in their notes indicating that the consultant or team member has made a decision that this particular measure was not appropriate for this patient. An example of a patient who could be considered NCI for this measure might be where fluid overload is problematic, for example in left ventricular failure. This should be clearly documented in the medical record.

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title	Q19. Intravenous fluid resuscitation initiated date/time

Q19. Intravenous fluid resuscitation initiated date/time

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
GP letter
Ambulance service notes
Fluid balance sheets

Answer options:

Answer option

Answer assistance

Unknown

If the date/time fluid resuscitation was given is unable to be determined from medical record documentation, select 'Unknown'.

The medical record must be abstracted as documented (taken at “face value”). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select 'Unknown'.

Examples:

Documentation within the medical record indicates the date fluid resuscitation was given was 12-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for “Day”, it is not a valid date and the abstractor should select 'Unknown'.

Documentation within the medical record indicates the time fluid resuscitation was given was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select 'Unknown'.

Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the date fluid resuscitation was given was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select 'Unknown'.

Date

The earliest documented day, month, and year that fluid resuscitation was initiated

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that fluid resuscitation was initiated

Examples:

Midnight - 00:00 Noon - 12:00

5:31 am - 05:31 5:31 pm - 17:31

11:59 am - 11:59 11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

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title	Q20. Is there documentation within the clinical record that serum lactate had already been taken prior to sepsis diagnosis?

Q20. Is there documentation within the clinical record that serum lactate had already been taken prior to sepsis diagnosis?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
GP letter
Ambulance service notes

Answer options:

Answer options	Answer assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that the patient had already had a serum lactate sample taken prior to sepsis diagnosis
No	There is no documentation within the clinical record that the patient had already had a serum lactate sample taken prior to sepsis diagnosis

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title	Q21. Is there documentation within the clinical record that serum lactate was taken?

Q21. Is there documentation within the clinical record that serum lactate was taken?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
Laboratory test results
High dependency unit notes
Hospital discharge summary
GP letter

Terminology related to this question:

Applicable	Not applicable
For example “Bloods taken, FBC, U&E, lactate, LFTs, gases”

Answer options:

Answer option	Answer assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that serum lactate was taken. Serum lactate levels may be one of many blood analyses performed at any point in the assessment of a patient. This may be listed as part of a set of blood tests taken by venepuncture.
No	There is no documentation within the clinical record that serum lactate was taken or it is unable to be determined from the medical record.
NCI	There is documentation within the clinical record that serum lactate and was not clinically indicated. There may be patients for whom this measure will be not clinically indicated (NCI). These patients may have documentation in their notes indicating that the consultant or team member has made a decision that this particular measure was not appropriate for this patient. An example of a patient who is NCI for this measure might be where a blood test was performed in a recent period of time before diagnosis/query sepsis. This should be clearly documented in the medical record.

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title	Q22. Serum lactate taken date/time

Q22. Serum lactate taken date/time

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
Laboratory test results
High dependency unit notes
Hospital discharge summary
GP letter

Answer options:

Answer option

Answer assistance

Unknown

If the date/time of serum lactate is unable to be determined from medical record documentation, select 'Unknown'.

The medical record must be abstracted as documented (taken at “face value”). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select 'Unknown'.

Examples:

Documentation within the medical record indicates the serum lactate date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for “Day”, it is not a valid date and the abstractor should select 'Unknown'.

Documentation within the medical record indicates the serum lactate time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select 'Unknown'.

Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the serum lactate date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select 'Unknown'.

Date

The earliest documented day, month, and year that serum lactate was taken

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that serum lactate was taken

Examples:

Midnight - 00:00 Noon - 12:00

5:31 am - 05:31 5:31 pm - 17:31

11:59 am - 11:59 11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

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title	Q23. Is there documentation within the clinical record that an accurate urine output measurement had already been commenced prior to sepsis diagnosis?

Q23. Is there documentation within the clinical record that an accurate urine output measurement had already been commenced prior to sepsis diagnosis?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
GP letter
Ambulance service notes

Answer options:

Answer option	Answer assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that the patient was already commenced on an accurate urine output measurement prior to sepsis diagnosis
No	There is no documentation within the clinical record that the patient was already commenced on an accurate urine output measurement prior to sepsis diagnosis

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title	Q24. Is there documentation within the clinical record that accurate urine output measurement was started?

Q24. Is there documentation within the clinical record that accurate urine output measurement was started?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
Laboratory test results
High dependency unit notes
Hospital discharge summary
Fluid balance sheets

Terminology related to this question:

Applicable	Not applicable
Fluid balance chart commenced, fluid balance chart started, urine output measured as xx mls per hour as per balance sheet, urinary output low at xx mls per hour

Answer options:

Answer option	Answer assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that accurate urine output measurement was started. For some patients accurate urine output measurement will have been commenced in the Emergency Department, Assessment Unit or ward before a diagnosis of sepsis was made. If it is clear that accurate urine output measurement in these patients was appropriate for this same episode of care then this should be accepted as “Yes” There is documentation within the clinical record that accurate urine output measurement was started. An episode of care consists of all clinically related activities for a patient for a single diagnostic condition from the onset of symptoms until treatment is complete. For example, a patient has a cough and temperature, develops a chest infection, pneumonia, sepsis and then recovers. All treatment surrounding this patient journey is described as an episode of care.
No	There is no documentation within the clinical record that accurate urine output measurement was started or it is unable to be determined from the clinical record.
NCI	There is documentation within the clinical record that accurate urine output measurement was not clinically indicated. There may be patients for whom this measure will be not clinically indicated (NCI). These patients may have documentation in their notes indicating that the consultant or team member has made a decision that this particular measure was not appropriate for this patient. This should be clearly documented in the clinical record.

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title	Q25. Accurate urine output measurement started date/time

Q27. Accurate urine output measurement started date/time

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary

Terminology related to this question:

Applicable	Not applicable
Fluid balance chart commenced, urine output measured as xx mls per hour as per balance sheet, urinary output low at xx mls per hour

Answer options:

Answer option

Answer assistance

Unknown

If the date/time accurate urine output measurement was started is unable to be determined from medical record documentation, select 'Unknown'

The medical record must be abstracted as documented (taken at “face value”). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select 'Unknown'

Examples:

Documentation within the medical record indicates the date accurate urine output measurement was started was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for “Day”, it is not a valid date and the abstractor should select 'Unknown'
Documentation within the medical record indicates the time accurate urine output measurement was started was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select 'Unknown'

Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the date accurate urine output measurement was started was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select 'Unknown'

Date

The earliest documented day, month, and year that accurate urine output measurement was started

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that accurate urine output measurement was started

Examples:

Midnight - 00:00 Noon - 12:00

5:31 am - 05:31 5:31 pm - 17:31

11:59 am - 11:59 11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

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title	Q26. Is there a reason documented for not undertaking a Senior Clinician review or is the Trust choosing not to audit senior review data?

Q26. Is there a reason documented for not undertaking a Senior Clinician review or is the Trust choosing not to audit senior review data?

Acceptable sources of information:

Accident and emergency notes
Admission notes
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary
GP letter
Ambulance service summary

Answer options:

Answer option	Answer assistance
Unanswered	No answer has been provided for this question
Yes	There is documentation within the clinical record that the patient had a reason for not undertaking a Senior Clinician review or the Trust are not auditing senior review data. If the Trust are not collecting/auditing senior review data answer ‘yes’ to this patient to exclude from this measure.
No	There is no documentation within the clinical record that the patient had a reason for not undertaking a Senior Clinician review.
NCI	There may be patients for whom this measure will be not clinically indicated (NCI). These patients may have documentation in their notes indicating that the clinician has made a decision that this particular measure was not appropriate for this patient. This should be clearly documented in the medical record

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title	Q27. Date/time of Senior Clinician review

Q27. Date/time of Senior Clinician review

Acceptable sources of information:

Accident and emergency notes
Admission notes
Laboratory test results
Medical assessment unit notes
Medical/surgical ward notes
High dependency unit notes
Hospital discharge summary

Terminology related to this question:

Applicable	Not applicable
Senior Clinician review

Additional Information:

This question is for data collection purposes only and does not contribute towards the passing, failing or exclusion of measures.

A review of a patient with sepsis will be considered to have been performed when there is evidence that it has been completed by an appropriately qualified individual and to an appropriate clinical standard.

This will have been proven when the clinician has recorded in the patient notes that a review has been undertaken.

Appropriate clinicians will include:

Consultants in emergency medicine
Consultants in anaesthetics and intensive care
Consultants in haematology and oncology
Consultants in medicine and surgery
Critical care outreach teams
Specialist nurses in sepsis, oncology, intensive care and haematology
Higher specialist trainees (ST) in medicine, surgery, oncology, haematology, intensive care, and emergency medicine

Answer options:

Answer option

Answer assitance

Unknown

If the date/time of a Senior Clinician review being undertaken is unable to be determined from medical record documentation, select 'Unknown'.

The medical record must be abstracted as documented (taken at “face value”). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select 'Unknown'.

Examples:

Documentation within the medical record indicates the Senior Clinician review date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the date is outside of the range listed in the Allowable Values for “Day”, it is not a valid date and the abstractor should select 'Unknown'.
Documentation within the medical record indicates the Senior Clinician review time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the time is outside of the range in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select 'Unknown'.
Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the Senior Clinician review date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select 'Unknown'.

Date

The earliest documented day, month, and year that Senior Clinician review was undertaken

DD	Day (01-31)
MM	Month (01 – 12)
YYYY	Year (2000 – 9999)

Time

The earliest documented time (24 hour clock) that Senior Clinician review was undertaken

Examples:

Midnight - 00:00 Noon - 12:00

5:31 am - 05:31 5:31 pm - 17:31

11:59 am - 11:59 11:59 pm - 23:59

HH	Hour (00 – 23)
MM	Minutes (00-59)

Measures

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title	PAESEPSEP-1: High flow oxygen given within 1 hour

SEP-1: Targeted oxygen delivered

Measure numerator statement: Number of Sepsis patients who have targeted oxygen delivered within 1 hour before/after sepsis diagnosis

Measure denominator statement: All patients included in the Assure Sepsis population minus exclusions.

Patients excluded from the population of SEP-1

If a patient meets any of the following criteria, they will be excluded from the measure

Patients receiving palliative care only
Patients who are not clinically indicated to receive targeted oxygen.

Measure pass criteria
To pass this measure, the patient must have received targeted oxygen within 1 hour before/after sepsis diagnosis.

Measure questions:

The following questions make up the SEP-1 measure.

Questions used to analyse measure outcome

(Pass/Fail/Exclude)

Questions for data collection

purposes only

Is there documentation within the clinical record that the patient received palliative care only?
Sepsis suspected, diagnosed or triggered date/time
Is there documentation within the clinical record that the patient was already receiving appropriate targeted oxygen at the time of sepsis diagnosis?
Is there documentation within the clinical record that targeted oxygen was delivered?
Delivery of targeted oxygen date/time

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title	SEP-2: Blood cultures taken

SEP-2: Blood cultures taken

Measure numerator statement: Number of Sepsis patients who have blood cultures taken within 1 hour before/after sepsis diagnosis.

Measure denominator statement: All patients included in the Assure Sepsis population minus exclusions.

Patients excluded from the population of SEP-2

If a patient meets any of the following criteria, they will be excluded from the measure

Patients receiving palliative care only
Patients who are not clinically indicated to have blood cultures taken

Measure pass criteria
To pass this measure, the patient must have had blood cultures taken within 1 hour before/after sepsis diagnosis.

Measure questions:

The following questions make up the SEP-2 measure.

Questions used to analyse measure outcome

(Pass/Fail/Exclude)

Questions for data collection

purposes only

Is there documentation within the clinical record that the patient received palliative care only?
Sepsis suspected, diagnosed or triggered date/time

Is there documentation within the clinical record that blood cultures were collected for another suspected source of infection within the last 24 hours?

Is there documentation within the clinical record that blood cultures were taken?

Blood cultures taken date/time

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title	SEP-3: Empiric IV antibiotics administered

SEP-3: Empiric IV antibiotics administered

Measure numerator statement: Number of Sepsis patients who have empiric intravenous antibiotics administered within one hour before/after sepsis diagnosis.

Measure denominator statement: All patients included in the Assure Sepsis population minus exclusions.

Patients excluded from the population of SEP-3

If a patient meets any of the following criteria, they will be excluded from the measure

Patients receiving palliative care only
Patients

aged 15 years or youngerPatients

who are not clinically indicated to receive empiric antibiotics

Measure pass criteria
To pass this measure, the patient must have either had empiric IV antibiotics administered within 1 hour before/after sepsis diagnosis

Measure Questions:

The following questions make up the SEP-3 measure.

Questions used to analyse measure outcome

(Pass/Fail/Exclude)

Questions for data collection

purposes only

Is there documentation within the clinical record that the patient received palliative care only?

Sepsis suspected, diagnosed or triggered date/time

Is there documentation within the clinical record that the patient was already on an appropriate antibiotic at the time of sepsis diagnosis?

Is there documentation within the clinical record that empiric intravenous antibiotics were administered?

Empiric intravenous antibiotics administered date/time

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title	SEP-4: Serum lactate taken

SEP-4: Serum lactate taken

Measure numerator statement: Number of Sepsis patients who have serum lactate taken within 1 hour before/after sepsis diagnosis.

Measure denominator statement: All patients included in the Assure Sepsis population minus exclusions.

Patients excluded from the population of SEP-4

If a patient meets any of the following criteria, they will be excluded from the measure

Patients receiving palliative care only
Patients

aged 15 years or youngerPatients

who are not clinically indicated to have serum lactate/full blood count taken

Measure pass criteria
To pass this measure, the patient must have either had serum lactate taken within 1 hour before/after sepsis diagnosis

Measure Questions:

The following questions make up the SEP-4 measure.

Questions used to analyse measure outcome

(Pass/Fail/Exclude)

Questions for data collection

purposes only

Is there documentation within the clinical record that the patient received palliative care only?

Sepsis suspected, diagnosed or triggered date/time

Is there documentation within the clinical record that serum lactate had already been taken prior to sepsis diagnosis?

Is there documentation within the clinical record that serum lactate was taken?

Serum lactate taken date/time

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title	SEP-5: IV fluid resuscitation initiated

SEP-5: IV fluid resuscitation initiated

Measure numerator statement: Number of Sepsis patients who have fluid resuscitation initiated within 1 hour before/after sepsis diagnosis.

Measure denominator statement: All patients included in the Assure Sepsis population minus exclusions.

Patients excluded from the population of SEP-5

If a patient meets any of the following criteria, they will be excluded from the measure

Patients receiving palliative care only
Patients who are not clinically indicated to receive intravenous fluid resuscitation

Measure pass criteria

To pass this measure, the patient must have either IV fluid resuscitation initiated within 1 hour of arrival or within 1 hour of sepsis diagnosis, depending on when the patient was diagnosed with sepsis. If the patient was diagnosed with sepsis within 4 hours of arrival, then IV fluid resuscitation will be calculated from arrival. If the patient was diagnosed more than 4 hours after arrival, then IV fluid resuscitation will be calculated from sepsis diagnosis. If the patient was already on IV fluid resuscitation at the time of sepsis diagnosis, then the patient will pass the measure.

Measure Questions:

The following questions make up the SEP-5 measure.

Questions used to analyse measure outcome

(Pass/Fail/Exclude)

Questions for data collection

purposes only

Is there documentation within the clinical record that the patient received palliative care only?

Sepsis suspected, diagnosed or triggered date/time

Is there documentation within the clinical record that the patient was already receiving appropriate fluid resuscitation at the time of sepsis diagnosis?

Is there documentation within the clinical record that intravenous fluid resuscitation was initiated?

Intravenous fluid resuscitation initiated date/time

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title	SEP-6: Urine output measurement commenced

SEP-6: Urine output measurement commenced

Measure numerator statement: Number of Sepsis patients who have accurate urine output measurement started within 1 hour before/after suspected sepsis or sepsis diagnosis.

Measure denominator statement: All patients included in the Assure Sepsis population minus exclusions.

Patients excluded from the population of SEP-6

If a patient meets any of the following criteria, they will be excluded from the measure

Patients receiving palliative care only
Patients who are not clinically indicated to receive urine output measurement

Measure pass criteria
To pass this measure, the patient must have had either urine output measurement commenced within 1 hour before/after sepsis diagnosis

Measure Questions:

The following questions make up the SEP-6 measure.

Questions used to analyse measure outcome

(Pass/Fail/Exclude)

Questions for data collection

purposes only

Is there documentation within the clinical record that the patient received palliative care only?

Sepsis suspected, diagnosed or triggered date/time

Is there documentation within the clinical record that an accurate urine output measurement had already been commenced prior to sepsis diagnosis?

Is there documentation within the clinical record that accurate urine output measurement was started?

Accurate urine output measurement started date/time

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title	SEP-7: Senior Clinician review

SEP-7: Senior Clinician review

This is a data collection measure, this will not affect your overall ACS/CPS scores

Measure statement: Number of Sepsis patients who have documentation of review by a Senior Clinician performed within 1 hour of suspected sepsis or sepsis diagnosis.

Measure denominator statement: All patients included in the Assure Sepsis population minus exclusions.

Patients excluded from the population of SEP-7

If a patient meets any of the following criteria, they will be excluded from the measure

Patients receiving palliative care only
Patients who are not clinically indicated to receive urine output measurement

Measure pass criteria
To pass this measure, the patient must have had either urine output measurement commenced within 1 hour before/after sepsis diagnosis

Measure Questions:

The following questions make up the SEP-7 measure.

Questions used to analyse measure outcome

(Pass/Fail/Exclude)

Questions for data collection

purposes only

Is there documentation within the clinical record that the patient received palliative care only?

Sepsis suspected, diagnosed or triggered date/time

Is there a reason documented for not undertaking a Senior Clinician review or is the Trust choosing not to audit senior review data?

Date/time of Senior Clinician review

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title	SEP-CQUIN2c: Antibiotics Reviewed 24 to 72 hours of diagnosis

SEP-CQUIN2c: Antibiotics Reviewed 24 to 72 hours of diagnosis

Measure statement: Number of Sepsis patients who have antibiotics reviewed within 24 to 72 hours of sepsis diagnosis

Measure denominator statement: All patients included in the Assure Sepsis population minus exclusions.

Patients excluded from the population of SEP-CQUINaCQUIN2c

If a patient meets any of the following criteria, they will be excluded from the measure

Patients receiving palliative care only
Patients who are not clinically indicated to receive antibiotics
Patients who have been discharged within 72 hours of sepsis diagnosis

Measure pass criteria
To pass this measure, the patient must have had antibiotics reviewed within 72 hours of diagnosis

Measure Questions:

The following questions make up the SEP-CQUINa CQUIN2c measure.

Questions used to analyse measure outcome

(Pass/Fail/Exclude)

Questions for data collection

purposes only

Is there documentation within the clinical record that the patient received palliative care only?

Sepsis suspected, diagnosed or triggered date/time

Is there documentation within the clinical record that the patient was already on an appropriate antibiotic at the time of sepsis diagnosis?

Is there documentation within the clinical record that empiric intravenous antibiotics were administered?

Empiric intravenous antibiotics administered date/time

Did the patient have an empiric review within 24 to 72 hours of sepsis diagnosis?

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title	SEP-DC: Data collection

SEP-DC: Data collection

The questions in this measure are for data collection purposes only and will NOT affect the overall outcome of the patient. Certain questions if unanswered WILL however affect your data completeness figures.

Questions affecting data completemesscompleteness

Questions with no affect on data completeness

Is there documentation within the clinical record that the patient received palliative care only?Was the patient aged 16 years or older on admission?

What was the severity of the suspected sepsis/sepsis diagnosis?

Is there documentation within the clinical record that the patient was suffering from neutropenic sepsis?

If there was a diagnosis/suspicion of septic shock enter the date/time

Was a screening tool present in the discharge notes?

Population Criteria and Codes

Population Criteria

	Criteria	Rank		CodeGroup
{	Primary Diagnosis Code	1	IN	SEPSISNE
{	AND
{	Age		>=	16
{	AND
{	Discharge Month		<=	Sep-15
OR
{	Primary Diagnosis Code	1	IN	SEPSISNE
{	AND
{	Discharge Month		>=	Oct-15

Population Codes

codeGroupID	label	Version	CodeType	Code	Description
SEPSISNE	Sepsis	Version 1	ICD	T814	Infection following a procedure, not elsewhere classified
SEPSISNE	Sepsis	Version 2	ICD	R651	Systemic Inflammatory Response Syndrome of infectious origin with organ failure
SEPSISNE	Sepsis	Version 2	ICD	R652	Systemic Inflammatory Response Syndrome of non-infectious origin without organ failure
SEPSISNE	Sepsis	Version 1	ICD	R652	Systemic Inflammatory Response Syndrome of non-infectious origin without organ failure
SEPSISNE	Sepsis	Version 1	ICD	T811	Shock during or resulting from a procedure, not elsewhere classified
SEPSISNE	Sepsis	Version 2	ICD	P362	Sepsis of newborn due to Staphylococcus aureus
SEPSISNE	Sepsis	Version 1	ICD	P362	Sepsis of newborn due to Staphylococcus aureus
SEPSISNE	Sepsis	Version 1	ICD	P363	Sepsis of newborn due to other and unspecified staphylococci
SEPSISNE	Sepsis	Version 2	ICD	P363	Sepsis of newborn due to other and unspecified staphylococci
SEPSISNE	Sepsis	Version 2	ICD	P360	Sepsis of newborn due to streptococcus, group B
SEPSISNE	Sepsis	Version 1	ICD	P360	Sepsis of newborn due to streptococcus, group B
SEPSISNE	Sepsis	Version 1	ICD	P361	Sepsis of newborn due to other and unspecified streptococci
SEPSISNE	Sepsis	Version 2	ICD	P361	Sepsis of newborn due to other and unspecified streptococci
SEPSISNE	Sepsis	Version 2	ICD	O85	Puerperal sepsis
SEPSISNE	Sepsis	Version 1	ICD	O85	Puerperal sepsis
SEPSISNE	Sepsis	Version 1	ICD	P36	Bacterial sepsis of newborn
SEPSISNE	Sepsis	Version 2	ICD	M726	Necrotizing fasciitis
SEPSISNE	Sepsis	Version 1	ICD	R571	Hypovolaemic shock
SEPSISNE	Sepsis	Version 1	ICD	R572	Septic shock
SEPSISNE	Sepsis	Version 2	ICD	R572	Septic shock
SEPSISNE	Sepsis	Version 2	ICD	R578	Other shock
SEPSISNE	Sepsis	Version 1	ICD	R578	Other shock
SEPSISNE	Sepsis	Version 1	ICD	R651	Systemic Inflammatory Response Syndrome of infectious origin with organ failure
SEPSISNE	Sepsis	Version 2	ICD	P368	Other bacterial sepsis of newborn
SEPSISNE	Sepsis	Version 1	ICD	P368	Other bacterial sepsis of newborn
SEPSISNE	Sepsis	Version 1	ICD	P369	Bacterial sepsis of newborn, unspecified
SEPSISNE	Sepsis	Version 2	ICD	P369	Bacterial sepsis of newborn, unspecified
SEPSISNE	Sepsis	Version 2	ICD	P364	Sepsis of newborn due to Escherichia coli
SEPSISNE	Sepsis	Version 1	ICD	P364	Sepsis of newborn due to Escherichia coli
SEPSISNE	Sepsis	Version 1	ICD	P365	Sepsis of newborn due to anaerobes
SEPSISNE	Sepsis	Version 2	ICD	P365	Sepsis of newborn due to anaerobes
SEPSISNE	Sepsis	Version 2	ICD	P36	Bacterial sepsis of newborn
SEPSISNE	Sepsis	Version 2	ICD	R571	Hypovolaemic shock
SEPSISNE	Sepsis	Version 1	ICD	M726	Necrotizing fasciitis
SEPSISNE	Sepsis	Version 2	ICD	B007	Disseminated herpesviral disease
SEPSISNE	Sepsis	Version 2	ICD	B377	Candidal septicaemia
SEPSISNE	Sepsis	Version 1	ICD	A42	Actinomycosis
SEPSISNE	Sepsis	Version 1	ICD	A427	Actinomycotic septicaemia
SEPSISNE	Sepsis	Version 1	ICD	A419	Septicaemia, unspecified
SEPSISNE	Sepsis	Version 2	ICD	A427	Actinomycotic septicaemia
SEPSISNE	Sepsis	Version 2	ICD	A42	Actinomycosis
SEPSISNE	Sepsis	Version 1	ICD	A483	Toxic shock syndrome
SEPSISNE	Sepsis	Version 2	ICD	A483	Toxic shock syndrome
SEPSISNE	Sepsis	Version 1	ICD	B007	Disseminated herpesviral disease
SEPSISNE	Sepsis	Version 1	ICD	B377	Candidal septicaemia
SEPSISNE	Sepsis	Version 1	ICD	A548	Other gonococcal infections
SEPSISNE	Sepsis	Version 2	ICD	A548	Other gonococcal infections
SEPSISNE	Sepsis	Version 1	ICD	A327	Listerial septicaemia
SEPSISNE	Sepsis	Version 2	ICD	A327	Listerial septicaemia
SEPSISNE	Sepsis	Version 2	ICD	A312	Disseminated mycobacterium avium-intracellulare complex
SEPSISNE	Sepsis	Version 1	ICD	A267	Erysipelothrix septicaemia
SEPSISNE	Sepsis	Version 1	ICD	A312	Disseminated mycobacterium avium-intracellulare complex
SEPSISNE	Sepsis	Version 2	ICD	A241	Acute and fulminating melioidosis
SEPSISNE	Sepsis	Version 2	ICD	A267	Erysipelothrix septicaemia
SEPSISNE	Sepsis	Version 1	ICD	A227	Anthrax septicaemia
SEPSISNE	Sepsis	Version 1	ICD	A241	Acute and fulminating melioidosis
SEPSISNE	Sepsis	Version 2	ICD	A021	Salmonella septicaemia
SEPSISNE	Sepsis	Version 2	ICD	A227	Anthrax septicaemia
SEPSISNE	Sepsis	Version 1	ICD	A021	Salmonella septicaemia
SEPSISNE	Sepsis	Version 2	ICD	A400	Septicaemia due to streptococcus, group A

Background Information

Why are we measuring quality of care in sepsis?

This focus area is designed to improve patient care, reduce mortality and morbidity across patients with severe infections.

Sepsis is a common condition with a major impact on healthcare resources and expenditure. The incidence of severe sepsis in the European Union has been estimated at 90.4 cases per 100 000 population.

There is clear international evidence that adhering to certain clinical standards has reduced mortality by 33% in these patients. These measures, three diagnostic and three therapeutic steps, are called the sepsis six and are designed to be delivered to patients over the age of 16 within 1 hour of onset of sepsis.”

Version	Old Version 7	New Version Current
Changes made by	Assure Administrator	Assure Administrator
Saved on	Oct 30, 2017	Oct 30, 2017

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Key

Data collection form

Measure questions

Q1. Is there documentation within the clinical record that the patient received palliative care only?

Q2. Please enter the date & time sepsis suspected/diagnosed/triggered

Q3. What was the severity of the suspected sepsis/sepsis diagnosis?

Q4. If there was a diagnosis/suspicion of septic shock, please enter the date/time

Q5. Is there documentation within the clinical record that the patient was suffering from neutropenic sepsis?

Q6. Was a screening tool present in the discharge notes?

Q7. Is there documentation within the clinical record that the patient was already receiving appropriate targeted oxygen at the time of sepsis diagnosis?

Q8. Is there documentation within the clinical record that targeted oxygen was delivered?

Q9. Delivery of targeted oxygen date/time

Q10. Is there documentation within the clinical record that blood cultures were collected for another suspected source of infection within the last 24 hours?

Q11. Is there documentation within the clinical record that blood cultures were taken?

Q12. Blood cultures taken date/time

Q13. Is there documentation within the clinical record that the patient was already on an appropriate antibiotic at the time of sepsis diagnosis?

Q14. Is there documentation within the clinical record that empiric intravenous antibiotics were administered?

Q15. Empiric intravenous antibiotics administered date/time

Q16. Did the patient have an empiric review within 24 to 72 hours of sepsis diagnosis?

Q17. Is there documentation within the clinical record that the patient was already receiving appropriate fluid resuscitation at the time of sepsis diagnosis?

Q18. Is there documentation within the clinical record that intravenous fluid resuscitation was initiated?

Q19. Intravenous fluid resuscitation initiated date/time

Q20. Is there documentation within the clinical record that serum lactate had already been taken prior to sepsis diagnosis?

Q21. Is there documentation within the clinical record that serum lactate was taken?

Q22. Serum lactate taken date/time

Q23. Is there documentation within the clinical record that an accurate urine output measurement had already been commenced prior to sepsis diagnosis?

Q24. Is there documentation within the clinical record that accurate urine output measurement was started?

Q27. Accurate urine output measurement started date/time

Q26. Is there a reason documented for not undertaking a Senior Clinician review or is the Trust choosing not to audit senior review data?

Q27. Date/time of Senior Clinician review

Measures

SEP-1: Targeted oxygen delivered

SEP-2: Blood cultures taken

SEP-3: Empiric IV antibiotics administered

SEP-4: Serum lactate taken

SEP-5: IV fluid resuscitation initiated

SEP-6: Urine output measurement commenced

SEP-7: Senior Clinician review

SEP-CQUIN2c: Antibiotics Reviewed 24 to 72 hours of diagnosis

SEP-DC: Data collection

Population Criteria and Codes

Population Criteria

Population Codes

Background Information