Fluid Resuscitation in Sepsis

[Summit]

Just to give you guys some perspective on how absurd these CMS mandates have become:

A few weeks ago I admitted an obese patient with ischemic cardiomyopathy and an EF of 20%. She was in respiratory failure from volume overload, on a background of severe COPD, and may have had pneumonia. She was weeping fluid from her legs. She was "hypotensive" (90/50) and "tachycardic" (110) with mild patchy airspace disease on her x-ray, more than likely from volume overload, but I gave her a possible pneumonia diagnosis as well and started Abx.

The patient had distended jugular veins. She had bilateral crackles. She just looked plethoric. You get the picture here. And of course that was documented in my exam.

She go intubated, she got placed on a low dose of inotropes. She got some antibiotics and some diuretics. And maintenance IV fluids.

Today, I have an email in my inbox. And the magical, number-scanning computer of mystery in the performance improvement department has flagged this "hypotensive" and "tachycardic" patient with "possible pneumonia" as falling out of CMS sepsis guidelines because I did not administer a 30 ml/kg fluid bolus to this 120 kg patient.

I'll give you a moment to do some math there....

And now, unless I correct my charting to explain why I elected not to administer that volume of fluid to the heart failure patient, the case will be a "fallout" and must be discussed at the monthly meeting of the sepsis minds, which interestingly enough does not even involve a physician. Lots and lots of white coats. But no physicians.

I get at least 3-4 of these per month. I am to go explain my clinical decision-making to a well-paid, full-time registered nurse in "performance improvement," lest the hospital lose money because of bad medical practice enforced by CMS.

Sadly, some of my colleges have resorted to just giving the fluids, no matter their clinical judgement, simply to avoid the hassle of explaining the Frank-Starling curve to a nurse in performance improvement every couple weeks.

It was so jaw dropping to me when I heard the CMS CM for Sepsis. I remember sitting in the room where some "educator" was explaining to the professional group was explaining these things like it was 2002 and the Surviving Sepsis campaign had just been announced. I remember looking at my fellow CCRN colleagues and shaking our heads as blanked protocols and mandation of questionable treatments in innaplicable circumstances were declared as if this was an idea of the Gods. One of my snarkier colleagues raised her hand and said something like "will CMS reimburse when their mandated removal of clinical judgement kill the patient?" Before the now-sour-faced presenter could respond, I asked "she just wants to know if CMS considers the results of these required therapeutic misadventures to be HACs? I want to know will there be a new ICD10 code for-" I got elbowed in the ribs.

I do hope your quality department doesn't need the Frank-Starling curve explained. I think I learned that A&P and again in Nursing Fundamentals and it was built on many other times. I do a little QI work and when I bring something to a provider like that, I take the time to understand the case so it usually goes: "good job, makes sense, but the system is stupid and here is how you can CYA." It goes over well except for the extra documentation requirement. A providerless star chamber treatment must be a frustrating waste of time.

I wrote some code to make an early warning program for our EHR. When I moved it from beta to production, the email I sent to the intensivists/hospitalists/ACNPs/charge RNs had 3 sentences:
1. This could give you early warning of sepsis indicators, drops in MODS, MEWS/PEWS
2. Click here to access
3. This is only to make you look twice: clinical judgement trumps all!

 

[aquabear]

Quick thread derail...

You know if WilCo EMS moved to an all ALS intercept service, I'd call it just about as close to a unicorn as one could ask for. Even still, you all have what I consider a career-service for paramedics down enticingly well.

...back to the sepsis talk.

Off topic, but Wilco already runs a single medic squad and will be staring a second one. The current squad is on a rotation with a busy station since the call volume is so low where they are located.

...back to the sepsis talk.