Infection Control & Hospital Epidemiology (2018), 39, 994–996 doi:10.1017/ice.2018.134
Concise Communication
Variability in determining sepsis time zero and bundle compliance rates for the Centers for Medicare and Medicaid Services SEP-1 measure
Chanu Rhee MD, MPH1,2, Sarah R. Brown MD2, Travis M. Jones PharmD3, Cara O’Brien MD4, Anupam Pande MD, MPH5, Yasir Hamad MD5, Amy L. Bulger RN, MPH6, Kathleen A. Tobin RN7, Anthony F. Massaro MD2, Deverick J. Anderson MD, MPH3, David K. Warren MD, MPH5 and
Michael Klompas MD, MPH1,2 for the CDC Prevention Epicenters Program 1Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, 2Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, 3Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina, 4Department of Medicine, Duke University Medical Center, Durham, North Carolina, 5Department of Medicine, Washington University School of Medicine, St Louis, Missouri, 6Department of Quality and Safety, Brigham and Women’s Hospital, Boston, Massachusetts and 7Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts
Abstract
We compared sepsis “time zero” and Centers for Medicare and Medicaid Services (CMS) SEP-1 pass rates among 3 abstractors in 3 hospitals. Abstractors agreed on time zero in 29 of 80 (36%) cases. Perceived pass rates ranged from 9 of 80 cases (11%) to 19 of 80 cases (23%). Variability in time zero and perceived pass rates limits the utility of SEP-1 for measuring quality.
(Received 19 March 2018; accepted 9 May 2018; electronically published June 22, 2018)
In October 2015, the Centers for Medicare and Medicaid Services (CMS) implemented the “SEP-1” sepsis core measure requiring US hospitals to report compliance with 3- and 6-hour bundles of care for patients with severe sepsis or septic shock.1 Hospitals are now devoting substantial resources to measuring and improving SEP-1 adherence, which requires all bundle components be met to “pass.”2,3 SEP-1 bundle adherence is measured relative to sepsis “time
zero,” defined as the first point at which there is documentation of suspected or confirmed infection, 2 or more systemic inflamma- tory response syndrome criteria, and one or more organ dys- function criteria within a 6-hour window.1 Time zero is also triggered if a clinician explicitly documents severe sepsis or septic shock. Given this complex definition, different abstractors may reach different conclusions about time zero, which, in turn, could lead to different impressions on whether cases passed or failed SEP-1.4,5 We compared time-zero determinations and SEP-1 pass rates
among hospital abstractors and clinicians in 3 US hospitals. We also examined clinical factors associated with lower agree- ment rates.
Author for correspondence: Chanu Rhee, MD, MPH, Department of Population
Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401, Boston, MA 02215. E-mail:
crhee@bwh.harvard.edu
Cite this article: Rhee C, et al. (2018). Variability in determining sepsis time zero and
bundle compliance rates for the Centers forMedicare and Medicaid Services SEP-1measure. Infection Control & Hospital Epidemiology 2018, 39, 994–996. doi: 10.1017/ice.2018.134
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. Methods
We randomly selected 80 SEP-1 cases discharged between July 1 and December 31, 2016, at 3 US tertiary-care hospitals: Brigham and Women’s Hospital in Boston, Massachusetts; Barnes-Jewish Hospital in St Louis, Missouri; and Duke University Hospital in Durham, North Carolina. Each case was reviewed by the official hospital SEP-1 abstractor and by 2 clinicians at each hospital (either internal medicine physicians or clinical pharmacists) for all SEP-1 components, including time zero (Table 1) and whether cases passed. Abstractors were blinded to one another’s deter- minations. Clinician reviewers underwent 1 hour of training on SEP-1 abstraction by the lead investigator (C.R.) to encourage standardization using the CMS specification in place during the study period.1 We applied CMS exclusion criteria prior to selecting cases for review (ie, outside hospital transfer, severe sepsis criteria not met on chart review, goals of care limitations, and antibiotic administration prior to 24 hours before time zero).1 We compared agreement on time-zero and SEP-1 pass-versus-
fail rates among the 3 abstractors at each site. Time zero was considered concordant between abstractors if they were within ±1 minute of each other. We also conducted sensitivity analyses allowing for agreement if time-zero determinations were within 1 hour and 3 hours of each other. We calculated interobserver variability on whether cases pas-
sed or failed SEP-1 using the Fleiss κ for 3-abstractor comparisons and the Cohen κ for 2-abstractor comparisons.6 We considered κ>0.75 to be strong agreement, κ=0.40–0.75 to be moderate agreement, and κ<0.40 to be poor agreement.7
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