Sep 18, 2023Liked by PulmCCM

"Sepsis 'Stasi" is not that much of an exaggeration. At a practical level, when hospitals stand to lose millions when not complying with these bundles, the natural inevitability of this is intense pressure/mandates on clinicians to comply.

I can think of no other instance in medicine where such non-specific criteria are used to establish a diagnosis, and where clinicians are then mandated to perform interventions on their patients regardless of whether they feel it is warranted or harmful.

Imagine if we began defining STEMIs as "anyone with chest pain", and mandated cardiologists take all such patients to the cath lab within thirty minutes or else they get dinged for not complying with the protocol? Sure, you'd probably catch a few subtle STEMIs that would have previously been missed, and patients would get to the lab faster. But there would also be countless harmful negative caths, and you would be doing a disservice to all the other patients not being seen in a timely manner.

Imagine if neurologists were obligated to give TPA to anyone presenting with altered mental status? Or if trauma teams were mandated to take EVERY trauma to the OR?

The clinician at the bedside HAS to have final say on whether or not an intervention is harmful or beneficial for that particular patient. And, yes, if you are tying hospital funding to compliance then it is inevitable that clinicians are absolutely being forced to comply as well.

To say nothing as to how unbelievably non-specific these criteria are. I meet SIRS criteria whenever I walk up a flight of stairs. Plus, practically any patient with fever is going to be a little tachy. So basically anyone comes in with fever, all of us in the ER stop what we are doing, call a "code sepsis", drown the patient in fluids regardless of their BP, give unnecessary broad spectrum abx (hello resistant organisms), and ignore all the sicker patients currently under your care. And if they are in pulmonary edema, "just intubate them" (I've been told that five separate times now).


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This is only going to lead to so much wasted time and energy. I work as a locums at a hospital that has a "code sepsis." What this means in this particular facility is that every lactate over 2 (yes, 2...not 4) as well as every lactic acid that is increasing (even if it becomes 2.3 from 2.0) gets reported to me and requires me to evaluate the patient. It is a lot of wasted time, especially when there are actually critically ill patients that require assessment and intervention. In fact, none of what is being done at this particular hospital is supported by data. My husband is the director of quality for the ED at a large academic center, and most of the stuff they have to do to get paid by CMS is also not evidence driven. I cannot stand these top down measures that do nothing to improve patient outcomes and everything to make a lot of busy work in the electronic chart.

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And there's the rub. Your attention, your available time, your cognitive bandwidth, your energy reserves are the most valuable resource the hospital has, from the standpoint of delivery of high quality critical care. But those resources are all unmeasured.

So a hospital is probably blind to how all those mostly unnecessary code sepsis evaluations are detracting from care of patients who really need it. As well as the responding physician's job satisfaction. One might say "And they don't care!" But they certainly should.

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