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Napa, Summer 2009

ED Consults & Admissions

Coding for Sepsis

- Evaluate ED patients for SIRS criteria and possible sepsis
- Make dot phrase screening tools in HealthConnect for Sepsis, Severe
Sepsis, and Septic Shock (feel free to use the ones listed below)
- Do not use UROSEPSIS as a diagnosis. Examples of proper diagnostic coding
are: SEPSIS due to UTI, or SEVERE SEPSIS from pyelonephritis with lactic
acidosis , or SEPTIC SHOCK from pyelonephritis with lactic acidosis.

Sepsis screen– An infection with systemic inflammatory response (SIRS):
Defined as any 2 of the following:
T > 38 or < 36:***
HR > 90:***
RR > 20:***
Altered level of consciousness:***
WBC > 12K or < 4K:***
Bandemia > 10%:***

Severe Sepsis Screen:
complicated by organ dysfunction:
Altered mental status:***
Acute renal insufficiency:***
Hypoxia:***
Hypercapnea:***
lactate level of > 2/lactic acidosis:***

Septic Shock Screen: Complicated by Refractory hypotension: ***

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Barrel tasting, Russian River, Fall 2008