0
Editorial |

Accountability for Sepsis Treatment: The SEP-1 Core Measure FREE TO VIEW

Christine A. Motzkus, MPH; Craig M. Lilly, MD, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

aClinical and Population Health Research Program, University of Massachusetts Medical School, Worcester, MA

bGraduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA

cDepartments of Medicine, Anesthesiology, and Surgery, University of Massachusetts Medical School, Worcester, MA

CORRESPONDENCE TO: Craig M. Lilly, MD, FCCP, Departments of Medicine, Anesthesiology, and Surgery, University of Massachusetts Medical School, UMass Memorial Medical Center, 281 Lincoln St, Worcester, MA 01605


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(5):955-957. doi:10.1016/j.chest.2017.01.011
Text Size: A A A
Published online

Improving care and outcomes for patients with sepsis is an increasingly achievable goal. The United States Centers for Medicare and Medicaid Services (CMS) and the Joint Commission (JC) have joined forces to provide new publicly reported measures that aim to reduce preventable sepsis-related mortality. The Centers for Disease Control has long recognized the importance of expeditious and effective treatment of infections and has implemented creative programs that urge patient and family advocacy by having them ask their providers “Do you think this might be sepsis?” The SEP-1 sepsis core measure is supported by increasingly clear reproducible high-quality evidence from clinical trials that defines the timing of specific treatments and assessments for patients recognized as having sepsis. Translation of key clinical trial interventions into improved patient outcomes has been a major focus of professional society and philanthropic efforts.

One of our most successful governmental programs for translating advances of clinical science into better patient outcomes is the Quality Initiative of the Department of Health and Human Services (HHS). This initiative was introduced by HHS Secretary Tommy Thompson in 2001 and was expanded in 2003 to include the Hospital Quality Initiative (HQI). The harmonization of the initial CMS and JC measure sets has led to improved outcomes for patients. Hospital Quality Initiative reporting requirements were defined by the Deficit Reduction Act of 2005 and augmented in 2007 by final regulation CMS-1488-F. During 2010, the JC classified each core performance measure as either accountability or nonaccountability and in 2012 introduced a standards-based expectation for minimum performance using ORYX accountability measures. The programs of this initiative that combine public reporting with CMS financial incentive programs have made high-quality care available to more Americans. Measures for acute coronary syndromes, venous thromboembolism, and stroke have fostered local programs that have reduced preventable complications of these conditions. These programs have gained public support because both their aims and implementation are perceived as being patient focused.

Responding to reports of adverse outcomes from sepsis, including the heart-wrenching death of Rory Staunton, a 12-year-old New York boy, advocacy groups, including the Sepsis Alliance, and physician groups, including the Surviving Sepsis Campaign, have advocated change. To improve sepsis care, CMS and the JC leveraged the National Quality Forum and resources including the Agency for Healthcare Research and Quality National Quality Measures Clearinghouse to create a new measure intended to encourage prompt responses when sepsis is recognized. The new sepsis CMS core measure is designated SEP-1. The SEP-1 measure is new territory for the programs of the Quality Initiative because it is more complex than its predecessors, and measurement has proved to be substantially more burdensome. There are increasing concerns that its impact may be limited, because the initial results of local measures designed to achieve high levels of adherence have been disappointing. It is also concerning that the laudable focus of the SEP-1 measure on timely responses when sepsis organ dysfunction is recognized could institutionalize incentives that in effect delay the diagnosis of evolving sepsis.

The SEP-1 measure is a ratio. SEP-1 is reported as the fraction of sepsis patients who receive all sepsis care elements during measure-specified time frames, as detailed in Table 1. The complexity of the measure is evident from the many clarifications and versions of the metric that have been posted since its public release. Clarifications like the one that allows assessment of the adequacy of resuscitation using catheters that are often placed in large peripheral veins rather than central veins is problematic because it is neither evidence-based nor considered acceptable critical care practice. To the extent that modifications of this complex measure deviate from evidence-based sepsis management strategies, they risk loss of support for the measure itself. One important aspect of the SEP-1 measure is that it does not strictly define how the time that sepsis first started is to be identified. This time is central, because it serves as the anchor for the SEP-1 time frames. This difficulty has led to subjectivity, variability of reported rates, and requests for SEP-1 clarifications. Unfortunately, it also has the potential to provide incentives that could delay the reporting of sepsis recognition and the initiation of lifesaving treatments. The unscheduled nature of the need for sepsis care and narrow time lines of the SEP-1 measure have made implementation complex. This is due, in part, to the requirement for 3-hour and 6-hour physician assessments that mandate labor-intensive workflows during a time frame in which transitions of responsibility for care often occur. Unlike the management of stroke and acute coronary syndromes, which also require unscheduled high-acuity interventions during narrow time windows, the activities of the SEP-1 measure are not similarly well reimbursed.

Table Graphic Jump Location
Table 1 Data and Time Elements of the SEP-1 Measure

ICD-10-CM = International Classification of Diseases, Tenth Revision, Clinical Modification.

Improving sepsis outcomes is an aim worthy of universal support and the SEP-1 measure is an important next step in the fight for patients with sepsis. SEP-1 needs to be buttressed with measures and programs that encourage the early recognition of infections that are evolving into sepsis. Programs like that of the Centers for Disease Control that encourage patients and their caregivers to engage providers in early sepsis recognition represent a particularly promising approach. The development of processes for more complex measures like SEP-1 is of interest both to institutions and to the practicing physicians who will have their electronic personas affected by public reporting. The importance of having accurate, fair, effective, and transparent measures that are free of manipulation is difficult to understate. The substantial number of revisions, clarifications, new details, changes, and updates of the SEP-1 measure are a clear indication that to a greater extent than its predecessor measures, SEP-1 remains a “work in progress.” In accordance with their responsiveness to input from clinical professionals, health-care provider organizations, state hospital associations, health-care consumers, performance measurement experts, and others who fostered the creation and development of the initial CMS/JC core measure set, HHS needs to encourage broad participation in a robust review process that continues to improve the SEP-1 measure. The success of the SEP-1 program has the potential to lead to successor programs that encourage better early sepsis recognition. Successor programs that integrate information from the electronic medical record with emerging diagnostics that identify the presence of sepsis causing pathogens hold great promise for expediting sepsis recognition. Inaction or frustration that leads to marginalization of the SEP-1 program risks the loss of its large potential benefits for our patients with sepsis.

References

Rhee C. .Gohil S. .Klompas M. . Regulatory mandates for sepsis care—reasons for caution. N Engl J Med. 2014;370:1673-1676 [PubMed]journal. [CrossRef] [PubMed]
 
Centers for Disease Control and Prevention. Sepsis questions and answers.https://www.cdc.gov/sepsis/basic/qa.html. Accessed December 20, 2016.
 
Lilly C.M. . Protocol-based care for early septic shock. N Engl J Med. 2014;371:386-387 [PubMed]journal
 
Dellinger R.P. .Levy M.M. .Rhodes A. .et al Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637 [PubMed]journal. [CrossRef] [PubMed]
 
Chassin M.R. .Loeb J.M. .Schmaltz S.P. .Wachter R.M. . Accountability measures—using measurement to promote quality improvement. N Engl J Med. 2010;363:683-688 [PubMed]journal. [CrossRef] [PubMed]
 
Cohen R.I. .Jaffrey F. .Reitzner J.B. .Baumann M.H. . Quality improvement and pay for performance. Chest. 2013;143:1542-1547 [PubMed]journal. [CrossRef] [PubMed]
 
Centers for Medicare and Medicaid Services, The Joint Commission. Specifications manual for national hospital inpatient quality measures discharges 10-01-15 (4Q15) through 06-30-16 (2Q16).http://www.jointcommission.org/assets/1/6/IQRManualReleaseNotes_V5_01.pdf. Accessed January 30, 2017.
 
Marik P.E. . Early management of severe sepsis. Chest. 2014;145:1407-1418 [PubMed]journal. [CrossRef] [PubMed]
 
Goeschel C.A. .Wachter R.M. .Pronovost P.J. . Responsibility for quality improvement and patient safety. Chest. 2010;138:171-178 [PubMed]journal. [CrossRef] [PubMed]
 
Borbas C. .Morris N. .McLaughlin B. .Asinger R. .Gobel F. . The role of clinical opinion leaders in guideline implementation and quality improvement. Chest. 2000;118:24S-32S [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 Data and Time Elements of the SEP-1 Measure

ICD-10-CM = International Classification of Diseases, Tenth Revision, Clinical Modification.

References

Rhee C. .Gohil S. .Klompas M. . Regulatory mandates for sepsis care—reasons for caution. N Engl J Med. 2014;370:1673-1676 [PubMed]journal. [CrossRef] [PubMed]
 
Centers for Disease Control and Prevention. Sepsis questions and answers.https://www.cdc.gov/sepsis/basic/qa.html. Accessed December 20, 2016.
 
Lilly C.M. . Protocol-based care for early septic shock. N Engl J Med. 2014;371:386-387 [PubMed]journal
 
Dellinger R.P. .Levy M.M. .Rhodes A. .et al Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637 [PubMed]journal. [CrossRef] [PubMed]
 
Chassin M.R. .Loeb J.M. .Schmaltz S.P. .Wachter R.M. . Accountability measures—using measurement to promote quality improvement. N Engl J Med. 2010;363:683-688 [PubMed]journal. [CrossRef] [PubMed]
 
Cohen R.I. .Jaffrey F. .Reitzner J.B. .Baumann M.H. . Quality improvement and pay for performance. Chest. 2013;143:1542-1547 [PubMed]journal. [CrossRef] [PubMed]
 
Centers for Medicare and Medicaid Services, The Joint Commission. Specifications manual for national hospital inpatient quality measures discharges 10-01-15 (4Q15) through 06-30-16 (2Q16).http://www.jointcommission.org/assets/1/6/IQRManualReleaseNotes_V5_01.pdf. Accessed January 30, 2017.
 
Marik P.E. . Early management of severe sepsis. Chest. 2014;145:1407-1418 [PubMed]journal. [CrossRef] [PubMed]
 
Goeschel C.A. .Wachter R.M. .Pronovost P.J. . Responsibility for quality improvement and patient safety. Chest. 2010;138:171-178 [PubMed]journal. [CrossRef] [PubMed]
 
Borbas C. .Morris N. .McLaughlin B. .Asinger R. .Gobel F. . The role of clinical opinion leaders in guideline implementation and quality improvement. Chest. 2000;118:24S-32S [PubMed]journal. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543