A simple measure to improve sepsis documentation and coding

Abstract

IntroductionSepsis incidence and mortality are increasing, yet sepsis appears to be under-recognised and under-reported. Accurate recognition and coding of sepsis allows for appropriate funding and accurate epidemiological representation. MethodsWe implemented a discharge summary template for all patients discharged from our infectious diseases service and analysed sepsis documentation and coding before and after its introduction. ResultsBeforehand, we found that 59% of 29 patients had sepsis, yet only 10% had it documented on their discharge summary, and 17% had it coded. Following implementation of the template, 38% of 52 patients had sepsis documented, yet only 20% of these had it coded. After delivery of a training session to the coders regarding the importance of sepsis, 38% of patients with a diagnosis of sepsis had it coded. DiscussionDespite requiring ongoing education and encouragement of clinicians and coders, implementation of the template was quick, cheap and easy and improved sepsis coding.

Beneficios de la implementación del código sepsis en pacientes con shock séptico en el área hospitalaria

“…En el año se cree que treinta y un millones de personas sufren de sepsis, entre estos casos, 6 millones de pacientes fallecieron presentando complicaciones por la patología según la Organización Mundial de la Salud (12).…”

“…Desde una monitorización de signos vitales básicos y una exploración física guiándose por el sistema ABCDE: vía aérea, respiración, circulación, el déficit neurológico y exposición. Así mismo, dentro de la anamnesis completa se atenderá a las enfermedades concomitantes y activas del paciente, como las recientes; al tratamiento médico habitual y a la toma de antibióticos previa en los últimos 3 meses(12).…”

Management of the Sepsis Protocol: An integrative litera-ture review

“…Subsequent audits showed progress in identifying the diagnosis of sepsis in patient discharge summaries. [13] Article 4 points out the importance of knowledge of the sepsis management protocol by the medical and nursing teams, the latter mainly because they are in direct contact and for the entire length of the patient's stay and must be able to recognize the signs and symptoms of sepsis. [14] In article 5, the effectiveness of the SFT program for the improvement of the patient is observed, since the group participating in this program received adequate management for the treatment of sepsis, that is, they were better managed by the multidisciplinary team.…”