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On October 1, 2015, Centers for Medicare and Medicaid Services (CMS) implemented its new core bundle measure Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) for severe sepsis and septic shock as part of its Hospital Inpatient Quality Reporting (Hospital IQR) program. In July 2018, these sepsis measures were made publicly available through Hospital Compare. Understanding these measures, the implications for the hospital and novel solutions like LifeFlow that may be able to improve performance is critical to working successfully in today’s environment of value-based care.

Test your knowledge of the CMS SEP-1 Measure by answering the following True or False statements:

SEP-1 Background

The Early Management Bundle, Severe Sepsis/Septic Shock Measure, commonly referred to as SEP-1, is a CMS National Inpatient Quality Measure, which went into effect October 1, 2015. Other examples of CMS Inpatient Quality Measures include heart attack care, emergency department care, complications and death, patient satisfaction, etc.  The SEP-1 Measure is specific to adult patients with an ICD-10 Principal or Other Diagnosis Code of sepsis, severe sepsis or septic shock, and with a length of stay less than 120 days.¹ There are a few other exceptions that exclude patients from the SEP Initial Patient Population algorithm, but these are among the most common.

There are two bundles to the SEP-1 measure.

The severe sepsis bundle requires the following within 3 hours of sepsis onset:

– lactate measurements;

– blood cultures; and

– broad-spectrum antibiotics

followed by repeat lactate measurements within 6 hours (if initial lactate level is elevated).

The septic shock bundle adds three additional requirements:

– 30 mL/kg of IV fluids within 3 hours;

– vasopressors within 5 hours for persistent hypertension; and

– repeat volume assessment within 6 hours.

Most critical to the SEP-1 measure is that all of the designated interventions, including IV fluids, must be completed in order for a case to pass the measure. It is this “all-or-nothing” requirement many hospitals struggle with because a case receives the same “credit” if all but 1 measure is met or if only 1 measure is met.  For instance, a team may complete every measure of the septic shock bundle for patient A, but if IV fluids are not administered within the timeframes determined by SEP-1, the hospital will fail the entire measure for that case. A recent study reported that hospitals are adopting a variety of actions in response to SEP-1, including new efforts to collect data, improve sepsis diagnosis and treatment, and manage clinicians’ attitudes toward SEP-1.²

Note that the SEP-1 bundle is different from the Surviving Sepsis Campaign (SSC) bundle.   SEP-1 is a quality measure, whereas the SSC bundle is a clinical guideline.  Recently, there has been significant debate around the IV fluid component of the SSC bundle, in part in reaction to a proposed new Hour-1 bundle.    CMS regularly monitors new data and information and will update quality measures, including SEP-1, as needed.

What is Hospital Compare?  Why is it important?^3,4

Hospital Compare was created in 2002 through the efforts of Medicare and the Hospital Quality Alliance (HQA). Hospital Compare allows consumers to select multiple hospitals and directly compare performance measure information related to heart attack, heart failure, pneumonia, surgery, and other conditions. On July 25, 2018 CMS began publicly reporting the results of each hospital’s SEP-1 measure on Hospital Compare. The SEP-1 measure is grouped with other clinical process-of-care measures under the Timely and Effective Care tab.  In addition to performance of the individual hospital, performance is also compared with:

1. the performance of the top 10% of hospitals reporting on SEP-1
2. the average performance of the hospitals reporting in that hospital’s state
3. the national average

Sample Hospital Compare: Timely & effective Care: Sepsis care – details

² Data submitted were based on a sample of cases/patients.

²⁰ State and national averages do not include VHA hospital data.

Finally, CMS, along with key stakeholders, developed methodology to calculate and display overall hospital-level quality using a star rating system. The goal of the Overall Hospital Rating is to improve the usability and interpretability of information posted on Hospital Compare by providing a simple overall rating based on multiple measures of quality into a single summary score.  Although it’s not currently included published Overall Hospital Rating, the goal is to include the new sepsis measures in the next release.

Why You Should Care.

Sepsis is the leading cause of death in US hospitals and is estimated to cost the healthcare system more than $24billion.  Making hospitals’ sepsis quality measures available via Hospital Compare is a critical step in improving transparency and improving care. Like it or not, we are all potential patients or family or friends to a potential patient.  If your loved one had sepsis-like symptoms and you had a choice of hospitals, wouldn’t you choose the one with a better rating? Consumer Reports specifically uses Hospital Compare data as one of their key resources when releasing their top hospital ratings.⁵

In addition, many experts have expressed that SEP-1 could eventually become a performance measure under the Value Based Purchasing Program (VBP) where financial incentives could be applied, as was the case with 30-day readmissions. In 2010, CMS added 30-day readmission as Inpatient Quality Measure for heart attack, heart failure and pneumonia patients. Two years later, in 2012, CMS expanded this measure and it became a payment measure under the Hospital Readmission Reduction Program.   There is a definite track record for starting new measures as quality measures only and moving them to VBP over time.

What Can You Do as a Provider?

First, know your Hospital Compare score. Second, discuss it with your manager or sepsis coordinator. Third, talk about how your hospital can improve its score. It is important to review the Hospital Compare data to understand where the gaps in care lie for your hospital and find ways to improve them. The SEP-1 measures in Hospital Compare will be updated quarterly, with the next release anticipated at the end of October 2018.

Based on the 2017 SEP-1 data, less than 55% of hospitals successfully met the Septic Shock 3-Hour Bundle.  Of those hospitals who failed to meet the bundle, more than 90% failed to meet the fluid resuscitation guidelines.⁶  New, innovative fluid resuscitation devices are available that can improve the speed and efficiency of fluid delivery.  In 2017 Piehl et al, presented the results of a simulation study where, with the use of LifeFlow for fluid resuscitation, the overall scenario time was reduced by 50%.  Similarly, new technologies and systems are being developed for more rapidly diagnosing sepsis and septic shock. While costs are often cited as a reason for not bringing in new technology, it is becoming the norm for payers to bundle all services, supplies and devices into one hospital payment. Hospitals should consider the big-picture impact in this age of transparency when considering life-saving technology that may also improve hospital outcomes.

To learn more about Hospital Compare or SEP-1 please email: jgarfield@transtechint.com

To learn more about LifeFlow and how it can help you improve fluid resuscitation in sepsis please contact Christine O’Neill MSN, RN-BC at coneill@410medical.com.

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