2021 ECPR40: Initiation of the Initial Sepsis Bundle

Measure Description

Percentage of Adult Emergency Department Patients Diagnosed with Severe Sepsis or Septic Shock That Have Initiation of the Initial Sepsis Bundle

Denominator

• Any patient > 18 years of age evaluated by the Eligible Professional in the Emergency Department (E/M Codes 99281-99285 & 99291-99292 AND Place of Service Indicator: 23) PLUS
• ED diagnosis of either of below:
  • Severe Sepsis:
    • ICD-10: A41.9 AND R65.20
  • Septic Shock:
    • ICD-10: A41.9 AND R65.21
• Transferred, eloped or AMA patients are excluded (V0700)
• Patients with Advanced Directives indicating preference for limited intervention are excluded (V0701)

Numerator

Emergency Department Patients Diagnosed with Severe Sepsis or Septic Shock Who Have Initiation of the Initial Sepsis Bundle

Definition of initiation of initial sepsis bundle: Provider order for (or protocol resulting in order for) ALL of the following:

• Lactate (venous or arterial)
• Blood cultures
• IV antibiotics
• IV fluid bolus

Numerator Options

• Performance Met (VE253): Patients who did have initiation of initial sepsis bundle (must include all components)
• Medical Performance Exclusion (Denominator Exception (VE254): Patients who did not have initiation of the initial sepsis bundle for documented medical reason(s) (i.e. IV fluids not ordered given patient is in congestive heart failure, or other medical reason)
• Patient Performance Exclusion (Denominator Exception) (VE255): Patients who did not have initiation of the initial sepsis bundle for documented patient reason(s) (i.e. blood cultures not ordered because patient refused or other patient reason)
• Performance Not Met (VE256): Patients who did not have initiation of the initial sepsis bundle, reason not given

Numerator Exclusions

None

NQF ID Number

N/A

NQS Domain

Effective Clinical Care

High Priority Measure

No

Includes Telehealth?

Yes

Inverse Measure

No

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be calculated and submitted

1

Risk-Adjusted Status?

No