The blood counts never came back to normal, even though they were supposed to. The toxic effects of the chemotherapy never went away, even though they were supposed to. The hospital stay was not short, even though it was supposed to be. Everything that could go wrong went so terribly wrong.

Then, on Saturday morning, something changed. Her breathing got worse. She was less responsive. She was immediately transferred to the ICU to get closer monitoring. All throughout the day and night, her organ systems began to fail – one by one. By the end of the night, she was on a ventilator and had to be transferred to another hospital to get dialysis.

Everything continued to deteriorate, and by the following morning, my daughter was dead. She succumbed to gram negative septic shock that caused multiorgan failure. All I could do was watch in horror and grieve over the death of my firstborn, a death I could do nothing to prevent.

This is the ruthless monster that is sepsis. This is the horror that I witnessed firsthand as a father and witness countless times as a physician in the ICU caring for sepsis patients.

Sepsis is defined as organ failure as a result of an abnormal response of the body to an infection. It can be devastating. In a matter of hours, it can take someone from awake, alert, and talking to fighting for his or her very life in shock on a ventilator and dialysis machine. It is the number one diagnosis we see in the ICU, and it has exacted a terrible toll on so many people and their family and loved ones.

We try to always be vigilant against this disease, because it can sneak up on our patients with very little warning. Decades of research have been conducted to try and fight this disease, and there have been many drugs and therapies that have been tried and tried without success. I “grew up” in the era of those drugs and therapies, and I have seen one after the other fail to prevent death and destruction from this disease.

At the same time, it is not hopeless: I have been blessed to help heal countless patients from certain death from sepsis, and seeing them survive this terrible illness brings a feeling of joy that is beyond words to describe. Sepsis can be treated successfully, as long as one is always thinking about it, is aggressive with resuscitation early on, and administers appropriate antibiotic therapy as soon as it is suspected.

September is Sepsis Awareness Month. It is of the utmost importance that we, as ICU clinicians, are ever vigilant against this ruthless monster that ravaged my poor daughter and sent her back to our Precious Beloved. And we should also take some time to remember and pray for all those who have lost their battles with sepsis, as well as their families and loved ones having to move on with the grief of horrible loss. May our Lord ever comfort them in this life and the next. Amen.

The post The Ruthless Monster That Is Sepsis appeared first on Medika Life.

Once, an insurance company actually denied the diagnosis of “acute respiratory failure” in a case of a teenage boy who suffered cardiac arrest at home and needed a ventilator in the hospital. When the treatment team finally got around to measuring the oxygen levels, after he was on a ventilator, his oxygen levels were great. So, the insurance company said there was “no evidence of respiratory failure in the medical record.” This was ridiculous, and the most egregious example of this type of denial. But, it happens, and it happens a lot.

One particular DRG denial with which commercial payers are having a field day is the sepsis denial. The definition of sepsis (previously known as septicemia) has gone through many iterations throughout the years. In the past, sepsis was defined as “a known or suspected infection along with two or more signs of the systemic inflammatory response syndrome, better known as SIRS.” This definition is still used by the Centers for Medicare and Medicaid Services (CMS) today.

In 2016, an International Consensus Group came together and re-defined sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” How do you define “life-threatening organ dysfunction”? They said that this can be operationalized by an increase in the SOFA score by 2 points of more, SOFA being “Sequential [Sepsis-related] Organ Failure Assessment.”

SOFA assigns a specific point value for dysfunction is six organ systems: mental status, oxygenation, blood pressure, bilirubin, platelet level, and renal function. The worse the organ failure, the higher the SOFA score. A normal, healthy human has a SOFA score of 0.

As a critical care physician, I understand why this change in the definition was made. Using the “old” definition of sepsis, which we call Sepsis-2, a patient with a urinary tract infection who has a fever and high heart rate has a diagnosis of “sepsis.” Yet, in clinical practice, this is really not sepsis. Sepsis is organ failure as a result of infection. A fever and high heart rate is not organ failure, it is a reaction of the body to inflammation.

If someone has a urinary tract infection and has renal failure and shock as a result, however, that is truly sepsis. The new definition of sepsis, called Sepsis-3, better encapsulates those patients who truly have sepsis. And word to the wise: if you were to call me up and say, “Hey Dr. Hassaballa, I can’t come to work today because I’m septic with a cold, a fever, and my heart rate is 105,” I would say, “Umm…that’s not sepsis. You better show up to work.”

This change in definition is not without controversy, and it does not help that CMS has one definition of sepsis (and holds hospitals to that definition) while the literature suggests another definition. Commercial payers have dived into this controversy head-on, and I have lost count of the number of DRG denials that come across my desk related to the definition of sepsis.

For example: a patient presents to the hospital with a pneumonia, and he has an elevated white blood cell count, a fever of 103, and a heart rate of 115 beats per minute. His blood pressure is normal, his kidney function is normal, he is awake and alert, he has no other organ failure. The doctor treating this patient, using Sepsis-2, diagnoses the patient with sepsis. The claim goes to the commercial insurance company, and they look through the chart and deny payment saying, “There is no evidence of sepsis in this record according to Sepsis-3.” Technically, they would be absolutely correct.

Now, they do these types of denials because, if there is no sepsis, the severity of illness related to the hospital stay decreases. And, with a lower severity of illness, the payment to the hospital will also become lower. In fact, many times, the insurance company will say in a letter, “We issued an overpayment on this claim. We looked at the record, and there was no evidence for sepsis. Thus, you owe us $10,000.”

That’s when I get the appeal, to argue against the allegation that there was no sepsis. Yet, if there is no organ failure, if there is no hypoxia, or shock, or renal failure, or high bilirubin, or altered mental status, or low platelet count, then there really is no sepsis according to Sepsis-3. And, therefore, my appeal will be inherently weak, because Sepsis-2 is not the most recent, evidence-based definition for sepsis. It just is not.

So how to avoid these denials? In short: check the face sheet.

The face sheet is the part of the chart that has the demographic and insurance information for the patient. If the patient has commercial insurance or has a Medicare Advantage plan, I will bet you dollars to donuts that they will be using Sepsis-3 as their definition for sepsis (and they are not wrong to do so). If the patient has traditional Medicare, however, the definition for is sepsis is Sepsis-2, which is SIRS plus infection.

Yes, it is confusing. Yes, it is quirky. Yes, it is annoying. It is the way of the world in 2022, and we clinicians have to become more sophisticated in our understanding of how our healthcare world operates in the United States. Complaining about it and saying, “Well this is ridiculous” does not change the reality. If we just spend the extra ten seconds and look at the face sheet, we can save ourselves a whole lot of pain and suffering later by avoiding a sepsis DRG denial. It is truly time well-spent.

The post From The Appeals Desk: Know Your Sepsis appeared first on Medika Life.

One of the phrases I tell myself came directly from a Maternal Fetal Medicine (MFM) attending, and anyone who trained at MSU has heard this.  “It’s better to have a living patient without a uterus than to bury them with it.”  I remember my intern year and the first time I heard this phrase.  It seemed so obvious to me.  Of course, I would do a hysterectomy to save someone’s life.  

I was chief rotating on the MFM service during my third year of residency.  We arrived early to conduct medical rounds, check patient vitals, ensure fetal status was stable, and plan for the day ahead.  We had been watching a patient for premature rupture of membranes (PPROM).  She had a very desired pregnancy and was seven weeks away from the fetus being able to survive outside of the uterus.  I was rounding with an amazing attending, and she was precise, detail-oriented, and focused on doing the right thing.  She spoke about all the pregnancy options with the family daily.  

She was keenly aware of the risks of continuing a pregnancy with PPROM.  One of the risks of this pregnancy is infection.  If the bag of water, the amniotic sac, is broken, then there is an open area where bacteria can take hold.  Unfortunately, this infection can become significant and risk the mother’s life.  

One day, this very thing happened to our patient.  Once an infection starts, patients often have more pain, uterine tenderness, and vaginal discharge.  Sometimes people will begin bleeding and can hemorrhage.  The uterus is a muscle; if infected, you can imagine, it will respond with contractions.  

At the same time, the infection could spread through the patient’s body.  This is something called sepsis.  A patient’s heart rate goes up, blood pressure can go down, and chills, dizziness, and a loss of consciousness can occur.  People can develop shortness of breath, nausea and vomiting, diarrhea, and other dangerous symptoms.  As sepsis progresses, organs can start shutting down.  When septic shock appears, mortality is between 30-50 percent.  

Physicians need to be trained to notice when someone is becoming sick and developing an infection.  The concern is the progression of the infection to shock and death.  In some states, the legislation is so vague that physicians wait for patient instability to act.  In Missouri, an ectopic pregnancy was being observed, and physicians felt like they couldn’t legally act until someone showed changes in their vital signs and hgb dropping, which means bleeding internally.

Now, imagine the physician unable to act to save a life – confused – confused by the ambiguity of state law – not medical best practice.  Imagine years of training and oversight; the patient must be shunted aside for procedures and policies. Will the residents of the future be trained to turn an eye to a primary medical credo written millennia ago and guiding skill and mission? “Do no harm.” 

These pregnancies aren’t viable, meaning the fetus will not survive outside the patient’s body.  If the patient dies, the fetus dies.  We are handicapping physicians from practicing evidence-based medicine.  We are putting people at risk, even in our hospital systems.  Who is going to be held accountable for this? Who will take responsibility for the impossible position healthcare workers are in?  

We should be acting in the best interest of our patients, always. 

Physicians specializing in women’s health should be part of critical policy conversations.  We are endangering the lives of the American people.  Laws created in 1849, like in Wisconsin, have no business regulating what a physician can and can’t do in modern-day healthcare.  Let healthcare be provided by the people who trained their whole lives to provide it.  Hospitals, administrators, nursing staff, and physicians need to meet and develop ongoing policies to handle things in a timely fashion instead of waiting for life-threatening events to happen.  

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