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Life of a Sepsis Case
Overview & Case Reporting
Effective May 1, 2013 NYSDOH Title 10 New York Codes Rules and Regulations (NYCRR) Sections 405.2 and 405.4 were amended to require that hospitals have in place evidence-based protocols for the early recognition and treatment of patients with severe sepsis and septic shock. Consistent with these regulations, subdivision 7 (i, ii) specified that “medical staff shall be responsible for the collection, use and reporting of quality measures related to the recognition and treatment of severe sepsis for purposes of internal quality improvement and hospital reporting to the Department."
To make this additional data reporting more user friendly, beginning in 2017, NYSDOH has aligned with select CMS SEP-1 data elements and measures. However, the denominator for the NYSDOH data submission still requires reporting ALL cases that meet criteria for severe sepsis or septic shock INCLUDING cases identified through coding AND/OR other avenues (e.g., concurrent case identification; retrospective review; and so forth).
The hospital is responsible for reporting all diagnosed cases of severe sepsis or septic shock, regardless of billing code designation. Cases diagnosed as sepsis but that do not meet criteria for severe sepsis or septic shock are not to be submitted.
Hospitals must report:
- Patients in inpatient settings:
- Includes psychiatric inpatient hospitals and units within hospitals but excludes ambulatory clinics
- If an ED patient was not admitted, but the patient had severe sepsis or septic shock, then the data is to be reported for this patient
- The first event of severe sepsis or septic shock for multiple sepsis events during a single admission
- A single case for patients who are internal transfers from other units within the hospital. Report the full episode of patient care as a single record which depicts complete hospital patient care.
Please note this is not an exhaustive list of all reporting requirements. Refer to the Data Dictionaries for additional information.
Cases excluded from the protocol using an acceptable exclusion reason in the data dictionary must still be reported though the full data capture of all data elements is reduced. If the ED patient had severe sepsis or septic shock but was never admitted, the data would still need to be reported. Admissions to observation alone would also need to be reported.
Data: Submission; Dictionary; & Exceptions
Data dictionary
The DATA DICTIONARY FOR SEVERE SEPSIS OR SEPTIC SHOCK, released by Office of Quality and Patient Safety, NYSDOH is a catalog of detailed information about the required data which must be submitted to the Department as per NYSDOH Title 10 New York Codes Rules and Regulations (NYCRR) Sections 405.2 and 405.4. The Dictionary provides specifications such as names, format, meaning, relationships to other data, and structure. Each dictionary(s) aligns with a particular discharge timeframe therefore the dictionary version and specification must be noted prior to data collection and submission.
Data must follow the formatting and structure as defined in the dictionary using the data dictionary template provided for each dictionary. For instruction on uploading cases please click here. High volume hospitals are eligible for sampling . Please click the link to read more about sampling.
What are Exceptions?
"Exceptions" are high level data discrepancies that indicate there was an obvious error in data submission. After your submitted data is received in the sepsis portal at the conclusion of a reporting quarter, each of the cases will be checked for exceptions. Specifically, when any two or more of your cases/records are overlapped by PCN (with different MRN), MRN (with different UPI) or the time interval between admission and discharge, they will be identified and categorized in the exception reports. Exception reports will be disseminated within a week of the close of the reporting period. The exception report is not intended to capture the accuracy of all data elements, only logical mistakes which can be found in simple data scans. An email notice will be sent to all hospitals that have elected to receive sepsis notices when exception reports are released.
What do I do?
Exception reports can be downloaded from https://ny.sepsis.ipro.org/. Facilities are expected to correct their data by requesting a file deletion and re-uploading the corrected data by the due date specified in the exception reports. Hospitals are provided threebusiness days to correct these errors. If these exceptions are not corrected by the due date, these exception cases will be removed from the dataset. In other words, the data for these discrepant cases will not be included in your hospital quarterly report.
Sample & Weighting
NYS DOH began accepting a sample of adult sepsis cases from high volume hospitals beginning with the January 2017 discharges. A high volume hospital is one that submitted greater than 400 eligible adult sepsis cases to the sepsis clinical database in a prior calendar year (CY). Those hospitals that are eligible for sampling and opt-in will be required to submit select data elements for ALL eligible cases to enable sample selection. The hospital will then be provided with a random sample of cases for reporting, and ultimately will submit data for a total of 400 cases for the reporting CY. Statistical analyses show that 400 cases per hospital are sufficient to estimate hospital-level risk-adjusted mortality rates. Sampling is not applicable to pediatric cases.
Hospitals that elect to sample will have their reported data weighted to appropriately reflect upon statewide performance.
Measures: Process & Outcome
Measures collected for the NYS Sepsis Improvement Initiative consist of process and outcome measures (i.e, risk adjusted mortality rates).
Process measure details are provided in the measure specifications, which are available for each year of sepsis data collection. Measures Specifications contains the algorithm/calculation used in deriving the rates for measures/bundles in quarterly hospital reports. For different calendar years, different specification documents are listed; therefore, you will want to review the measure specifications for the discharge timeframe under review.
Measures Specifications beginning in 2017 have been fairly closely aligned with CMS. For all measures, the variables and their associated reported values from the Data Dictionary are used. Please note that different measures may have different exclusions/denominators. Not all cases are included in all measures/bundles. For measures initial lactate administration, blood culture collection and antibiotics administration, the denominators are the same: cases not excluded within 3-hour of Severe Sepsis/Septic Shock. These three measures together are the 3-hour bundle.
For measures repeat lactate administration, crystalloid fluid administration, vasopressor administration and fluid assessment, the exclusions/denominators are different, since not all of these measures are applicable to all cases. Details are presented in the Measures Specifications. These measures, in combination with the 3-hour bundle, comprise the composite bundle.
Quarterly Hospital Report
New York State Severe Sepsis-Septic Shock Data Reports are generated each quarter for each hospital with sepsis cases submitted to the sepsis portal. Adult and pediatric cases are captured in separate reports for each facility.
Reports:
- Are generated quarterly to align with case submission reporting deadlines.
- Capture data submitted to the sepsis portal by the due date of data corrections after exception reports are released.
- Provide measure performance for the hospital and the state that align with the measure specifications for that discharge year.
Data Audit: Process & Purpose
Data is audited to ensure that the quarterly and annual process measures and the risk-adjusted mortality rates are accurate. In brief, the audit compares the NYSDOH portal submitted hospital data to the patient medical record to determine that the data is accurate. The auditors use the appropriate NYSDOH Data Dictionary, webex materials, helpdesk responses and the relevant CMS Data Dictionary to perform the audit.
Public Report & Risk-adjusted Mortality
Each annual report presents hospital-reported process measure and outcome data for all adult and pediatric patients with a diagnosis of severe sepsis or septic shock seen at the facility from the second quarter (Q2) of 2014 through the final quarter of the report discharge timeframe. Adult patients are defined as those age 18 years or older, and pediatric patients are those age younger than 18 years. Data in this report are presented through the calendar year of the report to align with risk-adjusted mortality data, which are available for that particular calendar year. Risk adjustment takes into consideration the different mix of characteristics and comorbid conditions, including sepsis severity, of patients cared for within each hospital and permits comparison of hospital performance.
Beginning in 2014, each acute care hospital in New York that provides care to patients with sepsis was required by amendment of Title 10 of the New York State Codes, Rules and Regulations (Sections 405.2 and 405.4)
- To develop and implement evidence-informed sepsis protocols, which describe their approach to both early recognition and treatment of sepsis patients.
- To report data to the Department that is used to calculate each hospital’s performance on key measures of early treatment and protocol use.
- To submit sufficient clinical information for each patient with sepsis to allow the Department to develop a methodology to evaluate ‘risk adjusted’ mortality rates for each hospital.
Announcements
NYSDOH Sepsis: Quarterly Rpts, Measure change, and Reminder of 7/22 Webex
NYSDOH Sepsis Adult Audit Reports Released 6/24/2019 - Upcoming Webex July 22, 2019
- Be sure the workbook is in tableau packaged workbook type
- Right click the file and select "unpackage"
- Two more files are created when you unpackage. One file is the performance averages. One file is the case-level audit results.
- Click the file of choice and it will open in excel
NYSDOH Sepsis 2019 Q1 Exception Reports - Corrections due June 10, 2019
For all previous announcements, click here.
