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.