By Cesar M Limjoco, M.D.
Chief Medical Officer
People do not realize that satisfying protocol at the outset of the admission does not seal in the diagnosis of SEPSIS. Protocols are meant to cast a wide net, but they are not very discriminating. There will be false positives. Monitoring the patient for the next several hours (let’s say, six hours) will confirm or rule out the Sepsis diagnosis. Sepsis features shouldn’t resolve that fast, unless it’s only hypovolemia (dehydration) in an elderly SNF patient’s whose mental status, Cr bump (due to hemoconcentration), and hypotension are corrected with IV fluid replacement in that time period. Basically, an elderly SNF patient with UTI and dehydration really does not need acute inpatient care (unless there are other extenuating circumstances that bear on the case). (If that creatinine bump persists 24+ hours, it would be indicative of true AKI [not just hemoconcentration] and may justify an inpatient stay.) Will the risks of acute inpatient care outweigh the benefits to the elderly patient whose simple UTI can be treated as an outpatient and whose dehydration has been corrected? Probably transferring to a more robust outpatient observation configuration (for 24 hours) should be enough, instead of transferring them directly to the inpatient floor. #medicalnecessity
Back when Medicare DRGs first came into IPPS in the late 80s, COPD (DRG 88) was consistently the top DRG in the nation for a couple of years. They later found out there was a revolving door between SNFs and Acute care hospitals for elderly SNF patients with COPD. They put a stop to it by mandating that there has to be an acute event that has to justify a COPD admission. DRG 88 came off the top DRG Admissions. Henceforth, acute exacerbations needed to be shown and reflected in the ICD codes.
About 2 decades ago, Urosepsis became a common admission for elderly SNF patients. They stopped that by mandating that it does not equal Sepsis (just UTI). Then SIRS came into being, and soon enough many elderly patients that presented with an infection had SIRS due to infection and diagnosed to have Sepsis.
SIRS has turned to be the current iteration of an unnecessary admission. Pure and simple. What has been a scientific attempt to explain sepsis pathophysiology has been misused and exposes the weaker, older population to the inherent risks of an inpatient admission and antibiotic overuse. I would like to refer you to one of the risks of inpatient stay, You Can Get Sick From Germs on Hospital Floors by Naveed Saleh, MD, MS. It serves as a reminder that MRSA, VRE, C. difficile are lurking in hospital floors!
We need to be aware of the balance between benefits and risks of an inpatient stay. If you can manage an otherwise simple UTI and dehydration in the elderly patient population (which definitely SNF patients have increased incidence) outside of a full inpatient stay, cost savings and healthcare benefits will be optimized.