SHM Converge Scientific Abstract ePoster Gallery-Grading the Graders: Are We Documenting and Coding Sepsis Appropriately?

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This study examined how well sepsis is documented by clinicians and captured in hospital coding data used for performance metrics. The team screened 2,453 patients across 13 units in two hospitals from April to May 2023 using a SIRS-based definition of sepsis plus evidence of suspected or confirmed bacterial infection. Of 274 patients identified with sepsis, 118 charts were reviewed in detail.<br /><br />The investigators found that sepsis was documented somewhere in the chart for 79 of 118 patients (67%). However, only 42 of those 79 patients (53%) were coded as having sepsis in the Vizient database. Three additional patients were coded with sepsis despite no chart documentation, resulting in an overall coding sensitivity of 38% (45/118). In a separate sample of 65 patients from the Vizient sepsis cohort, 64 met the study’s sepsis definition, suggesting high specificity (98%).<br /><br />The study also found no meaningful differences in sepsis coding based on where sepsis was documented in the chart. Documentation appeared in multiple note types, including admission notes, discharge notes, CDI notes, problem lists, and free-text sections, with similar capture rates across locations.<br /><br />The authors conclude that both sepsis documentation and coding are unreliable, especially for identifying all true sepsis cases. This raises concerns about using coded sepsis data to judge hospital performance or guide quality improvement and patient safety efforts. They recommend further interventions to improve both clinician documentation and coding accuracy.

Asset Subtitle

Alyssa Yeager

Meta Tag

Author List Alan A. Kubey, Alyssa Yeager, Christopher Haines, Joy Burke, Kimberly Berenbaum, Mark Liotta, Nisreen Jahshan, Sara Groome, Swathi Maddula

Category Research

Concept Sepsis

Concept Clinical Documentation

Concept Coding Data

Concept Chart Review

Concept Systemic Inflammatory Response Syndrome

Distinguished Non-Finalist

Presenter Organization Thomas Jefferson University Hospital

Presenting Author Alyssa Yeager

Track Technology in Hospital Medicine

Keywords

sepsis documentation

hospital coding

Vizient database

coding sensitivity

coding specificity

clinical documentation

performance metrics

quality improvement

patient safety

bacterial infection

Sepsis

Clinical Documentation

Coding Data

Chart Review

Systemic Inflammatory Response Syndrome