Severe Maternal Morbidity: Part 4

Sepsis is one of the top five causes of maternal deaths.

EDITOR’S NOTE: This article by Kristi Pollard concludes an exclusive four-part series focusing on maternal and morbidity and mortality, a vitally important and timely topic. Pollard, Director of Coding Quality and Education for Haugen Consulting Group, has been working with the California Material Quality Care Collaborative (CMQCC) as a subject matter expert.

No discussion about maternal morbidity and mortality is complete without addressing the elephant in the room: sepsis. Unsurprisingly, sepsis is one of the top five causes of maternal deaths. The World Health Organization (WHO) defines maternal sepsis as a life-threatening condition with organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or the postpartum period (up to 42 days). That simple definition does not make it any easier to determine the criteria necessary to identify and treat the condition in a timely fashion.

Most studies that evaluated sepsis criteria excluded pregnant women, which limits their application for maternal sepsis because of the significant changes that occur in vital signs with pregnancy. For example, the underlying cause of most cases of maternal sepsis is chorioamnionitis. In one study of 913 women, 575 met systemic inflammatory response syndrome (SIRS) criteria, but only five had sepsis. In fact, healthy pregnant women often meet all SIRS criteria, apart from temperature. By contrast, the poor sensitivity of qSOFA (Sequential Organ Failure Assessment) criteria in pregnant women can lead to a high rate (50 percent or more) of false negatives.

The California Maternal Quality Care Collaborative (CMQCC) developed a sepsis toolkit, which will soon be adopted by the Centers for Medicare & Medicaid Services (CMS) and incorporated into the SEP-1 core measure. Within its toolkit, CMQCC outlines the concerns about the diagnostic tools used in the pregnant population, because current screening systems perform poorly in pregnancy. They recommend a two-step approach for diagnosing sepsis in pregnancy and the postpartum period:

• Step 1: Initial sepsis screen for all patients with suspected infection (positive of two or more criteria are met)
  • Oral temperature < 36°C (96.8°F) or ≥ 38°C (100.4°F)
  • Heart rate > 110 beats per minute and sustained for 15 minutes
  • Respiratory rate > 24 breaths per minute and sustained for 15 minutes
  • White blood cell count > 15,000/mm³ or < 4,000/mm or > 10 percent immature neutrophils (bands)
• Step 2: Confirmation of sepsis by evaluating for end organ dysfunction. This includes lab studies and prompt bedside evaluation by the physician. Therapy should be initiated within an hour while awaiting lab results consisting of antibiotics administration and IV fluids.

What can we do as coding and clinical documentation integrity (CDI) professionals to ensure proper coding and reporting of maternal sepsis? CDI professionals should be on the lookout for upcoming changes to the SEP-1 CMS core measure. If hospitals don’t currently perform CDI reviews on obstetrics patients, this is an excellent opportunity to start.

Coders should be familiar with the coding guidelines associated for reporting sepsis, which are found in sections I.C.1. (infectious and parasitic disease) and I.C.15 (pregnancy), which addresses coding and sequencing for sepsis related to pregnancy or abortion, puerperal sepsis, and sepsis due to an infected obstetrical wound.

Programming Note: Join Kristi Pollard today on Talk Ten Tuesdays,10 Eastern, when she concludes her exclusive four-part series on maternal morbidity and mortality.

Reference:

CMQCC Sepsis Toolkit: https://www.cmqcc.org/resources-toolkits/toolkits/improving-diagnosis-and-treatment-maternal-sepsis