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Adult Inpatient Risk Adjusted Sepsis Mortality

CBE ID
3215
Endorsement Status
E&M Committee Rationale/Justification

Steward no longer seeking to maintain endorsement

1.0 New or Maintenance
1.1 Measure Structure
Previous Endorsement Cycle
Is Under Review
No
1.6 Measure Description

Annual risk adjusted inpatient mortality rate for adult patients (aged 18 and over) admitted to acute care hospitals with diagnosis of severe sepsis or septic shock. The measure includes patients in acute care hospital settings over one year timeframe who had, either on admission, or during their hospital stay, a clinical diagnosis of severe sepsis (now referred to as ´sepsis´) or septic shock using criteria described in the International Sepsis Definitions (Sepsis-2)

Hospitals were required to submit a protocol for early identification and treatment of severe sepsis or septic shock. Subsequent to protocol submission, hospitals were required to submit 100% of their patient cases to a data collection portal using a standardized data dictionary (see relevant sections for details). Numerous data elements including patient demographics and comorbidities among other patient care details were reported. A random sample of the data submissions were validated for accuracy. The full adult data for discharges within calendar year 2015 was used to generate statewide and hospital-specific risk adjusted mortality rates for the calendar year.

    Measure Specs
      General Information
      1.7 Measure Type
      1.3 Electronic Clinical Quality Measure (eCQM)
      1.8 Level of Analysis
      1.20 Types of Data Sources
      1.14 Numerator

      Outcome is risk adjusted inpatient mortality rate for adult patients (18 and over) admitted to an acute care hospital with a diagnosis of severe sepsis or septic shock or who develop severe sepsis or septic shock during their hospital stay.

      1.15 Denominator

      All adult patient discharges (18 and over) in a calendar year with a diagnosis of severe sepsis or septic shock on admission or at any time during their hospital stay. This may include multiple admissions of the same patient during the measurement year. Denominator includes all cases identified using any means (administrative, registry, electronic health records, billing data, etc.), either prospectively, retrospectively, or both, that meet the International consensus definition (Sepsis- 2) of severe sepsis or septic shock.

      Exclusions

      Patients with advanced directives in place prior to episode of sepsis which specifically restrict any hospital specific sepsis protocol interventions or who decline (or their proxy declines) treatment for sepsis. Patients who have been transferred from one acute care hospital to another are excluded.

      Most Recent Endorsement Activity
      Endorsed Infectious Disease Project 2016-2017
      Initial Endorsement
      Last Updated
      Removal Date
      Steward Organization
      New York State Department of Health
      Steward POC email
              Risk Adjustment
                Public Comments