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Documentation of Sepsis in Patients Meeting Pediatric Sepsis Criteria: An Area for Improvement
Gokhan Olgun1,2, Shelley Y Feng3, Amber J Veldman3
1Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota.
Insights
Accurate sepsis documentation in electronic medical records (EMR) is crucial for pediatric patients. This study found that only 7% of pediatric sepsis cases meeting criteria were properly documented in the EMR, highlighting a significant gap.
Area of Science:
- Pediatric critical care medicine
- Health informatics
- Clinical documentation improvement
Background:
- Effective patient status evaluation relies heavily on accurate medical documentation.
- Prompt and precise diagnosis of sepsis necessitates meticulous record-keeping.
- Electronic Medical Records (EMR) systems play a vital role in managing patient data and alerts.
Purpose of the Study:
- To retrospectively review patient charts and assess the accuracy and frequency of sepsis documentation within EMRs.
- To evaluate the effectiveness of an institutional EMR sepsis notification alert system.
- To identify pediatric patients meeting sepsis criteria and analyze their subsequent documentation.
Main Methods:
- A retrospective chart review was conducted on pediatric patients (0-18 years) flagged by an EMR sepsis trigger tool.
- Two pediatric intensivists manually reviewed EMR charts of admitted patients.
- The 2005 International Pediatric Consensus Conference Guidelines were used to confirm sepsis criteria, followed by an analysis of physician charting within 24 hours.
Main Results:
- Out of 359 pediatric patients who met the 2005 sepsis criteria, only 24 (7%) had sepsis or septic shock documented in the EMR.
- Of the documented cases, 16 involved septic shock and 8 involved sepsis.
- A significant under-documentation of sepsis and septic shock was observed despite meeting established criteria.
Conclusions:
- Sepsis is frequently under-documented in pediatric electronic medical records.
- Challenges in diagnosing sepsis and the use of alternative diagnoses may contribute to documentation gaps.
- The study highlights ambiguity in current pediatric sepsis criteria and difficulties in capturing the diagnosis within EMR systems.
Objective:
Documentation is a critical aspect for properly evaluating a patient's medical status. In order to accurately diagnose sepsis promptly, the need for proper documentation becomes even more necessary. We conducted a retrospective chart review to assess accuracy and frequency of sepsis documentation by electronic medical records (EMR) review. The patients are children aged 0 to 18 years of age in whom the sepsis trigger tool fired in the EMR and were admitted on the inpatient floor or pediatric intensive care unit.
Methods:
An EMR sepsis notification alert is currently utilized by our institution. Two pediatric intensivists reviewed the EMR charts of hospitalized, pediatric patients in whom the notification fired. The primary outcome was to identify the patients who met criteria for sepsis according to the 2005 International Pediatric Consensus Conference Guidelines. In patients who met the criteria, physician charting was inspected manually to evaluate documentation of sepsis and/or septic shock within 24 hours of meeting sepsis criteria.
Results:
Using the 2005 International Pediatric Consensus Conference Guidelines, 359 patients met sepsis criteria. Of those, 24 (7 percent) were documented to have sepsis and/or septic shock in the EMR. Sixteen of those patients had septic shock, while the remaining eight had sepsis.
Conclusion:
Although sepsis is not uncommon, it is often not documented appropriately in electronic medical records. Hypothesized explanations include difficulty in diagnosing sepsis and using alternative diagnoses. This study demonstrates the ambiguity of the current pediatric sepsis criteria and difficulty capturing this diagnosis in the EMR.
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