Posted on April 21, 2016
The Journal of the American Medical Association (JAMA) published “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” on February 23, 2016.1 A scant four days later, the American College of Chest Physicians in their journal CHEST accepted and published online an unedited manuscript that very strongly speaks out against this new definition. The manuscript states, “Physicians of multiple specialties express concern that widespread application of this new definition could cost patient lives, and we cannot support its adoption.”2
The author of the CHEST article exhibits a clear mastery of statistics in his writing. It is also apparent that he has a strong desire to protect his patients as well as practice sites with limited resources to educate providers about these changes. It seems his main point of concern is the movement away from systemic inflammatory response syndrome (SIRS) criteria to Sequential Organ Failure Assessment (SOFA) scoring, fearing that doing so will cause a delay in the treatment of a patient and the proper intervention might arrive too late. However, the JAMA article states that the task force of experts who convened to discuss the new definition unanimously agreed that using two or more SIRS criteria to identify sepsis is unhelpful. They acknowledge that “nonspecific SIRS criteria…will continue to aid in the general diagnosis of infection.”
Additionally, the task force recommended discontinuing the term of “severe sepsis,” as sepsis is already severe and adding the word severe is just superfluous. However, they provide two specific ICD-10 codes, one of which is ICD-10 code of R65.20, which designates “severe sepsis without septic shock,” according to at least two different ICD-10 coding websites.3,4 In an era of value-based purchasing, is this intended as guidance on a reimbursement strategy? It seems like the pieces are not quite fitting together just yet.
Physicians will inevitably do what they believe is right for the patient based on their clinical judgement, even if it means using a combination of SIRS and SOFA criteria. While pharmacists are not diagnosticians, they still need to be vigilant on the appropriate use of antimicrobials in the treatment of septic patients, as those guidelines have not changed.
This article is a clear example of how something that sounds good in theory may or may not translate well to reality. Upon review of the endorsing societies, four U.S. societies were listed as endorsing the new sepsis-3 definition: the American Association of Critical Care Nurses, the American Thoracic Society, the Society of Critical Care Medicine, and the Surgical Infection Society.
It will be interesting to see if other influential organizations will openly oppose the sepsis-3 definition. Where does your institution stand?