The clinical criteria for sepsis and septic shock has been redefined per an article published in the Journal of the American Medical Association (JAMA February 23, 2016). The new criteria is called SOFA (Sepsis-related organ failure assessment), which is a scoring system used to determine the extent of a patient’s organ function or rate of failure.  SOFA criteria includes measurements of the functioning of the major organ systems which requires fairly extensive testing, studies, and lab results.

qSOFA (quick sepsis-related organ failure assessment) is a simplified version of SOFA criteria and was developed to be used as an initial way to screen for sepsis.

qSOFA Criteria

• New or worsened altered mentation
• Respiratory rate ≥ to 22/min
• Systolic blood pressure ≤ 100 mm Hg

New Definitions for Sepsis and Septic Shock

Per the JAMA article, “These updated definitions and clinical criteria should replace previous definitions, offer greater consistency for epidemiologic studies and clinical trials, and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis.”

These new definitions will take time to incorporate into current Coding and CDI practices, but are a welcome replacement of the often controversial SIRS (systemic inflammatory response syndrome) criteria previously used to diagnose sepsis. The new criteria should help address the overuse of sepsis or suspected sepsis diagnosis for cases where patients meet SIRS criteria but are not found to have an infection. For more information, read the full article here, JAMA Article

With the focus on quality and hospital acquired conditions, now more than ever, it is critical for clinicians to have the tools to quickly and accurately diagnose sepsis and for CDI specialists to ensure appropriate documentation is available for accurate coding and reporting purposes.