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Sepsis is a leading cause of death and suffering, afflicting 1.7 million adults annually in the USA and contributing to over 250 000 deaths.1 The high burden of sepsis has catalysed numerous performance improvement and policy initiatives, including mandatory sepsis protocols in a growing number of US states, the Centers for Medicare and Medicaid Services’ (CMS) ‘SEP-1’ measure, and WHO’s resolution declaring sepsis a global health priority.2 Hospitals around the world are dedicating considerable resources to improving sepsis recognition and compliance with treatment bundles.
However, accurately measuring the impact of sepsis quality improvement efforts is challenging. The core problem is that diagnosing sepsis involves considerable subjectivity.3 Sepsis is a heterogeneous syndrome without a pathological gold standard. It is defined as infection leading to organ dysfunction,4 but it is often unclear whether a patient is infected and whether organ dysfunction is due to infection or other factors such as dehydration, medications, cancer, or inflammatory diseases.
The challenge of sepsis measurement is compounded by the rapidly changing clinical and regulatory milieu. Clinicians are being encouraged to screen for sepsis more aggressively and both clinicians and administrators are being encouraged to code for sepsis and organ dysfunction more diligently to maximise reimbursement. The net effect is that many patients that previously were never labelled with sepsis are now being counted.3 5–8 These additional cases tend to have milder disease and lower mortality rates. If a hospital uses administrative codes to track sepsis, there is a high probability they will see higher sepsis case counts and lower sepsis mortality rates that are due at least in part to more ascertainment.9 10
Some hospitals prospectively track cases that trigger sepsis screens or perform retrospective audits of hospitalizations flagged by administrative data.11 12 New York state’s ‘Rory’s Regulations’ allow …
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