Would you like a Lactate with that? Boosting Lactate Measurement in the Emergency Department for Early Sepsis Recognition

M McGowan1 C Hayes2 D MacKinnon1 L Barratt1 K Gaunt1 A Cheng1 V Leung3 G Modi3 and S Gray1, 2

on behalf of the St. Michael’s Hospital Departments of 1Emergency Medicine, 2Critical Care, and 3Laboratory Medicine

Funding has been provided by the St. Michael’s Hospital Medical Association Innovation Funds

ContextBoosting Lactate Measurement in the ED for Early Sepsis Recognition

• We used a collaborative Emergency Department – Critical Care approach to identify potentially septic patients early, initiate treatment and consult appropriately. This was implemented in September 2013.

Problem and Issue• Lactate is a marker of tissue hypoperfusion in sepsis and

should be assessed promptly upon presentation to the Emergency Department to guide resuscitation

• Lactate is a diagnostic test that is ordered by Emergency Physicians at their discretion, often after initial blood is collected by the nurse, thus necessitating an additional ‘poke’ for a specific tube

• Our lab has a 30-minute quality standard from time of registered receipt of sample in the lab to reporting of result in the electronic health record

• How could we increase quality measures of lactate (orderering, time-to-result) for potentially septic patients in the Emergency Department?

Actions Taken• Wide Clinical Variability was found in a 2012 review of 108 septic patients in the

Emergency Department who were admitted to ICU/Step-Up: 24 (22%) failed to have a lactate ordered by an Emergency Physician, including

7 (29%) of 25 who died during that admission Time-from-order-to-result was 0:50+3:37hr despite a 30-minute lab quality

standard

• Engaging Emergency Physicians. The 2012 Surviving Sepsis Guidelines were presented in Grand Rounds, followed by discussions of the utility of lactate. Barriers and opportunities were identified, including point-of-care testing.

Boosting Lactate Measurement in the ED for Early Sepsis Recognition

• Point-of-Care (POC) Lactate Testing. Discussions ensued with vendor, lab services, and Emergency

Department management to streamline lactate ordering, process, and results.

Cost analysis deemed POC lactate fiscally prohibitive with current and projected operational budget

Contribution to Patient Safety & Quality Improvement• A collaborative approach has led to enhanced monitoring of process and impact on

outcome in all steps of the septic patient journey• A monthly sepsis scorecard has been designed to monitor performance and outcomes,

while communicating feedback to all stakeholders from the front line in the Emergency Department to cross-departmental leadership in Emergency, Critical Care, Laboratory Medicine, and Quality and Risk Management

Boosting Lactate Measurement in the ED for Early Sepsis Recognition

Sepsis Lab Panel• Prioritizing lactate ordered on syringe vs green top tube

highlighted impact of process, method of collection and pre-analytical factors influence on lactate, including reliability and time-to-result with impact on clinical management

• Collaborative Emergency Department-Laboratory Medicine approach led to a “Sepsis” Lab bundle with lactate built in, measured on syringe, and facilitated under a RN medical directive to mitigate process and pre-analytical factors