PURPOSE: Sepsis is a complex disease process that possess a significant socioeconomic burden in the U.S [1].Adherence to the sepsis resuscitation bundle is crucial to improve mortality [2]. Serum lactate and lactate clearance forms an important component of the sepsis resuscitation bundle [3] and high levels correlate with worse outcomes [4, 5, 6]. Previous studies emphasized on the importance of utilizing lactate clearance and lactate monitoring to guide resuscitation in order to improve mortality [7, 8].
METHODS: We implemented a QI initiative on January 2016 triggering automated EMR Q2 lactate order alerts every 2 hours for 3 additional periods for sepsis patients with lactate level >= 2 mmol/L unless lactate level falls below 2. We included all adult sepsis patients admitted from the Emergency Department (ED) to the Medical Intensive Care Unit (MICU) from October 2014 to October 2017 with lactate level >=2 mmol/L .For this population, we aimed to compare the time from ED arrival to lactate levels of <2 mmol/L, time taken for >50 % lactate clearance to be obtained, and the total hospital stay days in the pre-intervention and post-intervention groups using Mann-Whitney test. Mortality rates were compared using a chi-square test.
RESULTS: Among patients with lactate >= 2 mmol/L, there were 511 patients in pre-intervention group (Oct 2014-December 2015) and 804 patients in post-intervention group (January 2016-October 2017). The median time for lactates levels to reduce to <2 mmol/L was higher in pre-intervention group at 22 hours (IQR 40) as compared to post-intervention 16 hours (IQR 32) (p<0.05). Similarly the median length of stay was higher in pre-intervention group at 9 days (IQR 16) as compared to post-intervention at 7 (IQR 9) (p<0.05). Among patients with initial lactates of >=4 mmol/L, median hours from ED arrival to the reduction of lactates by >=50% was similar in both groups. Among patients with an initial lactate of 2 to <4 mmol/L, the median time from ED arrival to lactate <2 was higher in the pre-interventional group as compared to the post-interventional group at 14hours (IQR 29) and 10 hours (IQR 22)respectively (p<0.05). Mortality was similar in the two groups with 30% deaths in pre-intervention and 31% in post-intervention groups (p=0.68).
CONCLUSIONS: Creating an automated repeat lactate order for sepsis patients resulted in an overall improvement in the lactate clearance as well as a reduction in the total hospital stay days. Patients with lactate levels from 2 to 4 had a significant reduction in time to 50% lactate clearance however, patients with lactate levels greater than 4 didn’t show any significant reduction.
