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387 Increasing Compliance With Repeat Lactate Measurement Utilizing Automated Repeat Lactate Ordering
Research Forum Abstracts CorPP, CerPP and ETCO2 values than when using the LUCASTM alone. Based on these data, the combined use of the LUCASTM and ITD interventions would therefore be recommended as part of a bundled approach to obtain an optimal synergistic benefit when implementing a head-up CPR technique.
Patients with hypoperfusion and ESRD alone, CHF alone or both received 18.4, 10.4 and 11.7 cc/kg (NS). Conclusions: Sepsis patients with CHF and/or ESRD often do not receive the volume of IV resuscitation recommended by current guidelines. These patients frequently have evidence of objective fluid overload. Patients with evidence of fluid overload had longer hospital lengths of stay, and may have received less IVF in the ED and experience increased in-hospital mortality.
386
Withdrawn
387
Increasing Compliance With Repeat Lactate Measurement Utilizing Automated Repeat Lactate Ordering
Santistevan JR, Brantman J, Pulia M, Babb D, Hamedani A, Sharp B/University of Wisconsin, Madison, WI
385
Management Patterns and Outcomes of Patients With Severe Sepsis or Septic Shock Admitted From the Emergency Department With End Stage Renal Disease or Congestive Heart Failure
Thom S, Kalarikkal Z, Kakarla P, Sherwin R/DMC Sinai Grace Hospital, Detroit, MI; Wayne State University, Detroit, MI
Study Objectives: Aggressive fluid resuscitation is a cornerstone of sepsis management. Concerns about fluid overload specifically in patients with ESRD and CHF can be a barrier to compliance. The objective of this study was to describe the resuscitation pattern of sepsis patients with ESRD or CHF in the ED. Methods: This is a descriptive analysis of resuscitation patterns and outcomes in patients with ESRD and/or CHF using a pre-existing sepsis database of patients from 2011-2015 based on ICD codes. The patients were seen within the Detroit Medical Center system, which is a large academic health system. Dual-abstraction by two EM residents was performed to collect additional demographics, confirmatory data, objective evidence of fluid overload, resuscitation and additional clinical and outcome data. Descriptive statistics were reported including as well as t-test and ANOVA. Results: Seventy patients were identified who met the inclusion criteria including forty-two patients with ESRD alone, sixteen patients with CHF alone and twelve patients with both CHF and ESRD. The mean age was 61.4 11.8 years, 66% were male. The mean admission SOFA score was 6.1 2.6, the mean intravenous volume received was 15.4 14.2 cc/kg while in the ED and overall in-hospital mortality was 4.2%. Thirty seven percent (26/70) patients had evidence of fluid overload in the ED. These patients were older (65.0 vs. 59.4; p¼ 0.049), had a higher qSOFA score at admission (1.73 vs. 1.25; p ¼ 0.023), and had a longer hospital length of stay (13.6 vs. 8.6 days; 0.021) compared to patients without evidence of overload. Total cc/kg IV fluid administration (18.0 vs.13.9 cc/kg; p¼0.234) and in-hospital mortality (19% vs 11%; p¼0.371) were also higher in patients with overload.Twenty-seven of the patients (19 with ESRD alone, 2 with CHF alone, 6 both) demonstrated hypoperfusion requiring a 30cc/kg bolus based on either a lactate >4.0 mmol/dL or a SBP <90 mmHg. The mean lactate was 3.6 2.2 mmol/dL and the mean SBP 88 30 mmHg. Of the hypoperfusion patients, objective evidence of fluid overload was present in 26% (5/19) of patients with ESRD, 100% (2/2) of CHF patients and 33% (2/6) with both. Overall, 25.9% (7/26) patients received the required 30cc/kg bolus for evidence of hypoperfusion.
Volume 70, no. 4s : October 2017
Study Objectives: The Centers for Medicare and Medicaid (CMS) sepsis management bundle (SEP-1) core measure requires that serum lactate levels be obtained and repeated within 6 hours if > 2.0 mmol/L and evidence supports prognostic value of improvement in serum lactate values. We developed an order in our electronic health record (EHR) that includes a repeat lactate order if the initial lactate level is elevated. We hypothesize that implementation of a lactate order that includes triggers for repeat testing will increase compliance with repeat lactate measurement in patients with severe sepsis and septic shock. Methods: A retrospective observational study was performed at one academic and one university-affiliated community emergency department (ED) with a combined census of 70,500 annual visits. We compared the rate of repeat lactate measurement compliance for adult patients who were suspected of having severe sepsis and septic shock (serum lactate >2, hospital admission, and received antibiotics within 12 hours of admission) before and after implementation of the repeat lactate order. The repeat lactate order created initially contained a conditional serum lactate order to be released by the ED nurse if initial lactate was >2mmol/L. This conditional component was later replaced with an automatic, reflex repeat lactate order to be collected every two hours (that can be canceled by nursing if the initial lactate was 2mmol/L). Repeat lactate compliance rates following implementation of each iteration of the repeat lactate order were compared using the chi-square test statistic. Results: Implementation of a conditional repeat lactate order for patients with suspected severe sepsis or septic shock significantly increased repeat lactate compliance (43.2% vs 63.5%; P .001). Replacing the conditional repeat lactate order with an automatic, reflex repeat lactate order resulted in further improvement in repeat lactate compliance rates (63.5% vs 70.1%; P ¼.05). Conclusions: The inclusion of a conditional repeat lactate order significantly improved compliance with the repeat lactate requirement of the CMS SEP-1 core measure with further improved compliance with a fully automated repeat lactate order. This automated approach is a promising alternative to relying on individual repeat serum lactate order entry.
Annals of Emergency Medicine S151
Patients with hypoperfusion and ESRD alone, CHF alone or both received 18.4, 10.4 and 11.7 cc/kg (NS). Conclusions: Sepsis patients with CHF and/or ESRD often do not receive the volume of IV resuscitation recommended by current guidelines. These patients frequently have evidence of objective fluid overload. Patients with evidence of fluid overload had longer hospital lengths of stay, and may have received less IVF in the ED and experience increased in-hospital mortality.
386
Withdrawn
387
Increasing Compliance With Repeat Lactate Measurement Utilizing Automated Repeat Lactate Ordering
Santistevan JR, Brantman J, Pulia M, Babb D, Hamedani A, Sharp B/University of Wisconsin, Madison, WI
385
Management Patterns and Outcomes of Patients With Severe Sepsis or Septic Shock Admitted From the Emergency Department With End Stage Renal Disease or Congestive Heart Failure
Thom S, Kalarikkal Z, Kakarla P, Sherwin R/DMC Sinai Grace Hospital, Detroit, MI; Wayne State University, Detroit, MI
Study Objectives: Aggressive fluid resuscitation is a cornerstone of sepsis management. Concerns about fluid overload specifically in patients with ESRD and CHF can be a barrier to compliance. The objective of this study was to describe the resuscitation pattern of sepsis patients with ESRD or CHF in the ED. Methods: This is a descriptive analysis of resuscitation patterns and outcomes in patients with ESRD and/or CHF using a pre-existing sepsis database of patients from 2011-2015 based on ICD codes. The patients were seen within the Detroit Medical Center system, which is a large academic health system. Dual-abstraction by two EM residents was performed to collect additional demographics, confirmatory data, objective evidence of fluid overload, resuscitation and additional clinical and outcome data. Descriptive statistics were reported including as well as t-test and ANOVA. Results: Seventy patients were identified who met the inclusion criteria including forty-two patients with ESRD alone, sixteen patients with CHF alone and twelve patients with both CHF and ESRD. The mean age was 61.4 11.8 years, 66% were male. The mean admission SOFA score was 6.1 2.6, the mean intravenous volume received was 15.4 14.2 cc/kg while in the ED and overall in-hospital mortality was 4.2%. Thirty seven percent (26/70) patients had evidence of fluid overload in the ED. These patients were older (65.0 vs. 59.4; p¼ 0.049), had a higher qSOFA score at admission (1.73 vs. 1.25; p ¼ 0.023), and had a longer hospital length of stay (13.6 vs. 8.6 days; 0.021) compared to patients without evidence of overload. Total cc/kg IV fluid administration (18.0 vs.13.9 cc/kg; p¼0.234) and in-hospital mortality (19% vs 11%; p¼0.371) were also higher in patients with overload.Twenty-seven of the patients (19 with ESRD alone, 2 with CHF alone, 6 both) demonstrated hypoperfusion requiring a 30cc/kg bolus based on either a lactate >4.0 mmol/dL or a SBP <90 mmHg. The mean lactate was 3.6 2.2 mmol/dL and the mean SBP 88 30 mmHg. Of the hypoperfusion patients, objective evidence of fluid overload was present in 26% (5/19) of patients with ESRD, 100% (2/2) of CHF patients and 33% (2/6) with both. Overall, 25.9% (7/26) patients received the required 30cc/kg bolus for evidence of hypoperfusion.
Volume 70, no. 4s : October 2017
Study Objectives: The Centers for Medicare and Medicaid (CMS) sepsis management bundle (SEP-1) core measure requires that serum lactate levels be obtained and repeated within 6 hours if > 2.0 mmol/L and evidence supports prognostic value of improvement in serum lactate values. We developed an order in our electronic health record (EHR) that includes a repeat lactate order if the initial lactate level is elevated. We hypothesize that implementation of a lactate order that includes triggers for repeat testing will increase compliance with repeat lactate measurement in patients with severe sepsis and septic shock. Methods: A retrospective observational study was performed at one academic and one university-affiliated community emergency department (ED) with a combined census of 70,500 annual visits. We compared the rate of repeat lactate measurement compliance for adult patients who were suspected of having severe sepsis and septic shock (serum lactate >2, hospital admission, and received antibiotics within 12 hours of admission) before and after implementation of the repeat lactate order. The repeat lactate order created initially contained a conditional serum lactate order to be released by the ED nurse if initial lactate was >2mmol/L. This conditional component was later replaced with an automatic, reflex repeat lactate order to be collected every two hours (that can be canceled by nursing if the initial lactate was 2mmol/L). Repeat lactate compliance rates following implementation of each iteration of the repeat lactate order were compared using the chi-square test statistic. Results: Implementation of a conditional repeat lactate order for patients with suspected severe sepsis or septic shock significantly increased repeat lactate compliance (43.2% vs 63.5%; P .001). Replacing the conditional repeat lactate order with an automatic, reflex repeat lactate order resulted in further improvement in repeat lactate compliance rates (63.5% vs 70.1%; P ¼.05). Conclusions: The inclusion of a conditional repeat lactate order significantly improved compliance with the repeat lactate requirement of the CMS SEP-1 core measure with further improved compliance with a fully automated repeat lactate order. This automated approach is a promising alternative to relying on individual repeat serum lactate order entry.
Annals of Emergency Medicine S151