A Computerized Alert Screening For Severe Sepsis In Emergency Department Patients Increases Lactate Testing But Does Not Improve Inpatient Mortality

T. Berger; A. Birnbaum; P. Bijur; G. Kuperman; P. Gennis

doi:10.4338/ACI-2010-09-RA-0054

Applied Clinical Informatics, Table of Contents

Appl Clin Inform 2010; 01(04): 394-407
DOI: 10.4338/ACI-2010-09-RA-0054

Research Article

Schattauer GmbH

A Computerized Alert Screening For Severe Sepsis In Emergency Department Patients Increases Lactate Testing But Does Not Improve Inpatient Mortality

T. Berger

¹University of California, Davis, Sacramento, CA

,

A. Birnbaum

²Jacobi Medical Center, Bronx, NY

,

P. Bijur

³Albert Einstein College of Medicine

,

G. Kuperman

⁴Columbia University, New York Presbyterian Hospital

,

P. Gennis

²Jacobi Medical Center, Bronx, NY

› Author Affiliations

Abstract

Summary

Objective: This study tested the hypothesis that lactate testing in ED sepsis patients could be increased using a computer alert that automatically recognizes systemic inflammatory response syndrome (SIRS) criteria and recommends lactate testing in cases of sepsis defined as ≥2 SIRS criteria plus physician suspicion of infection. Secondary outcomes included the effect of the alert on lactate testing among admitted sepsis patients, the proportion of admitted patients with lactate ≥4.0 mmol/L identified and the in-patient mortality difference before and after alert implementation.

Methods: After a 6 month pre-alert phase, a computer alert was implemented that computed and displayed abnormal vital signs and white blood cell counts for all patients with >2 SIRS criteria and recommended testing lactate if an infection was suspected. Data for admitted patients was collected electronically on consecutive patients meeting sepsis criteria for 6 months before and 6 months after implementation of the alert.

Results: There were a total of 5,796 subjects enrolled. Among all septic patients, lactate testing increased from 5.2% in the pre-alert phase to 12.7% in the alert phase, a 7.5% (95% CI 6.0 to 9.0%) absolute increase in lactate testing, p<0.001. Among the 1,798 admitted patients with sepsis, lactate testing increased from 15.3% to 34.2%, an 18.9% (95% CI 15.0 to 22.8%) absolute increase, p<0.001. Among admitted patients with sepsis, there was a 1.9% (95% CI 0.03 to 3.8%, p = 0.05) increase in absolute number of patients with elevated lactate levels identified and a 0.5% (95% CI -1.6 to 2.6%, p=0.64) decrease in mortality.

Conclusion: The proportion of ED patients who had lactate tested and the number of admitted patients identified with a lactate level ≥4.0 mmol/L improved significantly after the implementation of a computer alert identifying sepsis patients with >2 SIRS criteria while mortality among admitted sepsis patients remained unchanged.

Keywords

Sepsis - computerized alert - informatics - emergency - lactate - SIRS

Full Text

References

References
1 Strehlow MC, Emond SD, Shapiro NI, Pelletier AJ, Camargo Jr. CA. National study of emergency department visits for sepsis, 1992 to 2001. Ann Emerg Med 2006; 48 (Suppl. 03) 326-331 31 e1-3.
2 Shapiro N, Howell MD, Bates DW, Angus DC, Ngo L, Talmor D. The association of sepsis syndrome and organ dysfunction with mortality in emergency department patients with suspected infection. Ann Emerg Med 2006; 48 (Suppl. 05) 583-590 90 e1.
3 Marshall John C, MD FRCSC; Cook Deborah J, MD MSc, FRCPC; Christou Nicolas MD PhD V, FCCM Bernard Gordon MD R, Sprung Charles L, MD JD, FCCM; Sibbald William MD J. FCCM Multiple Organ Dysfunction Score: A reliable descriptor of a complex clinical outcome. Critical Care Medicine 1995; 23 (10) 1638-1652.
4 Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R. et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36 (Suppl. 01) 296-327.
5 Mikkelsen ME, Miltiades AN, Gaieski DF, Goyal M, Fuchs BD, Shah CV. et al. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med. 2009; 37 (05) 1670-1677.
6 Trzeciak S, Dellinger RP, Chansky ME, Arnold RC, Schorr C, Milcarek B. et al. Serum lactate as a predictor of mortality in patients with infection. Intensive Care Med 2007; 33 (06) 970-977.
7 Howell MD, Donnino M, Clardy P, Talmor D, Shapiro NI. Occult hypoperfusion and mortality in patients with suspected infection. Intensive Care Med 2007; 33 (11) 1892-1899.
8 Husain FA, Martin MJ, Mullenix PS, Steele SR, Elliott DC. Serum lactate and base deficit as predictors of mortality and morbidity. Am J Surg 2003; 185 (05) 485-491.
9 Meregalli A, Oliveira RP, Friedman G. Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients. Crit Care 2004; 8 (02) R60-R65.
10 Claridge JA, Crabtree TD, Pelletier SJ, Butler K, Sawyer RG, Young JS. Persistent occult hypoperfusion is associated with a significant increase in infection rate and mortality in major trauma patients. J Trauma 2000; 48 (Suppl. 01) 8-14 discussion 14-15.
11 Levy B. Lactate and shock state: the metabolic view. Curr Opin Crit Care 2006; 12: 315-321.
12 Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B. et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345 (19) 1368-1377.
13 Jones AE, Focht A, Horton JM, Kline JA. Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock. Chest 2007; 132 (02) 425-432.
14 Nguyen HB, Corbett SW, Steele R, Banta J, Clark RT, Hayes SR. et al. Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med 2007; 35 (04) 1105-1112.
15 Trzeciak S, Dellinger RP, Abate NL, Cowan RM, Stauss M, Kilgannon JH. et al. Translating research to clinical practice: a 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department. Chest 2006; 129 (02) 225-232.
16 Shapiro NI, Howell MD, Talmor D, Lahey D, Ngo L, Buras J. et al. Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol. Crit Care Med 2006; 34 (04) 1025-1032.
17 Jones AE. et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis Ttherapy: A randomized clinical trial. JAMA 2010; 303 (08) 739-746.
18 Carlbom DJ, Rubenfeld GD. Barriers to implementing protocol-based sepsis resuscitation in the emergency department –results of a national survey. Crit Care Med 2007; 35 (11) 2525-2532.
19 Kuperman GJ, Teich JM, Bates DW, Hiltz FL, Hurley JM, Lee RY. et al. Detecting alerts, notifying the physician, and offering action items: a comprehensive alerting system. Proceedings of AMIA Annual Fall Symposium 1996; 704-708.
20 Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J. et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005; 293 (10) 1223-1238.
21 Wilson GA, McDonald CJ, McCabe Jr. GP. The effect of immediate access to a computerized medical record on physician test ordering: a controlled clinical trial in the emergency room. Am J Public Health 1982; 72: 698-702.
22 Schriger DL, Baraff LJ, Rogers WH, Cretin S. Implementation of clinical guidelines using a computer charting system. Effect on the initial care of healthcare workers exposed to body fluids. JAMA 1997; 278: 1585-1590.
23 Schriger DL, Baraff LJ, Buller K, Shendrikar MA, Nagda S, Lin EJ. et al. Implementation of clinical guidelines via a computer charting system: effect on the care of febrile children less than three years of age. J Am Med Inform Assoc 2000; 7: 186-195.
24 Day F, Hoang LP, Ouk S, Nagda S, Schriger DL. The impact of a guideline-driven computer charting system on the emergency care of patients with acute low back pain. Proc Annu Symp Comput Appl Med Care 1995: 576-580.
25 Schriger DL, Gibbons PS, Langone CA, Lee S, Altshuler LL. Enabling the diagnosis of occult psychiatric illness on the emergency department: a randomized, controlled trial of a computerized, self-administered PRIME-MD diagnostic system?. Ann Emerg Med 2001; 37: 132-140.
26 Pozen MW, D’Agostino RB, Selker HP, Aytowski PA, Hood WB. A predictive instrument to improve coronary-care-unit admission practices in acute ischemic heart disease: a prospective multicenter clinical trial. N Engl J Med 1984; 310: 1273-1278.
27 Selker HP, Beshansky JR, Griffith JL, Aufderheide TP, Ballin DS, Bernard SA. et al. Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with the triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia: a multicenter, controlled clinical trial. Ann Intern Med 1998; 129: 845-855.
28 Selker HP, Beshansky JR, Grifith JL. TPI Trial Investigators. Use of the electrocardiographic-based thrombolytic predictive instrument to assist thrombolytic and reperfusion therapy for acute myocardial infarction: a multicenter, randomized, controlled, clinical effectiveness trial. Ann Intern Med 2002; 137: 87-95.
29 Wellwood J, Johannessen S, Spiegelhalter DJ. How does computer-aided diagnosis improve the management of acute abdominal pain?. Ann R Coll Surg Engl 1992; 74: 40-46.
30 Gonzalez ER, Vanderheyden BA, Ornato JP, Comstock TG. Computer-assisted optimization of aminophylline therapy in the emergency department. Am J Emerg Med 1989; 7: 395-401.
31 Sim I, Gorman P, Greenes RA, Haynes RB, Kaplan B, Lehmann H. et al. Clinical decision support systems for the practice of evidence-based medicine. J Am Med Inform Assoc 2001; 8 (06) 527-534.