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A Computerized Alert Screening for Severe Sepsis in Emergency Department Patients Increases Lactate Testing but Does Not Improve Inpatient Mortality

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A Computerized Alert Screening for Severe Sepsis in Emergency Department Patients Increases Lactate Testing but Does Not Improve Inpatient Mortality

T Berger et al. Appl Clin Inform.

Abstract

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: SIRS; Sepsis; computerized alert; emergency; informatics; lactate.

Figures

Fig. 1
Fig. 1
Example of the CDS Alert display as it appeared in an electronic ED patient chart during the study period
Fig. 2
Fig. 2
Conceptual flow of the CDS alert and patient selection. (Patients with sepsis were included in the study); Numbered vital signs and WBC count represent SIRS criteria cutoffs for each parameter.
Fig. 3
Fig. 3
Percent of subjects with sepsis who had a lactate tested by month among all sepsis patients. An analysis of the proportion of lactate tests among all sepsis patients in the first two months following alert implementation (months 7 and 8, n= 87/836, 10.4%) compared with the last two months of the alert phase (months 11 and 12, n= 134/1033, 13.0%) demonstrated no decrease in lactate testing.
Fig. 4
Fig. 4
Percent of subjects with sepsis who had a lactate tested by month among all admitted sepsis patients. An analysis of the proportion of lactate tests among all admitted sepsis patients in the first two months following alert implementation (months 7 and 8, n= 70/267, 26.2%) compared with the last two months of the alert phase (months 11 and 12, n= 108/300, 36.0%) demonstrated no decrease in lactate testing.

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