New diagnostic protocols that use lactic acid test cut deaths from sepsis
Laboratory testing plays a key role in a new diagnostic protocol for sepsis that is saving lives at hospitals operated by Methodist Le Bonheur Healthcare in Tennessee. Since implementation of this new sepsis protocol, patient outcomes have improved significantly.
Leadership at Methodist North Hospital (MNH) decided to adopt the protocol after reading a study by Emanuel Rivers, M.D., Ph.D., of Henry Ford Medical Center, published in the New England Journal of Medicine, that establishes criteria for identifying these patients.
Centerpiece of the warning system is a point-of-care test (POCT) for lactic acid that was developed by the MNH laboratory. This test can identify patients at risk for sepsis shock in as little as 10 minutes. “There is a crucial six-hour window to recognize and stop the sepsis downward spiral that can cause a patient to die,” noted Karen Hopper, M.D., Chief Medical Officer for MNH, noting that sepsis is difficult to diagnose because it can easily be confused with other ailments.
At MNH hospitals, it is now common practice to use lactic acid testing to screen for early sepsis in any patient with evidence of systemic inflammation responses (SIRs), like rapid pulse or respiration, very high or very low temperature, or mental status changes. “Prior to routine lactic acid testing, it was the drop in systolic blood pressure—signaling the onset of septic shock—that was often the first indicator of severe sepsis to catch the physician’s attention,” she said. “By introducing point-of-care testing for lactic acid, our lab has enabled us to catch these patients much sooner in the early, more treatable stage of the sepsis syndrome.”
“The exciting thing is we’re not missing the diagnosis anymore,” says Paula Jacobs, Director of Quality and Performance Improvement at MNH. She noted that, before implementation of the new sepsis protocols, diagnosis might be delayed or missed, because the patient presenting in the Emergency Center did not appear very sick. Often, after being admitted, it might be hours before lab tests were run on such patients. Those sepsis patients who survived often lost organ function and/or limbs. “Now these patients are tested on the spot,” she noted.
The MNH laboratory continues to play a key role. “Without the lab’s involvement to quickly assess for organ dysfunction, the opportunity for early diagnosis and intervention in severe sepsis would be missed for the overwhelming majority of patients,” observed Noel Florendo, M.D., Ph.D., Medical Director of the MNH Laboratory.
A lactic acid level of 2.2 mg per liter of blood starts the warning protocol in motion. The lab test result triggers the hospital’s electronic medical record (EMR) system to look at lab tests for indication of infection and/or onset of organ dysfunction. If the system finds elevated creatinine, bilirubin or glucose, it looks at medical history and initiates rules to determine if the abnormal value is associated with new organ dysfunction or a pre-existing medical condition.
A combination of two SIRs and one abnormal lab test sets off the alarm, notifying the patient’s care team of potential sepsis. If the patient is in the emergency room, a sepsis alert symbol appears next to their name on the tracking board. If the patient is already an inpatient, the House Supervisor is paged to do a reassessment.
Initially the hospital’s doctors were resistant to the program because they did not believe lactic acid could predict sepsis. Dr. Hopper acknowledged, “It took time to change the culture. Early in our initiative, very few lactic acid levels were run to assess for severe sepsis. Physicians have been taught to check lactic acid levels when looking for the cause of a severe acidosis. However, not many physicians were aware that lactic acid levels begin to rise in early sepsis—even in the absence of acidosis.”
The program for sepsis protocols was piloted at MNH and taken system wide. It is programmed into a Cerner Millennium EMR system which Methodist Le Bonheur Healthcare installed in 2002 to connect its seven hospitals. The MNH team hopes its sepsis protocol is recognized as a “best practice.” In turn, that would encourage other hospitals to implement this program. MNH has already shared details with a number of hospitals throughout the United States and Canada.
Most importantly, the warning system continues to save lives and money at MNH. According to Jacobs, the alarm identifies about 40 potential cases of sepsis monthly. It has helped reduce the number of monthly deaths from sepsis by 9% to 16%, depending on the time of year. The highest percentage of cases is during winter months. During this season, an average of six patients per month are discharged due to death by sepsis. Hopper noted, however, that 95% of sepsis deaths involve terminally ill and/or elderly patients with Do Not Resuscitate (DNR) orders.
Since implementing the program the hospital has experienced a three-day drop in average length of stay for these patients. This saves an estimated $2,800 per episode of care due to earlier identification and intervention. The experience of the seven hospitals at Methodist Le Bonheur Healthcare demonstrates how more effective use of laboratory testing can significantly improve patient outcomes while reducing the total cost per healthcare encounter. – P. Kirk