This document discusses efforts to boost early lactate measurement for sepsis recognition in the emergency department. It describes how a collaborative approach between emergency medicine, critical care, and laboratory medicine led to the development of a "Sepsis Lab bundle" that prioritizes lactate measurement on a syringe to reduce turnaround time. This sepsis panel facilitated by a nurse under medical directive aims to mitigate pre-analytical factors and enhance early recognition, treatment, and monitoring of potentially septic patients.

1. Would you like a Lactate with that?
Boosting Lactate Measurement in
the Emergency Department for
Early Sepsis Recognition
M McGowan1 C Hayes2 D MacKinnon1 L Barratt1
K Gaunt1 A Cheng1 V Leung3 G Modi3 and S Gray1, 2
on behalf of the St. Michael’s Hospital Departments of
1
Emergency Medicine, 2Critical Care, and 3Laboratory Medicine
Funding has been provided by the St. Michael’s
Hospital Medical Association Innovation Funds

2. Boosting Lactate Measurement in the ED for Early Sepsis Recognition
Context
• We used a collaborative Emergency Department – Critical Care approach to identify
potentially septic patients early, initiate treatment and consult appropriately. This was
implemented in September 2013.
Problem and Issue
• Lactate is a marker of tissue hypoperfusion in sepsis and
should be assessed promptly upon presentation to the
Emergency Department to guide resuscitation
• Lactate is a diagnostic test that is ordered by Emergency
Physicians at their discretion, often after initial blood is
collected by the nurse, thus necessitating an additional ‘poke’
for a specific tube
• Our lab has a 30-minute quality standard from time of
registered receipt of sample in the lab to reporting of result in
the electronic health record
• How could we increase quality measures of lactate
(orderering, time-to-result) for potentially septic patients in
the Emergency Department?

3. Boosting Lactate Measurement in the ED for Early Sepsis Recognition
Actions Taken
• Wide Clinical Variability was found in a 2012 review of 108 septic patients in the
Emergency Department who were admitted to ICU/Step-Up:
 24 (22%) failed to have a lactate ordered by an Emergency Physician, including
7 (29%) of 25 who died during that admission
 Time-from-order-to-result was 0:50+3:37hr despite a 30-minute lab quality
standard
• Engaging Emergency Physicians. The 2012 Surviving Sepsis Guidelines were
presented in Grand Rounds, followed by discussions of the utility of lactate. Barriers
and opportunities were identified, including point-of-care testing.
•
Point-of-Care (POC) Lactate Testing.
 Discussions ensued with vendor, lab services, and Emergency
Department management to streamline lactate ordering, process, and
results.
 Cost analysis deemed POC lactate fiscally prohibitive with current and
projected operational budget

4. Boosting Lactate Measurement in the ED for Early Sepsis Recognition
Sepsis Lab Panel
• Prioritizing lactate ordered on syringe vs green top tube
highlighted impact of process, method of collection and
pre-analytical factors influence on lactate, including
reliability and time-to-result with impact on clinical
management
• Collaborative Emergency Department-Laboratory
Medicine approach led to a “Sepsis” Lab bundle with
lactate built in, measured on syringe, and facilitated
under a RN medical directive to mitigate process and
pre-analytical factors
Contribution to Patient Safety & Quality Improvement
• A collaborative approach has led to enhanced monitoring of process and impact on
outcome in all steps of the septic patient journey
• A monthly sepsis scorecard has been designed to monitor performance and outcomes,
while communicating feedback to all stakeholders from the front line in the Emergency
Department to cross-departmental leadership in Emergency, Critical Care, Laboratory
Medicine, and Quality and Risk Management