I think it is important to clarify that this Q&A is from August 2017. The original question posed is in regards to the Specs that are effective for discharges starting January 1, 2019. So as I understand it, if the patient was discharged on 1.1.19 or later, you would use the HIGHEST lactate within the applicable time period. If the patient was discharged prior to 1.1.19, you would use the lactate that is CLOSEST to the time of severe sepsis presentation.
Jamie Haak, BSN, RN, CCRN-K Quality Outcomes Coordinator | Quality & Safety The University of Kansas Health System Phone 913-588-2848 | Fax 913-588-2869 | [email protected]<mailto:[email protected]> 4000 Cambridge Street, Delp G011, Kansas City, KS 66160 From: Sepsisgroups [mailto:[email protected]] On Behalf Of Overmyer, Diane Sent: Wednesday, January 16, 2019 5:38 PM To: 'Barbara Tribuiani' <[email protected]>; [email protected] Subject: [External] Re: [Sepsis Groups] Lactate question Hello: Below is a Q&A that I submitted through QNET. I have an even better one that I am searching for and will send it when I find it. Hope this helps a little bit at least. Initial Lactic Acid Discussion Thread Response Via Email (Reena Raveendran) 08/14/2017 02:23 PM Hi Diane, For purposes of the measure, the "Initial" lactate is the level drawn closest to severe sepsis presentation. The reason for using this lactate as the "Initial" is that the lactate accurately reflects what is physically going on with the patient in regards to their condition, whether they are decompensating, if they are developing septic shock, etc. Once severe sepsis is present, it is important to know what the most recent lactate is (closest in time) in order to order the appropriate treatment and carry out the most appropriate interventions. Also, since the patient did develop severe sepsis, it would be important to recheck the lactate close to the time of presentation, to determine whether the patient's condition is improving. Therefore, even though the Initial Lactate uses the word "initial", it is more in reference to when severe sepsis occurred, rather than which was the first one to be drawn in chronological order. Hope this clarifies. Customer By Web Form (Diane Overmyer) 08/14/2017 01:39 PM We have a patient that had a lactic acid drawn at 0855. Severe sepsis presentation was at 1045. A repeat lactic acid was drawn at 1150. If I am understanding the guidelines correctly, I would have to use the 1150 lactic acid as the initial and we will not pass the measure because there wasn't another lactic acid drawn. What is the rationale for not using the 0855 lactic acid for the initial? Question Reference #170814-000100 From: Sepsisgroups [mailto:[email protected]] On Behalf Of Barbara Tribuiani Sent: Wednesday, January 9, 2019 1:46 PM To: [email protected]<mailto:[email protected]> Subject: [Sepsis Groups] FW: Lactate question Hi All- Please see below. Does everyone agree with this? They make it so difficult. Thank you, Barb Barbara Tribuiani BSN RN Sepsis Coordinator/Quality Improvement Nurse Mercy Fitzgerald Hospital [email protected]<mailto:[email protected]> Phone: 610-237-4208 1500 Lansdowne Ave. Darby, Pa. 19023 STOP SEPSIS, SAVE A LIFE! From: Barbara Tribuiani Sent: Wednesday, January 09, 2019 1:44 PM To: Lisa Blount <[email protected]<mailto:[email protected]>> Subject: RE: Lactate question Hello again, I just checked the rules again and here is what I found which helps to clarify our problem with the lactate. The specified time frame within which an initial lactate must be drawn is within 6 hours prior through 3 hours following severe sepsis presentation. o If multiple lactate levels are drawn within the specified time frame, use the lactate drawn PRIOR to the Severe Sepsis Presentation Time with the HIGHEST level. o If multiple lactate levels are drawn ONLY in the 3 hours after the Severe Sepsis Presentation Time, use the lactate drawn with the HIGHEST level within this time frame. So Karla in answer to your question it appears that the LA drawn at 0609 is the initial LA per the rules. Hope this helps. Thank you, Barb Barbara Tribuiani BSN RN Sepsis Coordinator/Quality Improvement Nurse Mercy Fitzgerald Hospital [email protected]<mailto:[email protected]> Phone: 610-237-4208 1500 Lansdowne Ave. Darby, Pa. 19023 STOP SEPSIS, SAVE A LIFE! From: Lisa Blount Sent: Wednesday, January 09, 2019 10:42 AM To: Sarah Pashchuk <[email protected]<mailto:[email protected]>>; Tracey Melhuish <[email protected]<mailto:[email protected]>>; Tawnia M. Iwasinski <[email protected]<mailto:[email protected]>>; Karla A. Cleveland <[email protected]<mailto:[email protected]>>; HQTH DISGROUP SEPSIS COORDINATORS DG U <[email protected]<mailto:[email protected]>> Subject: RE: Lactate question Hi Everyone, The CMS specs manual clearly states for abstraction and passing the measure you must take the Lactic Acid closest to the time of severe sepsis. This can and does cause fall outs really easily and has for us when the repeat has to be considered the Initial by CMS standards. The new specs manual for January-July 2019 discharges has new criteria for the lactate. And Melanie is correct, if you have an order for an antibiotic sooner than 950, you can take that as documentation of infection, and possibly your severe time could be closer to the first drawn lactic acid. Thanks, Lisa Blount RN Sepsis Coordinator Quality Performance Specialist Mercy Medical Center Clinton 1410 N 4th St Clinton, Ia 52732 563-244-3763 [email protected]<mailto:[email protected]> From: Sarah Pashchuk [mailto:[email protected]] Sent: Wednesday, January 09, 2019 9:40 AM To: Tracey Melhuish; Tawnia M. Iwasinski; Karla A. Cleveland; HQTH DISGROUP SEPSIS COORDINATORS DG U Subject: RE: Lactate question Infection was not documented until 0950. Without that piece of information, you don't have Severe Sepsis. Once you have Severe Sepsis presentation at 0950, you would go by the lactate closest to presentation as the initial, which happens to be the 1201 draw in this scenario. Our organization has found this causes a fair number of repeat lactate fallouts, because typically you do not draw more than the initial 2 (although many places trend until less than 2). So, if the lactate is drawn "too early" in comparison with when infection is documented, it ends up skewing your data. This is a helpful conversation, I appreciate all the input. Thanks, Sarah Pashchuk, BSN, RN, CPAN Quality Improvement Advisor Sepsis Coordinator St. Joseph's Health [email protected]<mailto:[email protected]> W 315.448.6504 C 315.256.1687 F 315.448.6402 301 Prospect Avenue Syracuse, NY 13203 sjhsyr.org<http://www.sjhsyr.org/> | Facebook<https://www.facebook.com/StJosephsHealth/> | Twitter<https://twitter.com/stjosephshealth?lang=en> | LinkedIn<https://www.linkedin.com/company/932766/> [cid:[email protected]] From: Tracey Melhuish <[email protected]<mailto:[email protected]>> Sent: Wednesday, January 09, 2019 10:32 AM To: Tawnia M. Iwasinski <[email protected]<mailto:[email protected]>>; Karla A. Cleveland <[email protected]<mailto:[email protected]>>; HQTH DISGROUP SEPSIS COORDINATORS DG U <[email protected]<mailto:[email protected]>> Subject: RE: Lactate question Why the second one and not the first? You have SIRS with organ dysfunction Tracey Melhuish MSN, RN, CCRN Clinical Practice Specialist/Sepsis Coordinator Clinical Practice Holy Cross Hospital Phone: 954-229-7916 Cisco Ph: 954-229-8829 Email: [email protected]<mailto:[email protected]> A Member of Trinity Health, operating in the spirit of the Sisters of Mercy [cid:[email protected]] [cid:[email protected]] From: Tawnia M. Iwasinski Sent: Wednesday, January 09, 2019 10:18 AM To: Karla A. Cleveland; HQTH DISGROUP SEPSIS COORDINATORS DG U Subject: RE: Lactate question Good morning, I would like to say to use the one from 0609 BUT I have written down from a forum I came across that you are to use the lactate drawn CLOSEST to the Severe Sepsis presentation time, even if it is the 2nd one drawn. This seems not right to me because it was the first one that triggered the repeat draw and therefore could cause a fallout if a third one is not drawn (to be the repeat draw). Is this where your confusion comes from also? I'm wondering if this is correct? Sorry to add to your confusion, I am confused on this too! Tawnia Iwasinski RN,BSN Tawnia Iwasinski RN, BSN Clinical QI Coordinator/Sepsis coordinator Trinity Health Of New England [email protected]<mailto:[email protected]> W 413-748-9606 Mercy Medical Center 271 Carew Street Springfield, MA 01104 MercyCares.com TrinityHealthOfNE.org<http://www.trinityhealthofne.org/> | Facebook<https://www.facebook.com/THOfNewEngland> | Twitter<https://twitter.com/THOfNewEngland> | Instagram<https://www.instagram.com/thofnewengland/> [cid:[email protected]] From: Karla A. Cleveland Sent: Wednesday, January 09, 2019 9:37 AM To: HQTH DISGROUP SEPSIS COORDINATORS DG U Subject: Lactate question Good morning, I'll give you the scenario and then tell you what I'm struggling with. :) Criteria for meeting severe: Documented infection at 0950 SIRS at 0600 & 0645 Organ dysfunction at 0609 (lactate of 3.0) Time of severe = 0950 Here's my struggle... Lactate 3.0 at 0609 (this is my organ dysfunction) Lactate 2.8 at 1201 (this is closer to time of severe) Which one is my initial lactate? Can I have a lactate used as organ dysfunction that is NOT my initial lactate? Thank you in advance for your feedback. Karla Cleveland, BS, RN Coordinator, Quality Assurance Quality and Care Transformation Mercy Health A Member of Trinity Health [email protected]<mailto:[email protected]> W 231.672.2221 F 231.672.3965 1560 E. Sherman Blvd, Suite 334 Muskegon, MI 49444 MercyHealth.com<http://mercyhealth.com/default.cfm?id=1> | Facebook<https://www.facebook.com/WeAreMercyHealth/> | Twitter<https://twitter.com/mercyhealthwm?lang=en> [cid:[email protected]] Confidentiality Notice: This e-mail, including any attachments is the property of Trinity Health and is intended for the sole use of the intended recipient(s). It may contain information that is privileged and confidential. Any unauthorized review, use, disclosure, or distribution is prohibited. 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