Identifying opportunities for health promotion and intervention in the ED.

BACKGROUND: ED staff assess patients with modifiable risk factors for acute and chronic illness. Health promotion interventions delivered in the ED have been advocated for these patients. The engagement of staff is essential to provide effective screening and brief interventions for patients. This survey aimed to assess if staff support the ED as an environment for health promotion. METHODS: A multicentre, structured survey was conducted in four EDs in Scotland from 2017 to 2018. Physician and nursing staff at two teaching and two district general hospitals (n=423) were study eligible and offered a multicomponent survey. Outcomes measured included perceived barriers to practice and risk factor specific ED interventions. RESULTS: Of the 283 respondents, 116 (41%) were physicians and 167 (59%) were nurses. More physicians (86.1%) than nurses (49.7%) reported offering health promotion interventions. Time constraints and a lack of health promotion infrastructure in the ED were cited as challenges to intervention delivery. Staff believed that alcohol (n=170/283, 60.1%) and drug misuse (n=173/283, 61.1%) were more appropriately managed in the ED than primary care. ED staff believed same day brief interventions were more appropriate when alcohol/drug misuse and smoking were directly related to ED presentations. DISCUSSION AND CONCLUSIONS: Staff support the concept of the ED as a potential environment for offering health promotion interventions. ED physicians and nurses have different perspectives on the delivery of health promotion. The role of the ED in health promotion is likely to be multimodal and dependant on the reason for ED attendance.

Capillary and Venous Lactate Agreement: a pilot prospective observational study.

BACKGROUND: Blood lactate is a marker of patient illness severity. Capillary lactate (CAP-LACT) measurement can potentially improve patient screening; however, it has poor evidence of clinical utility. AIM: We aimed to investigate agreement between CAP-LACT and peripheral venous lactate (PV-LACT). METHODS: We performed a prospective observational pilot study of 99 patients requiring lactate measurement. Paired CAP-LACT and PV-LACT was recorded. Agreement was determined by Bland-Altman analysis. RESULTS: Bias was 0.2 mmol/L, with 95% limits of agreement from -1.9 to 2.3. CONCLUSIONS: CAP-LACT has poor agreement with PV-LACT. Further research is needed to improve its potential clinical utility.

Arterial lactate levels in an emergency department are associated with mortality: a prospective observational cohort study.

OBJECTIVES: Lactate measurements are routinely carried out in emergency departments and are associated with increased mortality in septic patients. However, no definitive research has been carried out into whether lactate measurements can be used as a prognostic marker in a clinically unwell population in the emergency department. METHODS: We carried out a prospective observational cohort study in consecutive patients whose arterial lactate concentration was measured in the emergency department of a tertiary referral hospital assessing 110,000 patients per year between 11th May and 11th August 2011. The main outcome measure was 30-day mortality. RESULTS: There were 120 deaths (16.1%) at 30 days postattendance in our cohort of 747 patients. Multivariate logistic regression revealed lower lactate levels were associated with 30-day survival: ORs for 30-day death compared with lactate ≥4 were 0.125 (95% CI 0.068 to 0.229) for lactate <2 and 0.273 (95% CI 0.140 to 0.533) for lactate 2-<4. Kaplan-Meier analysis showed a survival difference when dividing lactate concentrations into strata (p<0.0001). This survival difference was maintained when septic diagnoses were taken into account. CONCLUSIONS: A single arterial lactate measurement on presentation to the emergency department predicts 30-day mortality independent of other measures of illness severity.

Do lactate levels in the emergency department predict outcome in adult trauma patients? A systematic review.

BACKGROUND: Serum lactate may be associated with clinical outcomes in trauma, even in the absence of physiological abnormality. Sensitive markers of injury and outcomes are needed to guide triage and management of trauma patients within the Emergency Department. We completed a systematic review to determine if lactate levels in adult trauma patients presenting to the Emergency Department were associated with clinical outcomes including mortality. METHODS: A systematic literature search was conducted in August 2014, updated in March 2016, using MEDLINE, Embase, and CINAHL. Abstracts and full texts were screened for inclusion by two independent reviewers using predetermined inclusion and exclusion criteria. Data extraction and quality assessment was performed by each reviewer using a standardized form. A total of 998 studies were screened; 28 studies were included and reviewed. RESULTS: The 28 studies recruited 44,154 adults in eight countries between 1997 and 2016. Twenty-one studies found a significant association between elevated Emergency Department lactate and risk of mortality. Three studies looked at lactate clearance; two showed poor clearance was an additional determinant of mortality, but the other found no association. Ten studies also found an association between elevated lactate and other clinical outcomes. These included injury severity, Intensive Care Unit admission, length of hospital stay, organ failure, respiratory complications, blood loss, blood product requirement, catecholamine support, or emergency operation. Two studies concluded that lactate levels do not affect management. CONCLUSIONS: This review shows that elevated Emergency Department lactate levels are associated with mortality and may be associated with other clinical outcomes in adult trauma patients. We conclude that lactate is a useful marker of outcome in trauma, in addition to current markers of severity. The potential roles of serial lactate measurement and lactate clearance require further research. LEVEL OF EVIDENCE: Systematic review, level III.