Reducing Mortality in Metformin-Associated Lactic Acidosis Through a Fast-Track Clinical Pathway: A Controlled Interrupted Time Series Quality Improvement Study

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Background: Metformin-associated lactic acidosis (MALA) is extremely metabolic acidosis leading to high mortality. Timely diagnosis and early dialysis might improve the outcomes. The study objective was to evaluate the effectiveness of quality improvement (QI) intervention for reducing mortality in MALA. Methods: We developed and implemented the standardized protocol in MALA including diagnosis, access, entry and treatment including dialysis in Maharat Nakhonratchasima hospital (MNRH), in Thailand. Another hospital, Burirum Hospital (BH), did not implement QI was the control group. Controlled interrupt time series was analyzed to compare between two hospitals in 5 years observation and intervention period. The primary outcome was 30-day mortality. Process outcomes were door-to-dialysis time and MALA awareness. Results: A total of 347 cases in the study period (70 in MNRH pre-QI, 129 in MNRH QI period and 148 in BH) were enrolled. In MNRH, the 30-day mortality rate was reduced from 25.7% to 13.9% after implementing QI, whereas in BH the 30-day mortality rate was not reduced during the same period (27.2% and 30%). The trend of mortality rate in MNRH QI period decreased significantly by -2.08% per quarter (95%CI: -3.75 to -0.41%) and decreased -0.47% per quarter with nonsignificant (95%CI: -3.08% to 2.13%) in the pre-QI period. The mean door-to-dialysis was significantly reduced from 870 minutes to 690 minutes and MALA awareness increased from 38.5% to 89.9% after implementing QI. Conclusion: The implementation of a MALA fast-track clinical pathway resulted in a reduction in a trend of quarterly 30-day mortality, shortened door-to-dialysis time and increased awareness of MALA.Primary and process outcomes

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