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 Keys to successful implementation of protocols or care standards include the following:
- When possible, base them on firm evidence from the scientific literature.
- Design them using a multidisciplinary team.
- Involve all stakeholders, using an information feedback process to facilitate everyone's trust, confidence, and buy-in.
- Test the protocol using small plan-do-study-act (PDSA) cycles in the clinical environment, modifying the protocol as needed to make it unambiguous, safe, and acceptable to practitioners.
- Measure the impact on work processes and outcomes, and feed the information back to the users.
- Test vigorously using multiple small tests, in order to reduce problems with safety and compliance to a minimum before full implementation.
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Example: Use an insulin drip protocol to achieve tight glucose control
Plan
Use an adopted insulin drip protocol to control the glucose in a hyperglycemic septic patient, keeping it between 60 and 150 mg/dl as measured at the bedside.
Do
Use the protocol on one patient, recording insulin drip changes, amount and timing of insulin boluses, and blood glucose levels and timing. Also, document whenever the protocol was not followed and the time and reason for the protocol violation.
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The protocol resulted in two incidents of mild hypoglycemia.
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After the episodes of hypoglycemia, the nurse violated the protocol when the glucose was dropping rapidly by reducing the incremental drip change and omitting the bolus to avoid this complication.
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The protocol was ambiguous in a few places that the nurse felt could lead to mistakes.
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The protocol was very effective at reducing the glucose to below the 150 mg/dl range.
Act
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After discussing findings with the committee, the team modified the protocol to be less aggressive.
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The team removed areas of ambiguity in the protocol.
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Team is ready to plan next small test of change.
Example: Implement a process to manage blood glucose between 60 and 150 mg/dl consistently in patients with severe sepsis and septic shock.
Cycle 1:
Establish a system to monitor and document blood glucose measurements in critically ill patients.
Cycle 2:
Modify an adopted insulin drip protocol to control the glucose in a hyperglycemic patient between 60 and 110 mg/dl and send it out for comment and buy-in to practitioners who will use the protocol.
Cycle 3:
Test the protocol on one or two patients and modify as needed to improve safety and address objections to work flow problems.
Cycle 4:
Because of problems with frequent glucometer checks and difficulties in access to the instruments, purchase more for the unit.
Cycle 5:
Because there is overshoot when 50 percent dextrose is used for hypoglycemia in the test patients, modify the dose in the protocol to address this problem and measure the results.
Cycle 6:
Continue small tests and modifications until safety and consistency are established, then release for general use.
Example: Implement a process to ensure the use of the Central Line Bundle in critical care.
Cycle 1:
Set up a measuring system to collect data and use it in a retrospective chart review to establish how well we presently comply with the Central Line Bundle.
Cycle 2:
Develop a checklist of items that must be accomplished to fulfill the items in the Central Line Bundle.
Cycle 3:
Empower ICU nurses to control the process of line placement and to stop the process if the checklist items are not fulfilled.
Cycle 4:
Train staff in the meaning of maximal barrier precautions and test staff application of these precautions.
Cycle 5:
Test the protocol on the first central line patient. Document problems. Modify the protocol as needed to eliminate ambiguity, work process objections, and non-compliance with the protocol.
Cycle 6:
Test the protocol on another two to three patients and measure the results of compliance with the bundle and effectiveness of the checklist approach.
Cycle 7:
Modify the processes until all bundle items are executed every time on patients with central lines.
Example: Implement a fluid resuscitation protocol for septic shock patients.
Cycle 1:
Develop a fluid protocol and send it out to physicians who have to use it for comment and agreement to use it.
Cycle 2:
Using the feedback from the physicians, modify the protocol and test it on the next septic shock patient.
Cycle 3:
Modify the protocol according to the problems found in the first test, adding an albumin arm to the protocol, and retest on the next septic patient.
Cycle 4:
Resolve the pharmacy issue of quickly supplying albumin to the unit for rapid shock resuscitation and have another physician try the protocol on a septic patient.
Cycle 5:
Modify as needed from lessons learned, and try the protocol on the next three patents.
Cycle 6:
Educate all the nurses and physicians, using the data from the protocol-testing experience that demonstrate its safety and effectiveness.
Cycle 7:
Apply the protocol generally to all septic shock patients and collect feedback from the users.
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