Stony Brook University Hospital has participated in IHI’s Breakthrough Series Collaborative on Reducing Complications from Ventilators and Central Lines in the ICU, as well as the Improving Outcomes for High-Risk and Critically Ill Patients Learning and Innovation Community.

Team members included:
David Brown, MD, Director of the Cardiac Acute Care Unit
Sharon Kearney, RN, Nurse Manager of the Surgical Intensive Care Unit
Diane Marrone, RN, Nurse Manager of the Cardiac Acute Care Unit
Christine McMullan, Assistant Director of Continuous Quality Improvement
Margaret Parker, MD, Director of the Pediatric Intensive Care Unit
Paul Richman, MD, Director of the Medical Intensive Care Unit
Marc Shapiro, MD, Director of the Surgical Intensive Care Unit
Jeralyn Sigwart, RN, Nurse Manager of the Pediatric Intensive Care Unit
Lisa Sokoloff, RN, Quality Management Practitioner
Bernadette Valente, RN, Nurse Manager of the Medical Intensive Care Unit

To reduce complications in the Surgical ICU by maintaining tight patient glucose of 60–150 milligrams per deciliter (mg/dl).

• Glucose percent specified range: 0–59 mg/dl
• Glucose percent specified range: 60–150 mg/dl
• Glucose percent specified range: >150 mg/dl
• Glucose percent specified range: 80–110 mg/dl

Stony Brook University Hospital began efforts to tighten glucose control back in 2004. The initiative began in our Surgical Intensive Care Unit (ICU) and spread to our Medical ICU, Cardiac ICU, and Pediatric ICU. Although success was initially achieved in our Surgical ICU, it was clear that the order sets created to standardize treatment would have to be modified for the targeted patient population in order to be successful in the remaining ICUs. Using the same concept of standardization, the order sets were modified for our surgical and medical floors before implementation.

Changes implemented:

• Instituted the completion of daily goal sheets created for specific ICU population
• Conducted daily multidisciplinary rounding to review potential risks for complications
• Created (Adult) Rapid Acting Insulin (RAI) Correction Dose Order Set for tight glucose control
• Created and deployed Insulin Pump (Adult) Order Sheet and Worksheet
• Created and deployed (Adult) Insulin Regimen Table
• Educated nursing staff on the use of the order sets
• Provided glucose data to the individual ICUs in order to give feedback on their success in achieving the aim
• Modified order sets for medical-surgical units

Summary of Results:   

The teams set a target of achieving ≥80 percent compliance mean of patients whose glucose fell between the range of 60–150 mg/dl. During the time period of November 2007 to October 2008, the compliance mean for the Surgical ICU was 79 percent. Standardization of glucose management through the application of order sets assisted in more timely treatment. Providing monthly data to each ICU enabled the individual teams to monitor the success of unit-based changes.

Lessons Learned:

• Engaging nurse and physician champions is the key to success
• Seek out your physician champion to engage in one small test of change to get started
• People do what you inspect, not always what you expect — perception is not always reality and continual feedback increases reliability
• Drill-downs are insightful
• Leadership support is key to successful hospital spread of initiatives
• Small tests of change are easier to accept than wide-spread change
• It is better to test and modify protocols from other hospitals than it is to create protocols from scratch
• Standardization of care aids in the reliability of the services provided to the patient
• Decreased variation in the delivery of care is associated with improved compliance and better outcomes

Barriers:

• Staff is resistant to change
• Creating a simple and easy to use insulin order set can be challenging
• Large tests of change seldom lead to success

Next Steps:

• Maintaining our successes: Hold the gain in glucose control

Christine McMullan
Assistant Director of Continuous Quality Improvement
Stony Brook University Hospital
cmcmullan@notes.cc.sunysb.edu