Michael Culig, MD, Cardiothoracic Surgeon
Page Babbit, MHSA, Director, Clinical Informatics and Process Improvement
Gwen Hall-Pohlman, MBA, Senior Clinical Data Analyst
Michael Wallace, RN, BSN, MBA, Senior Clinical Data Analyst
Michele Gebhardt, RN, Cardiothoracic ICU Nursing Manager
Nancy Scenna, RN, Cartiodthoracic Step Down Nursing Manager
Susan Hudnall, MT, ASCP, Senior Medical Technologist
Ann Koliner, RN, MBA, MHA, Director, Cardiovascular Services
Jenifer Blasinsky, PharmD, Clinical Pharmacist
Mary McCormick, RN, MS, CDE, Certified Diabetes Educator
Marlene Sperl, RN, MSN, CDE, Certified Diabetes Educator
Phyllis Rebholz, RN, MS, Education and Development Specialist
Lawrence Sullivan, MD, Cardiothoracic Surgeon
Gretchen Medich, MD, Anesthesiologist
Michael Dishart, MD, Anesthesiologist

To improve glycemic control and reduce complications through increased compliance with the utilization of the cardiothoracic surgery insulin protocol within the current business year. 

• Composite insulin protocol compliance [implemented in Operating Room and continued through post-operative day 2 (POD2)]
• Number of cases having complications (overall and diabetic)
• Number of cases with surgical site infections (sternal/harvest) (pre-protocol vs. post-protocol)
• Length of stay (LOS) of cases having complications (overall and diabetic)
• Cost per case of cases having complications (overall and diabetic)
• Cost per case of mortalities (overall and diabetic)
• Individual example patient blood glucose levels (success of protocol)

Changes to the system were developed around facets which would directly benefit the caregivers and patient pathway. 

Operations/Processes:

• Revised current insulin protocol to provide greater control over blood glucose levels throughout the patient stay
• Implemented the revised protocol in the peri-operative (vs. post-operative) environment
• Implemented daily insulin protocol rounds
• Adjusted process for transfer orders from CTICU (cardiothoracic intensive care unit) to the step down unit to allow IV insulin to continue vs. a switch to subcutaneous insulin
• Established greater involvement (and subsequently greater consults) of diabetes educators in the patient process
• Implemented daily verbal reports of previous day's blood glucose levels to physicians during rounds

Tools:

• Created information system nursing documentation pathways
• Developed database to store all collected data
• Developed a monthly feedback report that summarized progress of the protocol implementation
• Developed an anesthesia insulin protocol card to be used in the operating room as an immediate prompt to institute the protocol
• Created a physician report card demonstrating physician compliance with protocol against his/her peers
• Created a laminated protocol card to hang from IV poles, giving nurses the information at the point of care
• Created an insulin sliding scale education card for residents to aid them in appropriate management of subcutaneous insulin

The project was extremely successful, reaching a 75 percent composite compliance rate with the protocol, including OR implementation to post-operative day two. Heightened awareness of the new protocol and its ability to better control glucose levels contributed to its acceptance and subsequently aided in achieving improved clinical outcomes:

• 17.1 percent decrease in complication cases
• 57.1 percent decrease in the number of deaths in diabetic complication cases
• 64.7 percent reduction in the number of surgical site infection cases when comparing months pre- and post-implementation of the revised protocol

Operational outcomes such as reductions in cost per case and length of stay were also successful, achieving significant cost savings to the hospital. 

Lessons Learned:

• Involve key stakeholders in the development stage of the insulin protocol. Having this buy-in aids in rapid acceleration of change.
• Establish a rigorous education campaign that addresses all disciplines. Education must be consistent, timely, and provided at regular intervals. 
• Address nursing staff fear of hypoglycemic episodes at the beginning of the project. Doing so will aid in improved nursing acceptance of the protocol.
• Prepare a strategy to address subcutaneous management of insulin upon discontinuation of the protocol. This will help to reduce the erratic swings in glucose levels once taken off the IV insulin. 
• Review your processes to eliminate unnecessary carbohydrates in the patient diet and pharmaceuticals.
• Review transfer processes from intensive care unit to step down units to ensure that the IV insulin protocol is not discontinued when transferred to the step down unit. 
• Investigate the possibility of downloading blood glucose readings via the lab information system versus hand-collection of daily readings. 
• Establish a concurrent data collection system (while patient is still in-house) versus a retrospective chart review process.  Doing so will provide more timely information with which to make decisions.
• Don’t be afraid to experiment. With physician oversight, pilot different changes to the protocol to identify potential improvements.

Page Babbit, MHSA, RHIA, Director, Clinical Informatics and Process Improvement
Western Pennsylvania Hospital
pcbabbit@wpahs.org

[Storyboard presentation at IHI's National Forum, December 2005]