Intensive-care patients at the Toledo (Ohio) Hospital have seen average daily glucose counts drop significantly during the past two years since the 480-bed facility implemented a glycemic management initiative.
Knowing that many critically ill patients battle hyperglycemia and insulin resistanceand drawing in particular from the article Intensive insulin therapy in critically ill patients, published in the New England Journal of Medicine in 2001the hospital empowered a clinical best-practice design team to examine the facilitys protocols vis-a-vis best practices.
Among the procedural changes instituted were pre-printed physician orders, a standardized pre-printed medication administration record, a metabolic flow record and nursing-care measures for diabetic patients. The hospital also hired a diabetes nurse practitioner, whom staffers see as critical to managing the efforts success.
During the pilot phase of the project, average daily glucose for the surgical intensive-care unit fell from 141 milligrams per deciliter to 138 milligrams per deciliter, while the percentage of patient days with less than 110 milligrams per deciliter average daily glucose rose from 17% to 22%. For these results, the Toledo Hospital has earned the 2007 Spirit of Excellence Award in Quality.
This is only the beginning, says John Brunner, an endocrinologist who has helped lead the effort. Its been a long road, and for anybody whos trying to undertake this in the future, they need to realize they cant expect huge changes overnight. Our success has been primarily the result of a very proactive team. This has been a huge project, and our outcomes have been awesome.
The project faced resistance from both physicians and nursing staff, which required extensive education, says Lynn Alvanos, disease management coordinator. The tight glycemic control was a significant paradigm shift, she says. Resistance came from not completely understanding what we were trying to accomplish. Once there was understanding, there was certainly buy-in because the evidence was overwhelming.
After the first pilot phase, staff also addressed resistance from family members of patients who were concerned about the multiple finger sticks used to draw blood; instead, staff drew blood from invasive lines, and they also developed an educational brochure about intensive insulin therapy to ease family members concerns, Alvanos says.
Next, Toledo plans to extend intensive insulin management to the operating arena and the emergency center while reviewing blood glucose management in the obstetric department. Its very timely, says Kathy Mikos, judge for the Quality category, formerly vice president of patient services at 468-bed Provena St. Joseph Medical Center in Joliet, Ill., and currently vice president of patient care services and chief nursing officer at 418-bed Ingalls Memorial Hospital in Harvey, Ill. Its a best practice hospitals across the nation can learn from.