Reducing hyperglycemia hospitalwide: the basal-bolus concept.

BACKGROUND: Hyperglycemia has been identified as potent and independent risk factor for adverse outcomes for patients. An initiative was undertaken to reduce hyperglycemia hospitalwide in adults. METHODS: In a multistep process, insulin protocols were implemented hospitalwide via an electronic provider order entry system. Education regarding basal bolus insulin delivery preceded implementation. Protocols were modified in an ongoing manner on the basis of clinical staff feedback and blood glucose monitoring. Key practice changes included intravenous insulin for initial management in ICU patients, insulin replacement based on the basal bolus approach, elimination of sliding-scale insulin, standardization of blood glucose monitoring before meals, adjustment of prandial dose insulin based on food consumed, administration of prandial dose after the meal, evening snacks ordered based on insulin type, and a glycosolated hemoglobin (A1C) determination for patients with admission glucose > 180 mg/dL. Median inpatient glucose levels in patients with diabetes were assessed using statistical process control methodology. RESULTS: Between January 2004 and September 2007, median glucose for all inpatients with diabetes decreased 15% from 159 mg/dL to < 135 mg/dL. The percentage of inpatients with diabetes who experienced a day with a glucose measurement above 180 mg/dl decreased from 66% to 53%. Frequency of hypoglycemia (< 60 mg/dL) did not change following protocol implementation. DISCUSSION: Major improvements in hospitalwide blood glucose control are feasible and safe, employing standard protocols based on the basal-bolus concept. Improvement was sustained during a four-year period with ongoing institutional support, multidisciplinary education, collaboration between clinical services, and monitoring of clinical outcomes on a quarterly basis.

Implementing computerized provider order entry with an existing clinical information system.

BACKGROUND: There are numerous barriers to successfully implementing computerized provider order entry (CPOE), and it is not entirely clear to what degree the proposed benefits extend to older, commercially available systems in place at most hospitals. METHODS: In 2000, Loyola University Health System leadership chartered a project to implement CPOE for hospitalized patients' medications. The impact of CPOE on workflow was analyzed before implementation. Hardware availability was ensured and input screens were customized for users when possible. A formal education and communication plan was implemented to help reduce resistance to change. RESULTS: Full implementation took 20 months. Transcription-related errors per month decreased by 97% from 72.4 to 2.2 per month. During the pilot period, prescribing-related errors increased by 22% from 150 per month to 184 per month-and subsequently decreased to an average of 80 per month, a 47% reduction compared with the baseline error rate. Pharmacist time saved was estimated at 23 hours per month. DISCUSSION: Using an existing CPOE system can provide an affordable, intermediate step on the journey toward implementing a new, state-of-the-art system that provides advanced clinical decision support.

Critical success factors for performance improvement programs.

BACKGROUND: Most health care organizations struggle with the design and implementation of effective, systemwide improvement programs. In 2000, the University HealthSystem Consortium initiated a benchmarking project to identify the organizational elements that predict a successful perfermance improvement (PI) program and that are best suited to support change initiatives. METHODS: Forty-one organizations completed a survey about the presence of critical components, processes used to improve performance, and organizational PI structures. Follow-up site visits were conducted at three organizations. CRITICAL SUCCESS FACTORS FOR A PI PROGRAM: Eight organizational success factors for an effective performance improvement program were identified: (1) Strong Administrative Fxecutive and Performance Improvement Leadership, (2) Active Involvement of the Board of Trustees, (3) Effective Oversight Structure, (4) Expert Performance Improvement Staff, (5) Physician Involvement and Accountability, (6) Active Staff Involvement, (7) Effective Use of Information Resources-Data Used for Decision Making, and (8) Effective Communication Strategy. DISCUSSION: The approach offered is grounded in the belief that effective organizational structures and processes are prerequisites to improving health care delivery. Although some empirical support for the proposed model is provided, additional research will be required to determine the effectiveness of this approach.

Unanticipated harm to patients: deciding when to disclose outcomes.

BACKGROUND: Patient safety standards of the Joint Commission on Accreditation of Healthcare Organizations require that "patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes." WHAT OUTCOMES SHOULD TRIGGER DISCLOSURE: Given that all medical treatments have an array of possible outcomes, how do we confidently say that an outcome is unanticipated? It is proposed that an adverse outcome meet one of two criteria to be considered unanticipated: (1) It would not be included in a reasonable informed consent process for treatment of the patient's condition(s) and/or would not be expected during the usual course of treatment; and (2) it may have been caused by human or systemic error--that is, it is not immediately possible to clearly and decisively rule out error. This definition requires less judgment because it represents an extension of the existing norms of communication that are expressed through the process of informed consent. The norms of the informed consent process require that the patient be given all pertinent information needed to participate in future treatment decision making. CONCLUSIONS AND RECOMMENDATIONS FOR ORGANIZATIONAL POLICIES: Institutional policies and procedures should provide a clear approach to the identification, reporting, and discussion of unanticipated adverse outcomes, whether or not they are associated with error, as well as guidance and an educational program to help physicians, staff, and students disclose unanticipated adverse events and error in the most appropriate manner.