A tight glycemic control initiative in a surgical intensive care unit and hospitalwide.

BACKGROUND: In 2002, tight glycemic control (TGC) was mandated at Henry Ford Hospital (Detroit) to reduce surgical site infections (SSIs). THE FIVE STEPS FOR IMPROVEMENT: The TGC initiative was developed in terms of the five primary steps of the Institute for Healthcare Improvement (IHI) framework for leadership for improvement to drive practice change and maintain continuous improvement. In terms of Steps 1-3 (set direction, establish the foundation, and build will), in April 2002 the chief executive officer of the Henry Ford Hospital (Detroit) announced a hospitalwide initiative to reduce SSIs. For steps 4 and 5 (generate ideas and execute change), the 40-bed surgical intensive care unit (SICU) was designated the practice-change setting. TGC protocols were implemented in cardiothoracic patients, followed by all SICU patients, with target glucose ranges moving from the initial < 150 mg/dL to 80-110 mg/dL. Results showed decreases in SSIs and mortality. The project's success led initiation of hospitalwide TGC in the next two years. RESPONDING TO A CHANGING EVIDENCE BASE: In 2009, as studies began to show that the recommended glucose target of 80-110 mg/dL was not associated with clinical improvement in ICU patients and perhaps may cause harm (increased mortality), the target ranges were modified. LESSONS LEARNED: Barriers to adoption of new practice change must be integrated into the planning process. Leadership champions are required across multiple levels of the organization to drive change to the bedside for effective and lasting improvement. CONCLUSIONS: A universal TGC protocol continues to be used throughout the hospital, with modifications and next-generation improvements occurring as evidence arises.

Reducing hospital standardized mortality rate with early interventions.

Henry Ford Hospital is undertaking multiple initiatives to reduce patient mortality. One such project is the deployment of a rapid response team (RRT). Rapid response teams contribute to reducing in-patient mortality rates by identifying and treating patients at risk for physiological deterioration outside the intensive care unit (ICU) setting. Rapid response teams differ from code teams because they proactively look for "at-risk" patients, whereas code teams are activated after a patient's arrest. Team members include ICU nurses, medical doctors, house managers, and respiratory therapists, with the ICU nurses acting as primary responders. The RRT at Henry Ford Hospital is available 24 hours a day, 7 days a week. Criteria for the members of the RRT were developed by a committee of physician and nursing leadership. Nurses on the RRT need a minimum of 2 to 3 years of intensive care background. Weekly meetings with planning committee members were held to discuss issues regarding the implementation of the RRT pilot. The RRT committee consists of 3 nurse administrators, a house manager, a clinical nurse specialist, 2 nurse managers, clinical coordinators, a quality assurance nurse, a statistician, and the medical director of medical critical care. The population analyzed was a sample of 1,335 RRT consults and 207 medical ICU discharge follow-ups. The processes that were measured were percentage of blue alerts outside the ICU, the number of calls to the RRT, and the location, reason, time, and outcome of an RRT call. Outcome measures consisted of unadjusted hospital mortality rate, blue alerts per 1,000 discharges, percentage of patients with blue alerts discharged alive, and number of days between blue alerts on the pilot unit. Initial results are positive, with evidence that the number of blue alerts on general practice units is being reduced. Statistical data collected from the consult forms indicate that the greatest number of occurrences were respiratory triggers. From a sample size of 1,335 consults, 30% of the sample group had low pulse oximetry, 30% presented with respiratory distress, and 20% had respiratory rate issues. Future implications for the RRT will be along the lines of early sepsis recognition, retention and recruitment tool, education and practice links, and using families as initiators of a RRT consult.