Testing Changes

The following are keys to successful implementation of protocols or care standards:

• When possible, base the protocol on firm evidence from the scientific literature.
• Design the protocol using a multidisciplinary team.
• Involve all stakeholders, using an information-feedback process to facilitate everyone's trust, confidence, and buy-in.
• Test the protocol in the clinical environment using small Plan-Do-Study-Act (PDSA) cycles, modifying it as needed to make it unambiguous, safe, and acceptable to practitioners.
• Measure the protocol's impact on work processes and outcomes and feed back the information to the users.
• Test the protocol vigorously, using multiple small tests to reduce safety and compliance problems to a minimum before full implementation.

Using the Plan-Do-Study-Act (PDSA) Cycle

 Example 1: Use an insulin drip protocol to achieve tight glucose control.

Plan

Use an adopted insulin drip protocol to control the glucose in a hyperglycemic septic patient, keeping glucose between 60 and 150 mg/dL as measured at the bedside.

Do

Use the protocol on one patient. Record insulin drip changes and amount and timing of insulin boluses, along with the blood glucose levels and the time they were done. Also, document whenever the protocol was not followed and the time and reason for the protocol violation.

Study

• The protocol resulted in two incidents of mild hypoglycemia.
• After the nurse's patients experienced episodes of hypoglycemia, the nurse violated the protocol when the glucose was dropping rapidly by reducing the incremental drip change and omitting the bolus to avoid this complication.
• The protocol was ambiguous in a few places and the nurse felt this ambiguity could lead to mistakes.
• The protocol was very effective at reducing the glucose to below the 150 mg/dL range.

Act

• After discussion with the committee, the team modified the protocol to be less aggressive.
• The team revoed areas of ambiguity in the protocol.
• Team is ready to plan next small test.

Example 2: Implement a fluid resuscitation protocol for septic shock patients.

• Cycle 1: Develop a fluid protocol. Send it to the physicians who will use it for their comment and buy-in.
• Cycle 2: Using the physician feedback, modify the protocol and test it on the next septic shock patient.
• Cycle 3: Modify the protocol based on the problems found in the first test, adding an albumin arm to the protocol. Retest on the next septic patient.
• Cycle 4: Resolve the pharmacy issue of quickly supplying albumin to the unit for rapid shock resuscitation and have another physician try the protocol on a septic patient.
• Cycle 5: Modify as needed from lessons learned and try the protocol on the next three patents.
• Cycle 6: Educate all the nurses and physicians, using the data from the protocol testing experience that demonstrate its safety and effectiveness.
• Cycle 7: Apply the protocol generally to all septic shock patients and collect feedback from the users.

Example 3: Implement a process to ensure the early detection of severe sepsis.

• Cycle 1: Set up a measuring system to collect data and use it in a retrospective chart review to establish how well we identify early patients with severe sepsis and septic shock within a 2-hour period.
• Cycle 2: Develop a screening tool for the triage nurse and/or admitting clerk to use to identify potential severe sepsis and septic shock patients. Get buy-in from emergency room physicians.
• Cycle 3: Have the emergency department admissions clerk and/or triage nurse prospectively flag potential severe sepsis and septic shock patients and measure any improvement in identifying these patients. Modify the screening tool as needed and retest.
• Cycle 4: Establish a system to automatically collect the physical and laboratory data by protocol that is agreed upon by physicians, nurses, laboratory technicians, and unit clerks.
• Cycle 5: Test the protocol on the next sepsis patient. Document problems. Modify the protocol as needed to eliminate ambiguity, work process objections, and non-protocol compliance.
• Cycle 6: Test the protocol on two or three more patients and measure the times until the information is available to make the diagnosis of severe sepsis or septic shock.
• Cycle 7: Modify the screening and information gathering processes until the time to identification is less than 2 hours from emergency department admission.

Example 4: Implement a process to manage blood glucose between 60 and 150 mg/dL consistently in patients with severe sepsis and septic shock.

• Cycle 1: Establish a system to monitor and document blood glucose measurements in sepsis patients.
• Cycle 2: Modify an adopted insulin drip protocol to control the glucose in a hyperglycemic septic patient between 60 and 150 mg/dl and send it out for comment and buy-in from practitioners who will use the protocol.
• Cycle 3: Test the protocol on one or two patients and modify as needed to improve safety and address objections to work-flow problems.
• Cycle 4: To address problems with frequent glucometer checks and difficulties in access to the instruments, purchase more for the unit.
• Cycle 5: Because there is overshoot when 50 percent dextrose is used for hypoglycemia in the test patients, modify the dose in the protocol to reduce this problem and measure the results.
• Cycle 6: Continue small tests and modifications until the safety and consistency of the protocol are established; then release for general use.