Ventilator Bundle Ventilator Bundle Slides Measurement ... · Ventilator Bundle . Ventilator Bundle Slides . Measurement Slides . Ventilator Bundle Performance Improvement . Tight

Johns Hopkins University and New Jersey Hospital Association Quality Institute VentBundle PDSA 4.5.04

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Ventilator Bundle

Ventilator Bundle Slides

Measurement Slides

Ventilator Bundle Performance Improvement

Tight Glucose Control Rounding Form

Tight Glucose Control Protocol

Tight Glucose Control Order Sheet


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VENTILATOR BUNDLE PERFORMANCE IMPROVEMENT

What is your goal?

To improve performance on the ventilator bundle.

How will you know when you reach your goal?

Monitor performance on the ventilator bundle using the ROUNDING FORM.

What will you do to reach your goal?

1. Improve education by distributing a FACT SHEET and hold in-services for bedside providers 2. Improve communication among providers by using the DAILY GOALS SHEET during

rounds in the ICU.

3. Create independent redundancy to insure that patients receive the processes of care included in the ventilator bundle.

4. Conduct glucose protocol rounds where you review a patient who is on the protocol.


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PDSA 1. STAFF EDUCATION TIME LINE: ___________________________________ PLAN: Based on staff surveys, we have found that bedside providers do not know that the

processes of care within the ventilator bundle can dramatically improve patient outcomes. A FACT SHEET will increase knowledge and improve performance on the ventilator bundle.

DO: 1. Calculate the opportunity to improve from baseline data. Based on your current

performance complete the FACT SHEET for your ICU. 2. Distribute the completed FACT SHEET to all staff members. Consider in-services for the providers to read the FACT SHEET and ask questions. 3. Consider using a brief quiz to test the provider’s knowledge after the FACT SHEET is distributed.

STUDY: 1. Once a week for two consecutive weeks, determine the number of providers that have

received the FACT SHEET and/or completed the quiz.

ACT: Make the results of the study known to providers. If <90 percent of providers received the

FACT SHEET and/or completed the quiz, plan a meeting with your team to evaluate additional opportunities to increase knowledge among providers.


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FACT SHEET ICU Process Measures

For mechanically ventilated patients: • Head of bed (HOB) elevation ≥ 30 degrees reduces the frequency and risk for nosocomial

pneumonia compared to supine position. • The use of thromboprophylaxis is effective for preventing deep venous thrombosis (DVT). • The use of peptic ulcer disease (PUD) prophylaxis reduces the risk of upper gastrointestinal

bleeding. • Daily interruption of sedative drug infusions decreases the duration of mechanical

ventilation and length of stay (LOS) in the ICU. • Intensive insulin therapy to maintain blood glucose </=110 mg per deciliter reduces

morbidity and mortality among critically ill patients. • Daily screening of the respiratory function followed by trials of spontaneous breathing can

reduce the duration of mechanical ventilation, decrease complications and costs of ICU care.

• Gastric decontamination can reduce ICU and hospital mortality and colonization with resistant gram-negative aerobic bacteria.

Base on our current performance, our opportunity to improve the care that we provide to patients : Quality Measure Adverse Events Costs

Elevate HOB xx deaths xx hospital days

$xx

DVT prophylaxis xx deaths xx hospital days

$xx

PUD prophylaxis xx deaths xx ICU days

$xx

Appropriate Sedation xx ICU days $xx

Total


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HEAD OF BED ELEVATION Bottom Line: In mechanically ventilated patients, head of bed (HOB) elevation ≥30 degrees reduces the frequency and risk for nosocomial pneumonia compared to supine position. Elevating the HOB ≥30 degrees is a simple no-cost intervention which will improve outcomes in our patients. The evidence supporting this therapy is from a study of patients who were mechanically ventilated in the ICU. The incidence of aspiration was reduced from 38 percent in the supine group to 8 percent in the group with HOB elevation. Days on the ventilator and ICU length of stay were also reduced. What is the opportunity to improve? In our ICU, xx percent of patients on mechanical ventilation had their HOB elevated ≥30 degrees. To calculate the opportunity to improve, please see opportunity calculator Mean performance on elevating the HOB

Excess ventilator-associated pneumonias per year

Excess deaths per year

Excess hospital days per year

Excess cost per year

xx% xx xx xx $xx *assumes xx admissions per year in our ICU If we can reach our goal of 100 percent, we may be able to prevent xx ventilator-associated pneumonias per year with this simple intervention. If we assume that ventilator-associated pneumonia increases the risk for in-hospital mortality by 40 percent and hospital LOS by 2 weeks, this would lead to xx excess deaths and xx additional hospital days per year in the ICU. If the marginal cost of an additional hospital day is $600, there would have been $xx in excess costs. By elevating the head of bed for patients who are mechanically ventilated, we can reduce their risk for a ventilator-associated pneumonia and the ensuing morbidity and mortality. Reference: Drakulovic MB, Torres A, Bauer TT, et al., Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Lancet 1999; 354: 1851-1858. APPROPRIATE DVT PROPHYLAXIS Bottom Line: In critically ill patients thromboprophylaxis is effective for preventing deep venous thrombosis (DVT). However, the method of prophylaxis proven in one group of patients cannot necessarily generalize to other patients, and multiple types of thromboprophylaxis appear to be effective. Nonetheless, there is agreement that patients who are critically ill or mechanically ventilated are at high risk for DVT and should receive thromboprophylaxis. Perhaps the best summary of this evidence comes from a recent review of critically ill patients admitted to medical and surgical ICUs. Multiple therapies for DVT prophylaxis were consistently reported to reduce the risk of DVT in critically ill patients. The effective therapies include unfractionated heparin, heparin and mechanical prophylaxis such as with TED hose or sequential compression devices. Nonetheless, the studies varied in the populations they studied. One of the important messages of these types of studies is that all of the therapies appear to be effective and it is generally more important to use a therapy than to focus on a specific therapy.


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What is the opportunity to improve? To calculate the opportunity to improve, please see opportunity calculator. In our ICU, xx percent of patients on mechanical ventilation had DVT prophylaxis. Our goal should be 100 percent. Mean performance on use of

DVT prophylaxis Excess DVTs

per year Excess deaths

per year Excess hospital days per year

Excess Costs per year

xx% xx xx xx $xx *assumes xx admissions per year in the ICU Let’s assume that DVT prophylaxis results in a 50 percent relative risk reduction in the incidence of DVT. Although the baseline incidence varies among groups, in most studies of critically ill patients, the baseline incidence of DVT was 30 percent. Therefore, a 50 percent reduction would reduce this incidence to 15 percent. In addition, let’s assume that thromboembolic events are associated with a 15 percent increased risk for in-hospital mortality and increase hospital LOS by 9 days. In our ICU, there were an additional xx DVTs, xx deaths, and xx hospital days per year because of the failure to use thromboprophylaxis. Assuming the marginal cost of an additional hospital day is $600, there were $xx in excess costs per year. This represents a significant opportunity for us to improve. Reference: Attia J, Ray JG, Cook DJ, et al., Deep vein thrombosis in critically ill adults. Arch Intern Med, 161(10):1268-79, 2001. APPROPRIATE PUD PROPHYLAXIS Bottom Line: In mechanically ventilated patients the use of PUD prophylaxis reduces the risk of upper gastrointestinal bleeding. Mechanically ventilated patients have an increased risk for upper GI bleeding and the evidence supports prophylaxis in these patients. In a study published by Cook in the New England Journal of Medicine, investigators found two important risk factors for gastrointestinal bleeding: mechanical ventilation >48 hours and coagulopathy. The specific therapy may be less important. Multiple therapies for PUD prophylaxis are effective. For patients who are not mechanically ventilated, the literature regarding the need for PUD prophylaxis is controversial.

What is the opportunity to improve? To calculate the opportunity to improve, please see opportunity calculator In our ICU, xx percent of patients on mechanical ventilation had PUD prophylaxis. Our goal should be 100 percent. Mean performance on use

of PUD prophylaxis Excess episodes of

GI bleeding per year Excess deaths

per year Excess ICU

days per year Excess Costs

per year xx% xx xx xx $xx

*assumes xx admissions per year in our ICU


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In our ICU, this would translate into xx episodes of significant upper GI bleeding due to the failure to use appropriate PUD prophylaxis. If we assume that GI bleeding results in an additional 5 day LOS, and the cost of an ICU day is $1200, our ICU would have had an additional xx ICU days and $xx in excess costs due to the failure to use appropriate PUD prophylaxis. There is also an estimated 13 percent relative increase in mortality associated with significant upper GI bleeding in the ICU. Reference: Cook DJ, Fuller HD et al., Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med, 1994;330(6):377-81.

APPROPRIATE SEDATION Bottom Line: Daily interruption of sedative drug infusions decreases the duration of mechanical ventilation and length of stay (LOS) in the ICU. The evidence supporting this measure comes from a study where patients were randomized to have their sedation held daily until they were able to follow commands or they became uncomfortable and agitated or to have routine care. They found that in the group that had daily interruption of sedation, the duration of mechanical ventilation was reduced by 33 percent and ICU LOS was reduced by 35 percent. Translating these results into days, the average duration of mechanical ventilation was reduced an average of 2.4 days and the ICU LOS was reduced 3.5 days. This study demonstrates the dramatic reduction in both mechanical ventilation and ICU LOS that can be achieved when patients are sedated such that they are able to follow commands daily.

What is the opportunity to improve? To calculate the opportunity to improve, please see opportunity calculator In our ICU, xx percent of patients on mechanical ventilation had sedation held until they were able to follow commands.

Mean performance of appropriate sedation

Excess days of mechanical ventilation

Excess ICU days

Excess Costs in Dollars

xx% xx days xx days $xx *assumes xx admissions per year in our ICU When this approach is not followed, patients have an increase of 2.4 days of mechanical ventilation and 3.5 ICU days. Using the mean performance in our ICU, we would have an annual excess of xx days of mechanical ventilation, xx ICU days and $xx in excess costs. Reference: Kress JP, Pohlman AS, O’Connor MF, Hall JB, Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med, 2000; 342: 1471-1477.

APPROPRIATE GLUCOSE CONTROL Bottom Line: Intensive insulin therapy to maintain blood glucose </=110 mg per deciliter reduces morbidity and mortality among critically ill patients.


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The evidence supporting this measure comes from a study where mechanically ventilated patients were randomized to receive intensive insulin therapy (maintenance of blood glucose at a level between 80 and 110 mg per deciliter) or conventional treatment. They found that in the group that had glucose levels </=110 mg per deciliter (mg/dl), in-hospital mortality decreased by 34 percent and 12-month mortality decreased by 43 percent. Rates of infection and acute renal failure were also decreased among patients that had glucose levels </= 110 mg/dl. This study demonstrates the dramatic reduction in morbidity and mortality that can be achieved when we maintain patient glucose levels </= 110 mg/dl.

What is the opportunity to improve? We currently do not have baseline rate for this measure in our ICU. We will be collecting data to determine the opportunity to improve the care that we provide to our patients. Reference: Van den Berghe G, Wouters P, Weekers F, et al., Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001 Nov 8;345(19):1359-67. ASSESSMENT OF READINESS TO EXTUBATE Bottom Line: Daily screening of the respiratory function followed by trials of spontaneous breathing can reduce the duration of mechanical ventilation, decrease complications and costs of ICU care. The evidence supporting this measure comes from a study where mechanically ventilated patients in medical and coronary care ICUs were randomized to receive daily screening of respiratory function. Patients that passed the screening test received a two-hour trial of spontaneous breathing. Physicians were notified when their patients successfully completed the trial of spontaneous breathing. The control subjects had daily screening only. They found that in the group that had daily screening followed by a spontaneous breathing trial, the duration of mechanical ventilation was 1.5 days less (4.5 days versus 6 days). Complications ie. removal of the breathing tube by the patient, reintubation, tracheostomy, and mechanical ventilation > 21 days, occurred in 20 percent of the intervention group and 41 percent of the control group. Total costs were also lower in the intervention group. This study demonstrates the dramatic reduction in morbidity and mortality that can be achieved when we assess readiness for extubation daily.

What is the opportunity to improve? To calculate the opportunity to improve, please see opportunity calculator We currently do not have baseline rate for this measure in our ICU. We will be collecting data to determine the opportunity to improve the care that we provide to our patients. Reference: Ely EW, Baker AM, Dunagan DP, et al., Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med, 1996 Dec 19;335(25):1864-9.


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GASTRIC DECOMTAMINATION Bottom Line: Gastric decontamination can reduce ICU and hospital mortality and colonisation with resistant gram-negative aerobic bacteria. The evidence supporting this measure comes from a study where medical and surgical patients with an expected duration of mechanical ventilation of at least 48 hours, expected length of ICU stay of at least 72 hours, or both were randomized to receive either standard care or gastric decontamination (SDD) with oral and enteral polymyxin E, tobramycin, and amphotericin B combined with an initial 4-day course of intravenous cefotaxime. They found that ICU mortality was lower in the SDD group (15 percent) compared to the standard care group (23 percent). Hospital mortality was lower in the SDD group (24 percent) compared to the standard care group (31 percent). Colonisation with resistant gram-negative bacteria was also less in the SDD group (16 percent) compared to the standard care group (26 percent). Colonisation with vancomycin-resistant enterococcus occurred in 1 percent of both groups and no patients in either group were colonised with methicillin-resistant Staphylococcus aureus. This study demonstrates the dramatic reduction in bacterial colonisation and mortality that can be achieved when we use gastric decontamination.

What is the opportunity to improve? To calculate the opportunity to improve, please see opportunity calculator We currently do not have baseline rate for this measure in our ICU. We will be collecting data to determine the opportunity to improve the care that we provide to our patients. Reference: de Jonge E, Schultz MJ, Spanjaard L, et al. Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet 2003; 362: 1011–16


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PDSA 2. DAILY GOALS SHEET TIME LINE: ___________________________________ PLAN: Implement DAILY GOALS FORM to enhance communication among providers and

improve compliance with the ventilator bundle. DO: Complete the DAILY GOALS FORM on each patient during morning rounds. The

completed form is reviewed and initialed by the ICU attending or fellow and left at the patient’s bedside. Consider placing the form on a wall-mounted clipboard in a visible location at the patient’s bedside. Any changes in the plan of care for the day should be documented on the DAILY GOALS FORM. Providers review and initial the form three times during the course of the day to ensure that the plan is up to date and complete.

STUDY: Once a week for two consecutive weeks, determine the number of patients that had the

DAILY GOALS FORM completed.

ACT: Make the results of the study known to providers. If <100 percent of patients had a completed DAILY GOALS FORM, plan a meeting with your team to evaluate additional opportunities to improve compliance with the DAILY GOALS FORM.


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Daily Goals

Room Number _____ Date ____/____/______ --Initial as goals are reviewed -

0700-1500

1500-2300

2300-0700

What needs to be done for the patient to be discharged from the ICU?

What is this patient’s greatest safety risk?

Pain Mgt / Sedation

Cardiac / Volume status; Net goal for midnight

Pulmonary/Ventilator (elevate HOB, glucose control, daily RSBI or SBT, weaning)

Is this patient receiving DVT/PUD prophylaxis?

Mobilization / OOB

ID, Cultures, Drug levels

GI / Nutrition / Bowel regimen

Medication changes (Can any be discontinued?)

Tests / Procedures today

Review scheduled labs

Morning labs and CXR; critical pathway ?

Consultations

Is the primary service up-to-date?

Has the family been updated? Have social issues been addressed?

Can catheters/tubes be removed?

Fellow/Attg Initials: _________


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PDSA 3. CREATING SYSTEMS OF INDEPENDENT REDUNDANCY PLAN: To incorporate reminders into the existing system and improve compliance with

the ventilator bundle. DO: Add reminders to the charting system to query the RN and/or respiratory therapist

when performing ventilator documentation that reads: Is the HOB elevated ≥30 degrees; is the patient receiving DVT prophylaxis, etc.

• Consider adding a ventilator bundle reminder to the charge nurse

report form, bedside nurse report form, and respiratory therapists report form. This provides independent redundancy such that the charge nurse, bedside nurse and respiratory therapist will be prompted to ensure compliance with the ventilator bundle.

• Consider using a preprinted set of orders for all patients being placed

on mechanical ventilation. These orders would include the ventilator settings, PUD prophylaxis, DVT prophylaxis, etc.

STUDY: Monitor performance for the ventilator bundle. ACT: Print a run-chart of your performance for the ventilator bundle over time. Plan a

meeting with your team to evaluate additional opportunities to improve performance.


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PDSA 4: WEEKLY GLUCOSE ROUNDS PLAN: To evaluate and overcome barriers with implementation of tight glucose control Protocols. DO: Once a week on one patient, the nurse manager or charge nurse conducts rounds

using the weekly glucose rounds form (see below). The charge nurse will select a patient on the glucose protocol, evaluate compliance and discuss barriers to compliance. These can include staffs’ awareness of, agreement with and ability to comply with the protocol.

STUDY: Monitor compliance with tight glucose control protocol. ACT: Track performance over time and plan a meeting with your staff to evaluate

additional opportunities to improve performance. Communicate compliance and improvement efforts to the entire unit.


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TIGHT GLUCOSE CONTROL PROTOCOL ROUNDS

This tool has been used by the nursing team at Johns Hopkins to help monitor the tight glucose control (TGCP). The nurse manager facilitates these rounds and the focus is staff education and discussion of clinical insights. The following are steps to help you conduct weekly glucose rounds. On average the manager and staff try to conduct glucose rounds 3x/week. This process can be done in a very short period of time and should be used on multiple patients each week.

1. Identify a patient currently on the TGCP

2. Report the following:

• Name • Age • ICU Admission date • Surgical Procedure and date (if any) • Brief synopsis of medical history • Brief synopsis of ICU course

3. Date TGCP initiated

4. Review of criteria – How does the patient meet the criteria?

5. Starting glucose level

6. Initial bolus/ongoing boluses

7. How long did it take to get the patient in range?

8. Factors that impact getting the patient in range

9. Percent of glucoses in last 24 hours in range. Contributing factors.

10. Did the patient leave the unit? How was it managed? Did the patient fall out of range?

If so, how long did it take to get the patient back in range?

11. Conversion to SSI? Did the patient stay in range on SSI? If not, how long was patient on SSI before going back on a drip?

12. Learning points


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Johns Hopkins University Hospital SICU/WICUProtocol for MANAGING THE PATIENT REQUIRING TIGHT GLUCOSE CONTROL Fast Facts: See Tight Glucose Control Protocol Fast Facts Sheet Table of Contents: Indications for Use Patient Care Objectives

Responsibilities Patient Care Management Assessment Interventions Reportable Conditions Documentation See Also: Related Protocols References Supportive Information Review Cycle Approval Date

INDICATIONS FOR USE: Patients with anticipated ICU stays of greater than 48 hours. The protocol does not apply to patients with ketoacidosis or IMC / floor status patients. PATIENT CARE OBJECTIVES: To maintain ICU patient glucose levels between 80-110 mg/dl. 1.0 RESPONSIBILITES:

1.1 An authorized prescriber’s order to initiate the Tight Glucose Control (TGC) Protocol must be placed in the patient chart utilizing the TGC Orderset.

1.2 The authorized prescriber will write an order to initiate nutritional support as indicated on the TGC order set. D10W, D20W or D5W D5W , D10W, or D20W should never be given as a bolus for intravascular volume expansion. 1.3 Only RNs in the SICU/WICU who have demonstrated competency will initiate TGC Protocol. 1.4 Daily assessments by the physicians, starting day two in the ICU, will determine the ability to provide increased nutritional support in the form of enteral, parenteral, or combined enteral/parental nutrition, and decrease or discontinue any concurrent IV dextrose therapy if possible. 1.5 A physician order for additional insulin in the TPN, if hyperglycemia is related to TPN, must be placed on the TPN orders. 1.6 The RN will initiate the Vesicant Administration Protocol when administering D10W, D20W, D50W, TPN or PPN


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RESPONSIBILITIES (continued):

1.7 Conversion from an IV Insulin Drip to subcutaneous (SC) is as follows: 1.7.1 The patient remaining in the ICU will follow the SC SSI coverage per the TGC Protocol. This does not require an authorized prescriber order. 1.7.2 The patient preparing for transfer from the ICU requires an authorized prescriber’s order for an initial SC dose of insulin, a designated SC

SSI, and an order to discontinue TGC Protocol. Discontinuation of the protocol includes discontinuing supplemental dextrose. Maintain TPN/PPN or enteral feedings as ordered. PATIENT CARE MANAGEMENT 2.0 ASSESSMENT: 2.1 The RN will assess the following:

2.1.1 The patient meets the criteria for inclusion in the protocol. 2.1.2 A completed TGC order set to initiate TGC Protocol is in the patient chart and signed by an authorized prescriber. 2.1.3 The order will include supplemental dextrose/ nutrition.

2.1.4 The RN will review the TGC order set and begin an IV insulin drip. In rare circumstances, a patient may start the TGC Protocol on SC SSI. A physician may write an order to start with the SC SSI scale of the TGC Protocol instead of an insulin drip, otherwise an IV insulin drip is initiated.

2.1.5 In rare instances when the patient begins TGC Protocol on SC SSI, the RN will provide ongoing assessment and notify the authorized prescriber if the patient is not progressing towards goal glucose levels so that IV insulin drip may be initiated. This does not require an additional physician order.

2.1.6 The RN will assess requirements for initial bolus dosing of IV insulin as clinically indicated, and implement as per

guidelines 3.5.1. IV insulin bolus dosing does not require an additional prescriber order.

2.1.7 The RN will assess requirements to convert from an IV insulin drip to SC SSI for patients who have been on TGC Protocol and are remaining in the ICU. The following criteria should be met to convert the patient from an IV insulin drip to SC SSI:

• 4 consecutive controlled glucose levels and • a maximal IV insulin drip rate ≤2 units/hour

The patient on an IV insulin drip of 2 units/hour, will

receive 4 units regular insulin SC one hour prior to discontinuation of the IV insulin drip. The RN will recheck

the glucose 4 hours from the initial SC dose.

The patient on an IV insulin drip < 2 units/hour, will receive


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2 units regular insulin SC one hour prior to discontinuation of the IV insulin drip. The RN will recheck the glucose 4 hours from the initial SC dose. Supplemental dextrose does continue even though the patient is on SC SSI section of the TGC Protocol. 2.1.8 In anticipation of ICU discharge, the RN will assess the patient’s criteria (2.1.7) to convert from IV insulin drip and obtain an order for the initial SC dose and SC SSI Scale and discontinuation of TGC Protocol. The initial SC insulin dose is to be administered one hour prior to the discontinuation of the IV insulin drip.

2.1.8.1 The RN will assess the patient’s response to the SSI conversion allowing glucose levels to

rise to ≤200mg/dl in anticipation of ICU discharge.

3.0 IMPLEMENTATION:

3.1 Upon implementation of the TGC Protocol, the RN will initiate an IV insulin drip utilizing the TGC Protocol algorithm as a guide, unless otherwise ordered. 3.2 Administer supplemental dextrose/nutrition as ordered in the TGC order set. 3.3 Check serum glucose every 4 hours while on SSI and every hour on IV insulin. SC SLIDING SCALE INSULIN Glucose (mg/dl) Regular insulin (SC) Q 4 hours 0-50 Administer ½ amp D50 IV; NHO 51-60 No action, NHO 61-110 No action 111-140 2 units 141-170 4 units 171-200 6 units 201-230 8 units; NHO 231-260 10 units; NHO 261-290 12 units; NHO >290 14 units; NHO

3.5 Administer bolus doses of IV insulin if clinically indicated, using the recommended dosages provided in the Initial Recommended Bolus Dose Regular Insulin IV algorithm below as a guide (3.5.1)

Insulin bolus doses should not be administered using the IV infusion pump, but drawn up separately and administered IV. This does not require an additional order.


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3.5.1 Initial Recommended Bolus Dose Regular Insulin IV

Glucose (mg/dl) Recommended action IV bolus Drip Rate >350 15 units 6-8 units/hr 301-350 10 units 5-6 units/hr 251-300 7 units 4-5 units/hr 201-250 5 units 3-4 units/hr 151-200 3 units 2-3 units/hr 111-150 0 units 1-2 unit/hr

3.6 RNs should use their experience and clinical judgment in titrating of the insulin drip.

3.7 Titrate insulin based on observed changes/trends in glucose levels rather than an absolute glucose value. When making the decision to adjust the drip rate it is important to consider the rate of glucose change, the actual level of glucose and the insulin drip rate. For example, a patient with an insulin drip rate of 10 units/hr whose glucose has decreased from 200mg/dl to 130mg/dl will be managed differently than a patient who is also on 10 units/hr but whose glucose dropped from 150 to 130 mg/dl. The RN may refer to the Initial Recommended Bolus Dose (3.5.1) and Insulin Titration Algorithm (3.7.1) below for initial drip rates and drip titration tables. The Insulin Bolus Dose and Titration Algorithms are to be used as guidelines only!

3.7.1 The Insulin Titration Algorithm Regular IV Insulin Drip

Glucose (mg/dl)

Rising Glucose

IV Drip Falling glucose

>350 301-350 251-300 201-250 151-200 111-150 81-110 61-80

Re-bolus 10 units 7 units 5 units 2 units 0 units 0 units 0 units 0 units

Increase rate 2-3 units/ hr 2-3 units/hr 2-3 units/hr 1-2 units/hr 1-2 units/hr 1 unit/ hr no change no change

Hold Drip - - - - -

0-30 minutes 0-60 minutes 0-60 minutes

Decrease rate 0% 0% 0%

0-10% 0-10% 0-25% 0-50% 25-75%

51-60 Stop drip; NHO: Assure adequate glucose administration

30-60 minutes Consider restarting when glucose is ≥ 90

≤ 50 Stop drip; NHO; Administer ½ amp D50W and check blood glucose in 30-60 minutes

Until adequate rebound in glucose

Consider restarting when glucose is ≥ 90

3.8 Insulin drips, in general, should not be increased by more than 5 units in any given hour.


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3.9 Patients leaving for OR or for Procedures/Tests: 3.9.1 Patients leaving the ICU to go to the Operating Room should have

the TGC Protocol maintained. 3.9.2.1.1 Patients leaving the ICU to go for a Procedures/Tests (other

than a monitored OR): 3.9.2.1.2 With an anticipated time off the unit less then 2 hours, the

TGC Protocol should be maintained. 3.9.2.1.3 With an anticipated time of being off the unit of greater than 2

hours, should have the TGC Protocol maintained if they have TPN/PPN or enteral tube feedings infusing. Patients that do not have TPN/PPN infusing require the insulin drip to be discontinued and the rate of the supplemental dextrose decreased by half. This does not require a physician order.

3.9.3 Interruption of enteral feeding for NPO status requires implementation of D20W IV at 40 cc/hr unless otherwise specified.

3.10 Patients on TGC Protocol remaining in the ICU and converting from IV insulin drip to SC SSI, should receive a SC dose of regular insulin one hour

prior to discontinuation of the IV insulin drip. 3.10.1 The patient on an IV insulin drip of 2 units/hour, administer 4 units SC regular insulin. Recheck glucose 4 hours after initial SC dose and follow the SC Sliding Scale Insulin.

3.10.2 The patients on an IV insulin drip of < 2 units/hour, administer 2 units SC regular insulin. Recheck glucose 4 hours after the initial SC dose.

3.11 Patients on TGC Protocol preparing for transfer should begin conversion to SC SSI 12 hours prior to the anticipated time of discharge.

3.11.1 An order for the following should be placed in the chart by an a authorized prescriber:

3.11.1.1 Discontinue the TGC Protocol. 3.11.1.2 Initial SC dose of regular insulin and new SC Sliding

Scale. 3.11.1.3 Frequency of glucose checks with SC Sliding Scale.

3.11.2 Supplemental IV dextrose should be discontinued except for TPN/PPN or enteral tube feedings.

3.11.3 Initial SC dose of Regular Insulin should be administered one hour prior to discontinuing IV insulin drip. 3.11.4 Check glucose level four hours after initial SC dose, then as

ordered per SC Sliding Scale. 3.11.5 Glucose levels may be allowed to rise as high as 200mg/dl in

anticipation of discharge from the ICU.

4.0 REPORTABLE CONDITIONS: 4.1 Blood glucose ≤ 60 or ≥200 mg/dl. 4.2 Signs and symptoms of hypoglycemia/hyperglycemia. 4.3 Loss of IV access for insulin drip or nutritional infusions.


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4.4 IV pump failure with resultant bolus. 5.0 DOCUMENTATION:

5.1 Document glucose levels and unit glucose meter # (if used) in the lab results section of Eclipsys. 5.2 Document insulin administration according to Medication Administration

Policy. 5.3 Document implementation of the TCG Protocol.

5.3 Document any possible adverse reactions/reportable conditions to the medication administered

5.4 Document two RN validation of IV insulin drip on initiation, and with rate and bag changes. This verification shall be documented on MAR or HFFS

6.0 SEE ALSO: 6.1 Education

6.1.1 Micromedex Intranet Knowledge Base 2003. 6.1.2 Johns Hopkins Hospital Formulary

6.2 Related Protocols 6.2.1 SICU/WICU/IMC Insulin Drip Protocol 6.2.2 Vesicant Administration Protocol 6.2.3 Medication Administration Policy 6.2.4 Enteral Tube Feedings Protocol 6.3 References 6.3.1 Van Den Berghe, G., Wouters, P., et al. Intensive Insulin Therapy in Critically Ill patients. N Engl J Med 2001; 1359-1367.

7.0 Review Cycle: 8.0 Approval Date:

revised 12/31/03, 1/6/04, 1/12/04, 1/16/04, final 1/21/2004 for review


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THE JOHNS HOPKINS HOSPITAL ORDER SHEET

Tight Glucose Control (TGC) Protocol To maintain serum glucose 80 to 110mg/dl

1. Insulin dosing • Initiate TGC Insulin IV drip (100 Units regular insulin/100cc) • All insulin drip adjustments must be doubled checked and witnessed by 2 RNs as

per the Department of Nursing Medication Administration Policy 2. Nutrition

• Choose one (Notify resident with any changes) D20 at 40cc/hr IV D10 at 80cc/hr IV D5 at 160cc/hr IV D5LR at _______ cc/hr IV TPN or PPN as ordered Enteral tube feeds as ordered

3. Operating Room or Procedures/Tests: • Maintain TGC Protocol for patients going to the Operating Room • Maintain TGC Protocol for patients going for Procedures that are receiving

TPN/PPN or enteral tube feedings • Maintain the TGC Protocol for patients going to Procedures (other than a

monitored OR) with an anticipated time off the unit less then 2 hours • Discontinue the insulin drip and decrease the rate of supplemental dextrose by

half, for patients going to Procedures/Tests (other than a monitored OR), with an anticipated time off the unit of greater then 2 hours and do not have TPN/PPN infusing.

• Start D20 at 40 cc/hr when enteral feeding is stopped for NPO status, unless otherwise ordered.

4. Notify House Officer:

• Glucose < 60 mg/dl or >200 mg/dl • Signs and symptoms of hypo/hyperglycemia • Loss of IV access for insulin drip or nutritional status parenteral nutrition

Rev jan 12 04, jan 16 04, jan 21 04

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Ventilator Bundle Ventilator Bundle Slides Measurement ... · Ventilator Bundle . Ventilator Bundle Slides . Measurement Slides . Ventilator Bundle Performance Improvement . Tight