Improving Staff Compliance with ICU Protocols
Improving Staff Compliance with ICU Protocols
Abstract & Commentary
By Leslie A. Hoffman, PhD, RN, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.
Leslie Hoffman reports no financial relationship to this field of study.
Synopsis: A rewards program improved adherence to ICU protocols and produced a change in culture in the ICU that sustained protocol adherence rates at > 90% for two years.
Source: Plost G, et al. Am J Crit Care. 2007;16:153-157.
In the institution in which this study took place, an audit revealed that adherence to 9 ICU protocols ranged from 62% to 77%. The protocols focused on a variety of patient care needs including sedation/analgesia, DVT prophylaxis, enteral nutrition, insulin administration, skin care, stress ulcer prophylaxis, and ventilator weaning. To effect change, the multidisciplinary ICU management team first developed a plan that encouraged nurses to recommend implementation of the protocols to physicians, a step that was unsuccessful.
The team next developed a rewards program designed to motivate change. Each staff member of any adult ICU with a 90% or greater compliance rate for the 9 selected protocols after 4 months of monitoring received a reward. The rewards were a catered dinner party, drawings at the party for individual awards (stethoscopes, personal digital assistants, gift certificates) and the grand prize which was a continuing education trip valued at $3,000.
With implementation of the rewards program, nurses became more assertive. They proactively recommended protocols to physicians or handed them directly to physicians during rounds. An audit of all ICUs found that protocol adherence ranged from 85-92% across ICUs at one month and 94-99% at four months. When the same tool was used to monitor compliance 1 and 2 years later, adherence was 91% and 95%, respectively. Initially resistant to change, physicians verbalized appreciation of the user-friendly, time-saving protocols and improved patient outcomes.
Commentary
Unfortunately, adherence to guidelines is low, despite evidence that protocols developed from these guidelines can positively impact patient outcomes. A number of reasons for this have been proposed in explanation, eg, poor dissemination of guidelines, disagreement concerning content, resistance to "cookbook medicine," and a low expectancy of benefit. In the present study, the ICU multidisciplinary team began with traditional approaches to improve adherence. Classes were provided by nurse educators, protocol booklets were developed, and staff nurses were required to demonstrate knowledge by passing an examination. The ICU medical director led educational presentations for physicians, and information order sheets were developed and conveniently placed in the charting area.
When these approaches failed, the team turned to the literature. They elected to use a behavioral (motivational) approach that was prompted by the knowledge that clinicians can be grouped into four categories that characterize their willingness to change. "Seekers" (2.5%) respond by changing practice based on knowledge-oriented strategies. "Traditionalists" (12.5%) require educational and behavioral strategies. "Pragmatists" (28%) require facilitative and directive behavioral oriented strategies. The largest group, termed "receptives" (57%) require facilitative behavior-oriented strategies and directive strategies.
Their conclusion was that 97% of clinicians require an approach beyond education. Therefore, the highly successful rewards program was implemented. In this institution, rewards prompted the nursing staff to become more proactive in discussing and prompting use of the protocols. The effort had a positive impact on physicians who supported collaborative efforts to revise and develop new protocols and nurses who now volunteer for protocol development projects.
In the institution in which this study took place, an audit revealed that adherence to 9 ICU protocols ranged from 62% to 77%. The protocols focused on a variety of patient care needs including sedation/analgesia, DVT prophylaxis, enteral nutrition, insulin administration, skin care, stress ulcer prophylaxis, and ventilator weaning.Subscribe Now for Access
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