EP - Exemplary Professional Practice

EP7EO: Care Delivery System(s)-Describe and demonstrate two (2) improvements in the practice setting that occurred as a result of the use of internal experts or external consultants.

External Consultants

Jersey CityMedicalCenter developed a strategy to lower medical device and equipment costs while reducing the amount of environmental waste that these supplies generate. Reprocessing companies offer services that reduce the purchase of new devices which can generate significant cost savings for healthcare facilities. The approach with reprocessing is to convert single use devices (SUDs) into reusable devices. These reprocessed devices typically cost 50% less than the cost of a new device.

A team was assembled to review the potential initiative. Primary issues that the team focused on included:

  • Quality and safety of reprocessed devices
  • Legal accountability for failed devices
  • Potential financial budgetary impact

The FDA rulings have closely monitored reprocessing centers and have carefully regulated what can and cannot be reprocessed. They have established guidelines related to quality, safety and accountability. The MedicalCenter determined to find a company that would meet our high standards of quality and safety. The team included members from the three departments that would be the most affected; Cardiac Catheterization Laboratory, Operating Room and Gastrointestinal Laboratory. The following were the team selected:

EP7EO-Table 1

Nurse Champions were selected from the units to monitor the process as well as report problem areas. Lists of noninvasive devices were selected, for example, tourniquet cuffs and pulse oximetry clips and some invasive items such as, biopsy forceps, trocars and orthopedic shavers. Mr. Mueller, our consultant assisted with the educational roll-out to the units and with the physicians. The nurse champions, as well as Mr. Mueller would trouble shoot problem areas.

The outcome of this venture resulted in a cost savings that progressed over a two year period, as well as an environmental savings. Review the graphics below:

Reprocessing 9/09 to 9/10

The second graphic is for the current twelve month period to September 5, 2012. Comparing the two reports, JCMC increased its overall reprocessing in just two years from an estimated savings of $161,811.00 in 2010 to $271,277.00 today. A small portion of this increase was represented by discovering new product categories within which to reprocess, such as the EP Laboratory, however, the bulk of the savings growth came from the determined efforts of nursing and staff to take the existing program to the next level. For example, in the two year period OR staff collection of energy devices such as Ligasure and Harmonic scalpel have more than doubled while trocar collection increased six-fold, representing an increase in annual savings of almost $50,000.00 from just these two categories alone.

Reprocessing 9/10 to 9/12

Environmental Savings (2011-2012)

Environmental Savings (2011-2012)

Internal Consultants

A trial was developed to evaluate a newly modified insulin drip protocol in a small sample of medical and surgical intensive care (ICU) patients prior to house wide implementation of the protocol. The American Diabetes Association and the American Association of Clinical Endocrinologists jointly recommend higher thresholds for the initiation of insulin therapy and a higher target glucose range for critically ill patients. A multidisciplinary approach was taken to modify the current critical care infusion protocol to achieve the target glucose range of 140-180 mg/dL. The revised protocol was expected to be more sensitive to patients with prolonged elevation in blood glucose. The objectives of this trial were:

  • Evaluate the new modified insulin drip protocol and identify areas of improvement prior to hospital-wide implementation
  • Evaluate the educational needs of the critical nurses and identify interventions that will reduce the likelihood of medication errors

The Internal Consultants for this process were Sandy Liu Pharm D and Nan Rao Pharm D. These two pharmacists round with the medical team, provide services to the nursing staff and assist with various clinical projects. They have assisted in the development and implementation of many clinical guidelines and protocols at the MedicalCenter.

The interdisciplinary team consisted of:

EP7EO-Table 2


The insulin infusion protocol was modified based on the following factors: current glucose target recommendation, consideration for insulin resistance, ease of use and adaptability. The published protocols were reviewed and the Davidson Protocol was selected for adaptation. The physician order sheet (Appendix 7EO-A) and the nursing infusion records (Appendix 7EO-B) were revised to incorporate the new protocol. Guidelines were also developed and used as a reference for the clinical staff (Reference 7EO-A).

Revised Insulin Management Using Davidson Protocol

Revised Insulin Management Using Davidson Protocol

A ICU patients with non-diabetic ketoacidosis were eligible for inclusion in this trial as deemed appropriate by the physician. If a patient met the criteria for inclusion the critical care physician placed the patient on the protocol by initiating the Adult Insulin Intravenous Infusion Coverage Orders. Extensive education was performed on the usage of the protocol prior to the trial.

The results included the following:

EP7EO-Table 3

  • Total of six patients were trialed since May 17th through June 2010
  • Patients 1 and 2 did not have this data available because their glucose readings were within target upon initiation
  • The percentage of time spent above target glucose while on insulin infusion for each patient was: patient 1 (25%); patient 2 (24%); patient 3 (50%); patient 4 (40%); patient 5 (25%); patient 6 (26%)
  • Minimum glucose reading=82 mg/dL, no incidence of hypoglycemia
  • A total of 7 errors were found in the medication administration record (calculation based errors)

MICU Patients Hourly Glucose Reading on Insulin Drip

SICU Patients Hourly Glucose Reading on Insulin Drip


Discussion Findings

  • Due to implementation of the revised protocol, the initial trialing emphasized heavily on staff education
  • The errors found involved miscalculations or deviations from protocol which could have potentially influenced the patients’ goal
  • Fluctuations in blood glucose control were noted in both groups. This may be attributed to the wide range between glucose holding and reinitiating parameters. Lowering the threshold for resuming the insulin infusion may potentially have a positive impact on blood glucose control

Impact of results

The trial led to further revisions of the protocol and guidelines. Modifications to the protocol include:

  • Changes made to wording of protocol as per nursing recommendations
  • Standardized the insulin drip rate calculation rounding
  • Evaluated the opportunity to transition non-NPO patients from insulin drip to scheduled insulin
  • Lowered glucose threshold for RESTARTING insulin drip from 180 mg/dL to 140 mg/dL and maintained initiation threshold at 180 mg/dL.

A power point presentation was developed and presented to the critical care staff to further decrease any potential errors. House wide implementation of the new protocol began in early 2011. The involvement of the nursing staff and critical care physicians contributed to a successful and sustainable change of the revised insulin protocol into 2012.

“I am more comfortable using this evidence-based insulin drip protocol as opposed to the former insulin protocol. This protocol has successfully maintained our patients’ glucose level closer to the recommended range, as opposed to the previous protocol which I was always vigilant for hypoglycemia. This new protocol has also been useful in establishing a therapeutic glucose range in a timely manner.”

Dr. David Flores, M.D.