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CE Article

Empowering critical care nurses to improve Compliance with protocols in the intensive care unit

Corresponding author: Delores Privette Nelson, St. John Medical Center, 1923 S Utica, Suite 803, Tulsa, OK 74104 (e-mail: dnelson{at}sjmc.org).

	Abstract

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•Background Practitioners often do not comply with evidence-based protocols.

•Objective To improve compliance with evidence-based protocols in an intensive care unit.

•Methods A baseline compliance range was obtained by using a sampling of 9 protocols for a 100% audit of 35 beds in an adult intensive care unit. Nurses were given positive rewards to promote an initiative to improve compliance with protocols. The original audit tool was used to assess compliance at intervals during a trial period and for a follow-up audit 3 years after implementation of the initiative.

•Results One month after the initiative was started, compliance with protocols increased from a range of 62% to 77% to a compliance of almost 90%. Within 4 months, the compliance rate increased to a mean of more than 95%. Three years later, the compliance rate was greater than 90%.

•Conclusion Extrinsic rewards improved compliance with protocols and resulted in a change in the culture in the intensive care unit that had a cumulative outcome.

Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following objectives: Compare traditional and nontraditional approaches for obtaining compliance with protocols. Describe the directive strategy used to improve compliance with protocols. 3. Identify the positive rewards associated with increased compliance with protocols. To read this article and take the CE test online, visit www.ajcconline.org and click "CE Articles in This Issue."

For the purposes of this report, the term protocol is used to describe a model of evidence-based, best-practice methods established, tested, and implemented by the interdisciplinary management team (the medical director, the nursing director, 2 nurse managers, 1 data collector, and 1 secretary) of the adult intensive care units (ICUs) at St. John Medical Center, Tulsa, Okla. The development of evidence-based protocols, with resultant improvements in patients’ outcomes, earned the center national recognition for high-performing ICUs from the National Coalition on Health Care, the Institute for Healthcare Improvement, and the Society of Critical Care Medicine in 2002.³ Even with national commendation for innovative protocol development, initial compliance with protocols remained average at best in the medical center in 2001.

	Problem Definition:

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Low Rate of Compliance With Protocols
The ICU interdisciplinary management team initially tried traditional approaches to obtain compliance with the protocols:

• nurse educators provided classes and developed protocol booklets for all nursing staff,
  
• all critical care nurses were required to demonstrate protocol competency by passing a competency examination,
  
• the ICU medical director provided instructional presentations for hospital physicians in all medical sections to familiarize the physicians with the protocols, and
  
• information and order sheets were placed conveniently in the physicians’ charting area.
  

After extensive education and emphasis on the importance of protocols, observation still indicated that physicians did not use the protocols consistently. The ICU management team wanted more definitive information on the level of compliance in the ICUs and requested the assistance of the hospital’s registered nurse data analysts. These nurses, trained and certified by Project IMPACT (a national database developed by the Society of Critical Care Medicine and currently owned and managed by Cerner Corp, Kansas City, Mo), selected a sampling of 9 protocols to assess the extent of the problem (Figure 1).

View larger version (27K): [in this window] [in a new window]   Figure 1 Protocol compliance audit tool used at St. John Medical Center, Tulsa, Okla. Abbreviations: DKA, diabetic ketoacidosis; DVT, deep vein thrombosis.

The data analysts reviewed 100% of the charts for the 35 adult ICU beds and compared the number of times each protocol was implemented with the number of times the protocol should have been implemented. The baseline compliance rate in 2001 ranged from 62% to 77% (Figure 2).

View larger version (15K): [in this window] [in a new window]   Figure 2 Protocol compliance.

• the nurses were experts in patients’ care and were a constant presence in the ICU,
  
• the nurses could use critical thinking skills to determine when a protocol should be implemented, and
  
• the nurses understood the evidence underlying the protocols.
  

Staff nurses were designated to take the lead in protocol compliance improvement.

 

The management team encouraged the nurses to recommend implementation of protocols to the physicians when indicated rather than accepting nonstandard orders from the physicians. The result was immediate resistance from many medical staff members, general discontent, and refusal to collaborate despite the previous educational efforts. Physicians’ responses ranged from "It’s cookbook medicine" to "I have my own way" and "I didn’t know about them" to "I forgot." Nurses in the ICU were accustomed to managing patients’ care, but taking the lead in implementing change was new to them, and the physicians’ negative responses to the protocols was daunting for even the experienced critical care nurses. The ICU management team then considered behavioral approaches patterned after a reinforcement method.

Two methods^5,6 can be used to motivate changes in behavior: knowledge-oriented strategies, such as education, and behavior-oriented strategies, such as facilitative strategies (removing barriers to change) and directive strategies (using rewards, penalties, and real-time reinforcement).

Clinicians can be grouped into 4 learning categories: seekers, receptives, traditionalists, and pragmatists.^5,6 These categories are defined by each clinician’s belief in evidence versus experience as the basis of knowledge, willingness to diverge from common or previous practice, and sensitivity to the pragmatic aspects of managing workload and patient flow. Seekers (2.5% of clinicians) respond by changing their practice patterns on the basis of knowledge-oriented change strategies such as scientific meetings, guidelines, and journal articles. Traditionalists (12.6% of clinicians) require knowledge-oriented and both facilitative and directive behavior-oriented strategies. Pragmatists (27.9% of clinicians) require facilitative and directive behavior-oriented strategies. Receptives (57% of clinicians) require facilitative behavior-oriented strategies and will respond to directive behavior-oriented strategies.

Tangible rewards were received by every nurse in units achieving 90% protocol compliance rates.

 

In summary, 97.5% of clinicians require some type of behavior-oriented change strategy in addition to knowledge-oriented change strategies for meaningful change to occur.

	A Process Improvement Initiative

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The ICU management team devised a directive strategy to empower the ICU nurses to enact change. Positive reinforcement was used to counteract the negative reinforcement the nurses were receiving from the medical staff. According to the plan, each staff member of any adult ICU with a 90% compliance rate for 9 selected protocols after 4 months of monitoring received a reward.

The rewards were a catered dinner party for the entire ICU staff, drawings at the party for individual rewards for everyone (stethoscopes, personal digital assistants, gift certificates, and scrubs), and a grand prize for a nurse from each ICU (medical, surgical, and cardiac). The grand prizes were continuing medical education trips valued at $3000 each.

	Results

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Positive rewards helped the nursing staff become more assertive. Once rewards were in place, nurses and unit secretaries placed protocols on all appropriate patient charts for the physicians to sign. If that method was not successful, the nursing staff took active measures to obtain physicians’ compliance with protocols. Nursing staff recommended protocols at the bedside and handed protocols directly to the physicians while asking the physicians to sign the protocols. Nurses were so motivated to achieve compliance with the protocols that they sometimes followed physicians to discuss protocol use even as the physicians were leaving the unit.

Nursing staff became more assertive, patient survival rates increased, and intensive care unit costs decreased.

 

After 1 month the data analysts used the baseline audit tool to repeat a 100% sampling of charts tracking the 9 protocols. In 1 month, compliance increased to a range of 85% to 92%, and by the fourth month the improvement ranged from 94% to 99% (Figure 2). After the 4-month monitoring period, staff from the 3 ICUs received their rewards and the rewards program ended. The same audit tool was used to track compliance yearly to determine whether the improvement was sustained. Compliance rates remained high (91%–95%) 1 year and 2 years later.

Increased use of protocols led to higher survival rates for patients and decreases in ICU costs as con-firmed by the Project IMPACT critical care database. Project IMPACT uses methods reported by Rapoport et al⁷ to benchmark national ICU outcomes. This method provides a 2-dimensional graphic display conveying severity-controlled values for patients’ survival and resource use; the Mortality Probability Model at time of admission is used to determine severity, and weighted hospital days are used for resource use. Project IMPACT confirmed a sustained cost reduction of $350 000 per bed per year for our ICUs. Additionally, the number of patients treated in the ICUs increased 50% without increases in beds or staff.

A total of 3000 patients were treated annually in our adult ICUs before implementation of protocols. After implementation, 4500 patients were treated each year, and currently 5000 patients are treated. In addition, patients are admitted to an ICU that consistently performs above average in national comparisons, as evidenced by Project IMPACT comparative reports.⁷

	Discussion

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Short-term, extrinsic rewards elicited a desired change in behavior. Compliance with protocols not only was obtained but also was sustained over time. Initially resistant to change, physicians finally verbalized appreciation of the user-friendly, time-saving protocols and improvement in patients’ outcomes. The ICU quality improvement initiative expanded. Staff physicians began suggesting new protocols and asking for hospital-wide protocols. Development of protocols evolved into a more collaborative interdisciplinary team approach. Nurses, physicians, and other staff members now work together drafting and updating protocols. The critical care nurses’ discovery of previously untapped self-confidence, strength, and autonomy did more than promote compliance with protocols. The nursing staff has reported a continued empowerment as they take an active role in developing protocols, suggest new protocols, and volunteer for protocol development projects.

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FINANCIAL DISCLOSURES
None reported.

	REFERENCES

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1. Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients [published correction appears in Mayo Clin Proc. 2005;80:1101]. Mayo Clin Proc. 2004;79:992–1000.[Medline]
2. Garcia R, Jendresky L, Colbert L, Bailey A. 48-month study on reducing VAP using advanced oral-dental care: protocol compliance, infection rates, LOS, mortality, and cost. Am J Infect Control. 2006;34:E47–E48.
3. Beresford L. Decreasing costs by improving care: data-driven quality improvement programs in three ICUs. In: Accelerating Change Today (ACT) for America’s Health. Washington, DC: National Coalition on Health Care and Boston, Mass: Institute for Healthcare Improvement; September 2002:8–12. Available at: www.nchc.org/materials/studies/CareintheICU2.pdf. Accessed December 11, 2006.
4. Cleary BA. Supporting empowerment with Deming’s PDSA cycle. Empowerment Organ. 1995;3:34–39.
5. Wyszewianski L, Green LA. Strategies for changing clinicians’ practice patterns: a new perspective. J Fam Pract. 2000;49:461–464.[Medline]
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7. Rapoport J, Teres D, Lemeshow S, Gehlbach S. A method of assessing the clinical performance and cost-effectiveness of intensive care units: a multi-center inception cohort study. Crit Care Med. 1994;22:1385–1391.[Medline]

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