Research Article: Successful Implementation of a Perioperative Glycemic Control Protocol in Cardiac Surgery: Barrier Analysis and Intervention Using Lean Six Sigma

Date Published: September 6, 2011

Publisher: Hindawi Publishing Corporation

Author(s): Elizabeth A. Martinez, Raul Chavez-Valdez, Natalie F. Holt, Kelly L. Grogan, Katherine W. Khalifeh, Tammy Slater, Laura E. Winner, Jennifer Moyer, Christoph U. Lehmann.


Although the evidence strongly supports perioperative glycemic control among cardiac surgical patients, there is scant literature to describe the practical application of such a protocol in the complex ICU environment. This paper describes the use of the Lean Six Sigma methodology to implement a perioperative insulin protocol in a cardiac surgical intensive care unit (CSICU) in a large academic hospital. A preintervention chart audit revealed that fewer than 10% of patients were admitted to the CSICU with glucose <200 mg/dL, prompting the initiation of the quality improvement project. Following protocol implementation, more than 90% of patients were admitted with a glucose <200 mg/dL. Key elements to success include barrier analysis and intervention, provider education, and broadening the project scope to address the intraoperative period.

Partial Text

Methods to develop evidence-supported practices for quality improvement projects became prevalent in the 1990s, yet, two decades later, significant gaps persist in translating the best evidence into practice [1]. This is particularly true for complex disease states (such as insulin resistance) coupled with complex procedures (such as cardiac surgery). In addition, the majority of clinical research has focused on understanding disease processes and identifying effective therapies, yet there is relatively little emphasis on the implementation side. The available literature tends to recommend using system-wide changes to alter provider behaviors [2]. System change is becoming increasingly important as public reporting of compliance with evidence-based protocols and “pay-for-performance” reimbursement gain ground. Yet, ultimately, to change provider behavior, we must first understand facilitators and barriers. To this end, Cabana and colleagues [3, 4] explored physician barriers to the implementation of best practices and proposed general approaches to modifying individual provider behavior. Unfortunately, such generalizations do not address the unique complexities of the intensive care unit (ICU), where a confluence of provider preferences, patient comorbidities, and system factors make an interdisciplinary local approach more effective.

In 2003, as part of a performance improvement project, we evaluated the current process of glycemic control in the CSICU of a tertiary care center. To manage the project, data were collected prospectively with periodic chart reviews using standardized tools during the study period June 2003–2007. After Institutional Review Board (IRB) approval, additional electronic data were captured retrospectively for this publication according to the processes outlined next.

The implementation timeline and five real-time audit data are presented in Figures 1 and 4. Data from the real-time audits informed the ongoing quality improvement process while the retrospective analysis was used to evaluate the overall impact of the LSS project. The seven data collection periods (Baseline, Phases 1–5, and Final) are included in the retrospective analysis (Table 2 and Figures 1, 6, and 7).

This work represents the use of LSS methodology to successfully implement a glycemic control protocol in a CSICU. While many articles have highlighted the evidence to support perioperative glucose control in cardiac surgical patients [15, 18–21] and some have included actual protocols utilized [18, 22, 23], we are unaware of any prior articles detailing the multifaceted process of implementing a comprehensive insulin protocol in a critical care setting. This paper demonstrates that LSS methodology can be an effective tool in achieving new process implementation. In particular, we emphasize how barriers to success can be successfully identified and overcome.

Implementation of evidence-based practices is very complex and failure prone. Evidence is necessary but not sufficient to complete implementation: the evidence provides the “what to do” but not the “how to do.” The lack of translational science providing the path from evidence to the bedside may be the reason why the literature suggests it takes one to two decades for evidence-based guidelines to be incorporated into clinical practice [1].