Background Glycemic control in critically ill patients decreases infection and mortality. While capillary blood glucose values are accurate in normotensive patients and correlate with arterial samples, patients on vasopressors have altered peripheral perfusion that may affect accuracy of capillary blood glucose values tested using point of care devices. Objectives To compare capillary and arterial blood samples using point of care testing (POCT) with arterial blood samples using the clinical chemistry lab in patients following cardiothoracic surgery, and to determine if vasopressor medications or diminished peripheral perfusion influenced the accuracy of POCT values. Methods In a prospective, convenience sample (n=50) of adult post-operative cardiothoracic patients on insulin and vasopressors, samples (n=162) were obtained simultaneously from capillary and arterial sites during insulin infusion and tested on both POCT and clinical chemistry lab, respectively. Quality of peripheral perfusion was recorded using a standardized scale. Clarke error grid analysis and ISO 15197 were used to analyze the level of agreement between the three samples. Two-way ANOVA was used to analyze differences in blood glucose values with respect to vasopressor use and peripheral perfusion. Results An unacceptable level of agreement was found between the capillary POCT and arterial samples tested in the clinical chemistry lab (only 88.3% of values fell in Zone A, or within the ISO 15197 tolerance bands). Arterial POCT showed 94.4% agreement with the clinical chemistry lab. Vasopressor use demonstrated a statistically significant effect on the accuracy of arterial blood glucose values (F=15.01; p= .0001). Conclusions Capillary POCT is not within acceptable limits of agreement with the clinical chemistry lab. Even when using the more accurate arterial blood with POCT, patients with >2 vasopressors demonstrate significantly less accuracy as compared to patients on fewer vasopressors. Using the clinical chemistry lab may be safer for insulin titration in these patients.

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Background Prolonged intubation after cardiac surgery increases the risk of morbidity and mortality and lengthens hospital stays. Factors that influence the ability to extubate patients with speed and efficiency include the operation, the patient’s baseline physiological condition, workflow processes, and provider practice patterns. Local Problem Progression to extubation lacked consistency and coordination across the team. The purpose of the project was to engage interprofessional stakeholders to reduce intubation times after cardiac surgery by implementing fast-track extubation and redesigned care processes. Methods This staged implementation study used the Define, Measure, Analyze, Improve, and Control approach to quality improvement. Barriers to extubation were identified and reduced through care redesign. A protocol-driven approach to extubation was also developed for the cardiothoracic intensive care unit. The team was engaged with clear goals and given progress updates. Results In the preimplementation cohort, early extubation was achieved in 48 of 101 patients (47.5%) who were designated for early extubation on admission to the cardiothoracic intensive care unit. Following implementation of a fast-track extubation protocol and improved care processes, 153 of 211 patients (72.5%) were extubated within 6 hours after cardiac surgery. Reintubation rate, length of stay, and 30-day mortality did not differ between cohorts. Conclusions The number of early extubations following cardiac surgery was successfully increased. Faster progression to extubation did not increase risk of reintubation or other adverse events. Using a framework that integrated personal, social, and environmental influences helped increase the impact of this project.

Introduction: Delirium is common in cardiac intensive care units due to illness related stress, polypharmacy, interventions, excessive light and noise, disorientation and sleep disruption. Delirium assessment is poor due to limited nursing knowledge and the lack of integrated features in electronic health platforms (EHR) to support accurate assessment and documentation. Hypothesis: We hypothesized that education on use of the Confusion Assessment Method for the ICU (CAM-ICU) and enhanced features in the EHR would improve the ability to detect delirium in our CTICU. Methods: We conducted a QI intervention using a PDSA approach and pre-post evaluation design. In the Planning phase audited 100 randomly selected charts to determine baseline documentation of delirium. We conducted a survey of nurses’ knowledge of delirium and documentation criteria and identified a knowledge deficit. In the Do phase, a multi-stage educational initiative was used to address delirium awareness, knowledge, and CAM-ICU documentation competency. Enhancements in the EHR were made to enable accurate assessment, documentation and scoring using embedded logic. Post-intervention audits (n=100) were performed. Results: Survey respondents (n=64) averaged 31 years old (SD 1.4) and had 6 years nursing experience on average (median=3, range <1-40). Nurses believed patients with delirium had longer ICU LOS and worse outcomes and patients would benefit from screening. Most lacked training in delirium screening (88.1%, n=58). Baseline documentation of at least one assessment of delirium was 44% (n=44) and post-intervention was 100% (p<0.001). Accuracy of CAM-ICU assessments at baseline was challenging to determine due to a single field (YES/NO/UTA) in the EHR, however, positivity of pre-intervention assessments was 1% (n=1) and post- intervention at least 1 positive CAM score was recorded in 33% (n=33) of patients (p<0.001). Conclusions: Findings suggest that a multi-stage educational intervention paired with EHR integrated scoring logic improves awareness, knowledge and documentation accuracy for delirium in the ICU, which may improve patient safety and ICU outcomes. Better assessment and documentation may improve patient safety and ICU outcomes.