Overcoming Barriers on the Way to Evidence-Based Practice

Using Six Sigma to implement a glycemic control protocol in an oncology setting.

By Diane Garry, RN; and Robert Bradbury, RPh

Introducing change to practice in healthcare is not easy. While it is well established that evidence-based care of patients can improve patient outcomes, prevent harm, and reduce healthcare costs by as much as 30%, adoption into practice has been slow (Melnyk et al., 2004). Although nurses and physicians support evidence-based care in principle, barriers to adoption include resistance from colleagues, nurse leaders, and physicians (Melnyk et al., 2004). More than one-half of physicians do not use available guidelines (Advisory Board, 2013). Their resistance is a key deterrent to the successful rollout of evidence-based practice.

In this article we aim to describe the approach that was used to transfer evidence into practice at an academic oncology center. To facilitate the systemwide adoption and sustainability of an evidence-based insulin protocol, the Six

Sigma process was used in a pilot in which patients being treated for cancer and hyperglycemia were treated with a basal/prandial/correctional insulin protocol instead of the center’s existing insulin sliding-scale protocol. It was believed that a structured scientific, fact-based approach for leading change, such as Six Sigma, would accelerate adoption of the protocol by the medical staff and provide a foundation for sustaining the change in practice. However, adoption of the new insulin protocol was not optimal. While the Six Sigma process proved useful in identifying root causes of abnormal glucose levels and reducing process variation and defects, changes in the center’s culture are still needed to fully implement the evidence-based protocol.

When implemented appropriately, Six Sigma is an effective tool for improving clinical outcomes, but it is not sufficient to sustain adoption of evidence-based practice. Changes to organizational culture are equally important. Time, auditing, and feedback, as well as the ongoing support of senior leadership, individual practitioners, and change champions, are all needed to effectively sustain practice change.

Cancer and malglycemia

The clinical management of patients with both cancer and malglycemia can be challenging. The two illnesses are difficult to treat separately, and in combination they may exacerbate each other (Psarakis, 2006). Malglycemia is defined as hypoglycemia (blood glucose less than 70 mg/dL), hyperglycemia (blood glucose of 126 mg/dL or greater), or glycemic variability (standard deviation of two or more blood glucose measurements of 29 mg/dL or greater) (Hammer & Voss, 2012). Findings suggest that malglycemia may have a negative impact on outcomes for hospitalized patients with cancer, increasing their rates of infection, mortality, length of stay, and toxicities, as well as decreasing their chances of survival (Storey & Von Ah, 2012; Umpierrez, 2002). Malglycemia in patients with cancer may be attributed to nutritional imbalances, high body mass index, high stress levels, infections, concomitant use of glucocorticoids, certain chemotherapeutic agents, cancers of the pancreas, and preexisting diabetes (De Vos-Schmidt & Dilworth, 2014; Hammer & Voss, 2012).

The prevalence of diabetes in the general population in the United States is 9% (NIDDK, 2014). Approximately 18% of all individuals with cancer have preexisting diabetes at the time of diagnosis (Hershey et al., 2014). A link between diabetes and cancer was first proposed in 1934 and has been investigated extensively (Zhang et al., 2012). A statement issued jointly by the American Cancer Society and the American Diabetes Association reports strong epidemiologic evidence suggesting that diabetes is a risk factor for certain malignancies, including cancer of the liver, pancreas, and endometrium; and to a lesser degree, cancer of the colon, rectum, breast, and bladder (Hammer & Voss, 2012; Habib & Rojna, 2013; Giovannucci et al., 2010; Zanders, Haak, van Herk-Sukel, van de Poll-Franse, & Johnson, 2015). It has been observed that patients with diabetes tend to show impaired response to cancer treatment (Braun, Bitton-Worms, & LeRoith, 2011). Exposure to hyperglycemia, insulin, and insulin growth factor (IGF-I) may stimulate the development or progression of cancer (Sandhu et al., 2002). Older adults with diabetes and high-risk stage 2 and 3 colon cancer experience significantly higher rates of mortality and cancer reoccurrence (Hurria et al., 2014). Patients with hypoglycemia have higher incidence of all-site cancer (Kong et al., 2014).

A plausible relationship exists between malglycemia and five major outcomes (infection, mortality, toxicities, survival, and length of stay) in patients with cancer who have diabetes (Storey & Von Ah, 2012). Based on these findings, it is incumbent upon oncology providers to be vigilant in preventing malglycemia and provide optimal care using evidence-based insulin care standards (Clement et al., 2004).

The goal of this article is to describe the implementation of an evidence-based insulin protocol at a 206-bed academic adult oncology medical center utilizing Six Sigma methodology. The Moffitt Cancer Center (the Center) is an academic medical center designated by the National Cancer Institute as a Comprehensive Cancer Center. The Center received American Nurses Credentialing Center Magnet® designation in 2014. Located in west central Florida on the campus of the University of South Florida, the Center’s mission is to contribute to the prevention and cure of cancer. The Center is dedicated to providing compassionate and effective patient care and emphasizes the concepts of patient- and family-centered care. The Center is licensed for 206 hospital beds.