Overcoming Barriers on the Way to Evidence-Based Practice

Methods

In 2014, after participating in a Florida Hospital Association Partnership for Patients Hospital Engagement Network (HEN) project, the Center examined adverse events associated with administration of insulin, specifically hypoglycemia (blood glucose less than 70 mg/dL). One goal of the HEN project was to reduce harm from adverse drug events by 40%. The Institute for Safe Medication Practices and The Joint Commission have identified insulin as a high-alert medication, which means it is more likely to be associated with harm than other medications. High-alert medications cause harm more often, the harm they produce is more serious, and they “have the highest risk of causing injury when misused” (The Joint Commission, 2007). Hypoglycemia is most often preventable. The association between hypoglycemia and patient harm, including mortality, is well documented (Rubin & Golden, 2013; Brutsaert, Carey, & Zonszein, 2014).

The current rate of hypoglycemia in the United States is 3.5%–8% among non-critically ill patients with diabetes (Rubin & Golden, 2013). The Center’s rate of hypoglycemia was 15% for patients treated with an anti-diabetic agent. Hypoglycemia was defined as a patient experiencing one or more events of blood glucose of < 70 mg/dL during an inpatient admission.

Hypoglycemia rates at the Center were monitored regularly by surveillance of administration of intravenous dextrose. Use of intravenous dextrose was 27% among patients with hypoglycemia. The medical records were reviewed for all inpatients who received an anti-diabetic agent at the Center. During a four-month period, 30% of all inpatients were treated with an anti-diabetic agent. Fifteen percent of these patients experienced blood glucose of < 70 mg/dL.

The Center was using a sliding-scale insulin (SSI) regimen, although there is little evidence that the protocol is effective for managing overall glycemic control. A Medline search of 52 clinical studies from 1966 to 2003 showed no evidence of benefit from SSI (Nau, Lorenzetti, Cucuzzella, Devine, & Kline, 2010). In 2009, the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) issued a consensus statement recommending that—rather than using a sliding scale—non-critical hospitalized patients should be managed with components of inpatient subcutaneous insulin regimens that have a basal, a nutritional, and a supplemental (correction) element (Moghissi et al., 2009). Additionally, the AACE and ADA stated that “prolonged therapy with SSI as the sole regimen is ineffective in the majority of patients and potentially dangerous in those with type 1 diabetes” (Moghissi et al., 2009).

The Center’s quality mission is to become the leader in the delivery of superior-value oncology care and to fulfill the Institute of Medicine’s six aims of quality care by providing care that is safe, effective, efficient, timely, patient centered, and equitable. Using the SSI protocol was, therefore, not consistent with the Center’s mission and exposed a compelling opportunity to improve quality. The Center took immediate steps to evaluate its practices for managing glycemic control.

Senior leaders at the Center expressed their support for this quality improvement project by creating a multidisciplinary task force of inpatient nurses, an endocrinologist, physicians and advanced practice professionals from the internal medicine program, the patient safety officer, pharmacists, dietitians, and food service staff. Because Six Sigma lends itself well to complex, organizationwide problems (Tague, 2005), it was selected as the process improvement methodology. The Six Sigma structure has three components: process management, process design/redesign, and performance improvement (Pande, Neuman, & Cavanagh, 2000). Process management was integral to the success of the project as the focus required changes in the organizational culture and ongoing management of varied operational practices across the organization. Process owners included the medical staff, nursing, pharmacy, and dietary. The collaboration of these key stakeholders was essential for developing solutions to improve existing processes and/or design new ways to manage glycemic control.

Performance improvement involved a five-step problem-solving process called DMAIC (define, measure, analyze, improve, control). The DMAIC process is a sequential, data-driven process that systematically separates relevant from non-relevant data to identify and validate root causes of problems. It also aids in the development and implementation of effective and sustainable solutions. Use of Six Sigma adds scientific rigor, reduces process variability, and aids in the successful translation of evidence-based practices to the bedside (Martinez et al., 2011).