Overcoming Barriers on the Way to Evidence-Based Practice

Define

The project began in September 2014. The vice president of nursing served as the project sponsor and an endocrinologist served as the project leader. A pharmacist and the patient safety officer served as facilitators and were the Six Sigma green belt project leaders. An independent consultant was the Six Sigma master black belt coach. A charter was developed to address the business case for the project, opportunity statement, scope, membership, and preliminary plan. At that time, the rate of hypoglycemia at the Center was 15% for patients receiving an anti-diabetic agent. The project focus was to investigate why the rates of hypoglycemia were as high as they were. The target goal was to reduce the rate of hypoglycemia to 9% by July of 2015. This goal was in alignment with the HEN goal to reduce hypoglycemia by 40%.

Measure

The next step in the process was to assess the current practice state. Data were collected from 40 medical records to assess hypoglycemia frequency, blood glucose measurement, mealtime delivery, and insulin prescribing and administration. Blood glucose monitoring, communication of blood glucose values, food service delivery, and insulin administration were observed directly. Nursing staff members were surveyed about their attitudes toward existing glycemic control practices.

Data were stratified by multiple factors, including nursing unit, time of day, type of anti-diabetic agent, treatment with steroids, diminished swallowing capacity, and presence of nausea and vomiting. No correlation of hypoglycemia with a single stratification was identified; it was being caused by variable and systemic multifactorial practices of diabetes management. A flowchart of the process demonstrated a very complex system that involved six staff members performing 10 separate steps (Figure 1). Many possible points of failure were noted. The team hypothesized that implementation of standardized evidence-based glycemic control practices would reduce the incidence of hypoglycemia.