Overcoming Barriers on the Way to Evidence-Based Practice

Analyze

The project team analyzed the process for managing glycemic control. Flowcharting revealed that it involved many steps and was highly variable, with problems that included variation in the timing of obtaining pre-prandial glucose (+/- 90 minutes before meals), lack of consistency in meal delivery time, and lack of recording of the patient’s carbohydrate intake. Wide variation in prescribing was noted in chart reviews, comprising the use of the SSI protocol, multiple types of anti-diabetic agents within the hospital formulary, and lack of adherence to evidence-based insulin prescribing practices. At the onset of this project, the hospital did not have an established order set that incorporated the evidence-based insulin prescribing practice, which includes basal, prandial, and correctional insulin modalities.

A survey measuring awareness of evidence-based practice revealed that 78% of staff members falsely believed that SSI was effective in preventing hypoglycemia. A cause-and-effect diagram established that factors contributing to the rate of hypoglycemia included lack of adherence to evidence-based practice and problems with blood glucose monitoring. Root causes were verified through medical record review and direct observation. Countermeasures for variable blood glucose monitoring practices included education of best monitoring practices, implementation of carbohydrate documentation tools, and establishment of a carbohydrate monitoring process. Countermeasures for non-adherence with evidence-based insulin prescribing included competency education of prescribers, order set implementation, and establishment of a basal, prandial, and correctional insulin ordering process. Barrier and aids analysis was performed to identify and overcome forces that would prevent changes needed to implement improvements. Medical record reviews prior to implementing countermeasures indicated that 39 of 40 (97%) patients had variances in blood glucose monitoring practices and 38 of 40 (94%) had variances in evidence-based practice prescribing for insulin. The following targets for improvement were to be met by July 2015:

• Reduce the number of patients whose blood glucose was not monitored according to published best practices from 97% to 37%
• Reduce the number of patients whose insulin was not prescribed according to published evidence of best practice for hyperglycemia management from 94% to 29%

Improve

The project team developed an effective, safe, and feasible evidence-based insulin protocol. A 30-day pilot of the protocol was planned for a 22-bed oncology medical/surgical inpatient unit. Patients were managed by a select internal medicine team. The project goal was to use the new protocol to manage the care of 30 patients who were receiving insulin. The expected outcome was a 40% reduction in hypoglycemia.

Nurses, pharmacists, food service staff, and the medical staff were educated on the use of the evidence-based insulin protocol. Food service staff implemented a process to ensure consistency in the timing of meal delivery. Patient food menus were modified to include carbohydrate content. Oncology technicians (nursing assistants) were taught how to measure and record carbohydrate intake. Blood glucose monitoring was performed within 30 minutes of meal delivery and recorded in the medical record. Nurses were educated about how to calculate the insulin dose based on blood glucose value and carbohydrate intake. Education was provided for managing steroid-induced malglycemia and patients with transient nutritional imbalances. Insulin formulary choices were standardized. “Super users” from the nursing, pharmacy, and medical staff were available to provide clinical support and to assist in making daily adjustments to the insulin dosing protocol to minimize the risk of hypoglycemia.

Control

Daily process control measures were monitored to ensure the stability of the new changes and prevent process variability. Physicians, nurses, and pharmacists were given daily feedback on patient glycemic status and adherence to the protocol and process changes. Daily monitoring of nutritional intake, concomitant medications, and comorbid conditions were required in the event that adjustments to insulin dosing were needed to maintain a normal level of blood glucose.