Improving Inpatient Glycemic Control by

Introduction

kjohannes — 2017-04-06 21:14:39 UTC

Welcome to my capstone presentation on glycemic control in non-critically ill hospitalized patients!

About the Issue

kjohannes — 2017-04-06 21:15:07 UTC

Inpatient glycemic control is an issue for diabetic patients on a local medical-surgical unit (C. Kollarik, personal communication, April 6, 2017)
Maintaining proper blood glucose (BG) levels is challenging when diabetic patients are hospitalized due to
- Acute illness
- Medication changes
- Inconsistent carbohydrate consumption
- Improper timing of blood sugar monitoring and insulin administration (Magali & Johnston, 2011)
Poor glycemic control worsens patient outcomes and increases healthcare costs (Ross et al., 2014)

What Does the Literature Say About Inpatient Glycemic Control?

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Glucose variability was linked to higher mortality rates in follow-ups of hospitalized diabetic patients (Timmons, Cunningham, Sainsbury, & Jones, 2016)
Hyperglycemia is a risk factor for surgical site infections (Martin et al., 2016)
Perioperative hyperglycemia untreated with insulin is linked to increased risk of reoperative interventions, infection, and death (Kwon et al., 2013)
≥3 days of inpatient hypoglycemia significantly increases length of stay (Jones, Timmons, Cunningham, Cleland, & Sainsbury, 2017)

Current 5B Practice for Inpatient Glycemic Control

kjohannes — 2017-04-06 21:16:49 UTC

Insulin administration
- BG measurement/insulin administration sometimes not coordinated <30 minutes pre-prandial
  - Impairs therapy's effectiveness (Engle, Ferguson, & Fields, 2016)
- Fearing hypoglycemia, insulin sometimes held unnecessarily, causing hyperglycemia (M. Roncal, personal communication, April 6, 2017)
RNs notify physicians of BG <70 or >400 mg/dL, which facilitates treatment adjustments
- Persistent hyperglycemia often unreported unless >400, so hyperglycemia often remains unaddressed (M. Roncal, personal communication, April 6, 2017)
Diabetes education
- No standardized referral system for diabetes educator causes underutilization (Ryder et al., 2014)

How Can Nurses Potentially Affect Inpatient Glycemic Control?

kjohannes — 2017-04-06 21:17:33 UTC

Being knowledgeable of factors affecting blood glucose (nutrition status, disease process, medication regimen) and understanding insulin pharmacology supports good nursing judgments about insulin administration/glycemic control (American Association of Clinical Endocrinologists, n. d.)
Altering nursing workflow facilitates timely insulin administration and improved therapy effectiveness (Engle, Ferguson, & Fields, 2016)
Referring patients to a diabetes educator can improve diabetes management (Healy, Black, Harris, Lorenz, & Dungan, 2013)
Nurses can advocate for evidence-based practice for glycemic control via interdisciplinary teams (Rodriguez et al., 2014)

Barriers to Change

kjohannes — 2017-04-06 21:18:07 UTC

Comfort with current methods
- Basal-bolus insulin administration viewed as more difficult than sliding scale insulin (I. Gonzales, personal communication, April 6, 2017)
- Nurses cannot determine insulin orders, so must persuade doctors to discontinue SSI/increase basal-bolus use
Time and costs of electronic referral system implementation
Cost of hiring more educators, who may be needed to accommodate increased demand (Ryder et al., 2014)
Additional tasks added to RN and dietary mealtime workflow may be seen as a burden
Attending educational seminars may also be perceived as extra work

References

kjohannes — 2017-04-06 21:18:45 UTC

Reflection #1

kjohannes — 2017-04-06 21:19:25 UTC

These recommendations would require staff support for their success
Our curriculum's modules from the Institution of Healthcare Improvement explained that presenting supportive data, such as showing the change's successful implementation in other hospitals, might positively affect opinion (2016)
I used this strategy for my recommendations, such as by detailing how altering workflow positively impacted glycemic control elsewhere
As a nurse, I may lead efforts for change in my workplace, and I must support these changes with evidence to convince others of their value

Recommendation #3

kjohannes — 2017-04-27 17:25:13 UTC

Hold educational seminars for nurses and providers to increase knowledge on glycemic control, insulin administration practice, inpatient goals for blood glucose levels, and current glycemic best practice.

In one hospital, grand rounds hyperglycemia education of healthcare professionals led to

Improved self-reporting of diabetes competence
Reported plans to changes to practice related to glycemic control (Moghissi et al., 2015)

Recommendation #2

kjohannes — 2017-04-27 19:08:07 UTC

Create a hospital-wide interdisciplinary glycemic control committee in which nurses can promote best practice.

Interdisciplinary glycemic committees can champion evidence-based hospital practices (Rodriguez et al., 2014)
- Nurses can promote:
  - Reduction of sliding scale insulin therapy use, which increases glycemic variability and only treats hyperglycemia retroactively (Badlani et al., 2014)
- Increased use of basal-bolus insulin regimen (Fig. 3), which provides superior glycemic control (Fig. 4) and consists of
  - Basal (long-acting) insulin
  - Meal (nutritional) bolus insulin
  - Corrective insulin

Recommendation #4

kjohannes — 2017-04-28 00:15:27 UTC

Implement an electronic system to identify candidates for diabetes educator referrals.

SPAH has only one inpatient diabetes educator, with no standardized method of referring patients for her services
An electronic assessment/referral system (Fig. 5) increased one hospital's use of the nursing educator team from 83 to 452 patients/month (Ryder et al., 2014)
Inpatient diabetes education is associated with decreased length of stay (Flanagan, Moore, Baker, Wright, & Lynch, 2008)
Involvement of a nursing educator paired with an endocrinologist increased the diabetic patient percentage in good glycemic control from 46% to 75% (Koproski, Pretto, & Poretsky, 1997)

Reflection #2

kjohannes — 2017-04-28 02:12:18 UTC

Nursing leadership often entails improving quality of care while managing costs, as explained in our leadership text (Sullivan, 2014)
Improving glycemic control may reduce healthcare costs by reducing infection rates and length of stay (Ross et al., 2014)
In nursing leadership roles involving maintenance of a balanced budget, I must remember that costs cannot be reduced at the expense of quality care
In actuality, improving quality is often the key to a hospital's financial success (Sullivan, 2014)

Automated Referral Systems to Diabetes Educator Team

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Fig. 4. Ismail-Beigi, F. (2016). Inpatient insulin administration [Online image]. Retrieved from http://www.medscape.org/viewarticle/728190_transcript

kjohannes — 2017-04-30 15:46:26 UTC

Fig. 5. Referral criteria for diabetes team. Adapted from

Ryder, B., Burbridge, W., Braycotton, L., Ryder, B., Cull. M., Davies, P. Paijat, D., Basu, A., & Lee, B. (2014). Inpatient diabetes: Do-it-yourself electronic referral system to support and enhance the Think Glucose project. Practical Diabetes, 31(5), 194-196.

Basal Bolus Vs. Sliding Scale Insulin

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Fig. 3. Adapted from Badlani, S., Ford, W. T., Yu, D. J., Brogan, G. X., Pollack, C. V., & Volturo, G. A. (2014). Evidence for basal-bolus insulin versus slide scale insulin. Current Emergency Hospital Medicine Reports, 2014(2), 26-34. doi: 10.1007/s40138-013-0032-4

kjohannes — 2017-04-30 19:43:56 UTC

Recommendation #1

kjohannes — 2017-04-30 20:09:31 UTC

Alter mealtime insulin process, with nurses performing glucose checks, insulin administration, and diabetic tray delivery.

In current practice (Fig. 1), BG checks/insulin administration often occur outside 30-minute pre-prandial timeframe due to lack of coordination between staff.

In one study, workflow modifications (Fig. 2) led to

Increased meal insulin administration < 30 minutes of glucose checks
Reduction of extreme hyperglycemia (>300 mg/dL)
Increase of patients with percent perfect BG (70-180 mg/dL) (Engle, Ferguson, & Fields, 2016)

kjohannes — 2017-04-30 20:44:41 UTC

Fig. 1. Current mealtime insulin administration workflow on 5B

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Fig. 2. Proposed modifications to mealtime insulin administration workflow

Conclusion

kjohannes — 2017-05-01 22:48:34 UTC