Running Head: QUALITY IMPROVEMENT

Leadership Strategy Analysis Quality Improvement Belinda Bonter, Mindi Groenendyk, Amanda Hubbard, Julie Walker Ferris State University

QUALITY IMPROVEMENT Abstract The following paper addresses a clinical need at a local healthcare facility. The need is in reference to the time period between morning blood glucose checks and the subsequent dosing

and administration of insulin. Evidence will show that insulin should be dosed and administered within an hour after this check and within thirty minutes of the meal. This timing is important for prevention of complications such as hyperglycemia and hypoglycemia. Ideas for how such a change could be implemented and the team that should be involved are also presented in this paper. Finally, the authors also explain how such a change will have a positive impact on patient outcomes and how this plan can be evaluated.

QUALITY IMPROVEMENT Quality Improvement At every inpatient hospital today, blood glucose monitoring is performed for all diabetic patients. Each organization and unit establishes a policy by which blood glucose levels are

checked and by which insulin is administered. This paper discusses a scenario in which too great a time exists between blood glucose checking and the dosing and administration of insulin. The authors establish evidence for this clinical need and discuss the strategies by which this process can and should be improved. Clinical Need The timing of insulin administration is based on the type of insulin being given. Most of the time, in acute care settings, sliding scale insulin (SSI) is given just prior to meals in order to help reduce blood glucose levels after food is consumed. However, in some facilities glucose levels are checked an hour or two before the meal, and insulin is dosed upon this information. Checking blood glucose levels two hours before administering insulin can be deadly. In two hours, blood glucose levels can change rapidly in some patients. The safety of the patient could be compromised by dosing insulin based on a two hour old blood glucose level. Checking blood glucose (BG) levels just before administration of insulin can decrease the safety issues associated with insulin administration. In a study done by Trotter, Conaway, and Burns (2013), The study demonstrated timing of blood glucose measurement does affect the required SSI dose. The closer the blood glucose was obtained to the patient's meal time, the lower the glucose value (lower insulin requirement). Results suggest BG value and insulin dose administration should be accomplished immediately prior to meal time. BG levels checked right before insulin administration showed that less insulin was required than when the glucose readings were taken an hour or more before the

QUALITY IMPROVEMENT insulin was administered. Had the insulin been given based on a BG reading done too far in

advance of the meal, a patient could have an adverse reaction because of too much insulin given. As stated in the article by Lampe, Penoyer, Hadesty, Bean, and Chamberlain (2014), if BG testing is performed too far before the nurse gives the insulin, the dose may be insufficient for glycemic control and can lead to hyperglycemia or hypoglycemia, (pg. 166). This is considered a medication error if insulin is given and an adverse event happens based on a BG level that was outside of the recommended time frame. It was found in this study that the ideal timing for BG testing was within one hour prior to the meal, (Lampe et al. 2014, pg. 166). When the investigators of this study used a thirty minute time window that was recommended in another study, 87% of the blood sugar checks were done outside of that 30 minute window (Lampe et al. 2014, pg. 166). With the BG timings being so far in advance of insulin dosing, the diabetic patient is facing detrimental effects. High and low blood sugars can be seen based on BG levels done too far in advance. This is a patient safety issue that can be corrected by following guidelines recommended by the type of insulin being given to the patient. Interdisciplinary Team Investigating any clinical issue will require other disciplines to become involved. In this scenario, the interdisciplinary team should consist of a staff nurse, the nursing director of the unit, the medical director of the unit, a pharmacist, and a member of nutrition services. These team members should meet together to share each ones concerns and ideas regarding this matter. The concerned staff nurse should be included due to his or her hands-on experience with this issue. The nursing director will have concerns about how changing times of the blood

QUALITY IMPROVEMENT glucose checks will impact his or her staff routines. Further, both the nursing director and the medical director are responsible for the patients outcomes. The medical director may have to write new orders depending on the policy of the organization. Additionally, he or she will

continue to monitor hemoglobin A1C for each diabetic patient that is under his or her care for the long term. This will ensure that blood glucose levels are being maintained at a stable level. A pharmacist should be involved in this quality improvement process. Different types of insulin have varying times of onset, peak, and duration. The pharmacist will be a great resource for the specific type(s) of insulin being administered at this facility. Finally, nutrition services should also be included. This is important due to blood glucose being impacted by snacks and meals. Staff must ensure that the morning fasting blood glucose level is truly fasting and does not conflict with the timing of snacks or meals being delivered by nutrition services. Data Collection A fishbone diagram is an effective method of summarizing a brainstorming session, (Yoder-Wise, 2011, p.399). In determining poor outcomes as a part of the significant amount of time between glucose checks and administration of insulin, the fish bone diagram was selected to see complications or effects of the clinical problem indicated in diagram 1. Diagram 2 indicates some strategies in fishbone structure to improve the issue. Some further data collection may be requiring a flow chart. A flow chart could be used to document blood glucose measurement timing and the amount of insulin at meal time over a certain period. The interdisciplinary team looks at all the possible poor outcomes and possible strategies to improve the problem. One strategy is selected while continuing to collect data. During the data collection period, evaluation continues to see if the appropriate outcomes are met (Yoder-Wise, 2011).

Diagram 1

QUALITY IMPROVEMENT Patients get hypoglycemia Increased chance for complications

Harder time to control blood sugars

Too much time between blood glucose checks and insulin administration and dosing

Overall dissatisfaction with hospital

Increased Death Rates

Increased hospital stay More money out of patients pockets

Diagram 2 Nurses check their own blood sugars for accuracy Hire more staff

Educate nurse Techs

Too much time between blood glucose checks and insulin administration

Review Compliance with the protocol of timing of sugars

Better communication about workload of blood sugars so they get done at the appropriate time and not too soon. Outcomes The goal of every diabetic individual is to have good blood glucose control. Unfortunately, many diabetics do not follow the proper timing when checking their blood sugars and taking insulin. If a patient is on a rapid acting type insulin, which is often used for sliding scale checks, it should be injected within 15 minutes before a meal or directly after the meal

QUALITY IMPROVEMENT

(American Diabetes Association, 2014). The ultimate outcomes for the patients would be for the person to test per their individual plan, and if using sliding scale insulin, to administer it per these recommended guidelines. The interval from time of insulin injection and eating a meal should be about 30 minutes, if the meal is eaten right away this results in a delayed hypoglycemic event (American Diabetes Association, 2014). By following the recommended guidelines it may decrease the episodes of hypoglycemia, which in turn will lead to better glucose control. Implementation Many factors play into the importance of correct timing of glucose checks as well appropriate insulin administration based on the glucose level. Data suggest that the most common causes of both hypoglycemia and hyperglycemia are deficiencies in the use and monitoring of insulin therapy, (American Society of Health-System Pharmacists, 2004, p.9). It is critical to come up with appropriate measures to be sure that of obtaining accurate blood sugars at the appropriate time. Some strategies to improve and correct the improper timing of blood sugar checks are measures such as reviewing compliance and data that shows when the blood glucose checks were done. Upon reviewing such information, the director of nursing for the unit should follow up with any individuals not following the protocol. Another strategy to improve monitoring is caregiver competency for nursing assistants and nurses. This may involve further education on the importance of timed blood sugar checks and the consequences of inaccurate blood sugars. Caregivers should also be informed of appropriate and inappropriate results in order to know when an emergency exists. The organization should also define time limits in which it is unsafe to administer insulin after a given period of time. After such time, the

QUALITY IMPROVEMENT

blood sugar check must be repeated to ensure safe administration of insulin (American Society of Health-System Pharmacists, 2004). Evaluation Every diabetic patient needs to have good documentation about not only their blood sugars, but also the amount of insulin received, and time of day along with any symptoms that they may be feeling. The American Association of Diabetes (2014) recommends keeping a diary or journal so that the diabetic care team is aware of everything that occurs in case something needs to be changed. In order to properly evaluate the changing of when blood sugars are checked and when patients receiving their insulin, the outcome standards need to be followed. Documentation on each patient that receives sliding scale insulin needs to be reviewed after a one-month time frame to see any correlation with the recommended techniques for monitoring and insulin control. Scholarship The aforementioned clinical problem and strategies reflect that there is abundant evidence regarding the timing of blood glucose checks as related to insulin dosing and administration. In order to ensure a high standard of care, the facility can adjust the timing of blood glucose checks to be within one hour of the meal, as recommended by Lampe et. al (2014). The interdisciplinary team can use various means at their disposal to ensure that outcomes within the facility are improving. Many facilities take advantage of electronic medication administration records (EMAR), and these software programs offer reports that can be periodically reviewed. The team can review not only the results of the blood glucose checks, but also the time at which the check was performed. Further, the team can then review insulin dosing based on the blood glucose check.

QUALITY IMPROVEMENT Conclusion This paper has shown that there is supporting evidence for a change to be made in the timing of blood glucose checks at this facility. Strategies have been presented to assist staff

members in making this change. An interdisciplinary team will be established in order to trouble shoot the new policy and evaluate it over time. It is clear that a facility that desires to provide a high standard of care and deliver positive outcome would certainly be interested in quality improvement in this area.

QUALITY IMPROVEMENT References American Diabetes Association (2014). Diabetes care: insulin administration. Retrieved from http://care.diabetesjournals.org/content/27/suppl_1/s106.full American Society of Health-System Pharmacists. (2004). Recommendations for Safe Use of Insulin in Hospitals (pp. 1-41). Retrieved from http://www.ashp.org/s_ashp/ docs/files/Safe_Use_of_Insulin.pdf Lampe, J., Penoyer, D., Hadesty, S., Bean, A., & Chamberlain, L., 2014. Timing is everything: Results to an observational study of mealtime insulin practices. Clinical Nurse Specialist, 28(3), 161-167. doi:10.1097/NUR.0000000000000045 Trotter, B., Conaway, M., & Burns, S., 2013. Relationship of glucose values to sliding scale insulin (correctional insulin) dose delivery and meal time in acute care patients with diabetes mellitus. MedSurg Nursing, 22(2), 99-105.

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Yoder-Wise, P. S. (2011). Leading and Managing in Nursing (5th Ed.). St. Louis, MO: Elsevier.