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Running head: MANAGEMENT OF HYPOGLYCEMIA AND HYPERGLYCEMIA 1 A Multidisciplinary Team Approach to Process Improvement for the Management of Hypoglycemia and Hyperglycemia Kendall M. Williamson University of Florida College of Nursing
MANAGEMENT OF HYPOGLYCEMIA AND HYPERGLYCEMIA 2 Abstract Introduction : A Diabetic Management Work Group (DMWG) was established at the North Flo rida/South Georgia VAMC to assess the quality of the processes related to documentation and administration of sliding scale insulin (SSI) and medications for hypo and hyper glycemia. P urpose : To a ssess the effects of the proces s change on documenta tion of SSI administration and the usage of glucose gel I ntravenous (I V ) dextrose, and r egular insulin Method(s) : T he DMWG modified n the scheduled medication area versus the PRN medication area of the computerized medication record Additionally, glucagon and glucose gel were made available in the Pyxis. Data collected before and after the process change were compared to assess the effects of the process change on documentation Data included whether the patie nt was ordered insulin, the patient was given or not given insulin, and the frequency of administration of regular insulin, glu cose gel, and dextrose Resul ts : T here were a decrease in errors of omission a decrease in f requency of IV dextrose, and an increase in frequency of oral glucose gel. Conclusion : The process change was an effective way to improve administration of SSI insulin to patients who had documented hyperglycemia Oral glucose administration was enhance d and IV dextrose administration was decreased.
MANAGEMENT OF HYPOGLYCEMIA AND HYPERGLYCEMIA 3 A Multidisciplinary Team Approach to Process Improvement for the Management of Hypoglycemia and Hyperglycemia Introduction A large proportion of all hospitalized patients are being placed in jeopardy because of missed nursing care and errors of omission (Kalisch, Landstrom, & Williams, 2009). Specifically, errors in administering medication cause about 400,000 preventable injuries in hospitals and about $3.5 billion in extra medical costs a year (Colli ver, 2009). People with diabetes are more likely to be hospitalized and to have longer durations of hospital stay than those without diabetes (Moghissi Korytkowski, DiNardo, Einhorn, Hellman et al. 2009). However, d iabetes team intervention appears to r educe the hospital length of stay, improve glycemic control, and significantly reduce the rate of recurrent hospitalization (Koproski, Pretto, & Poretsky, 1997 ). Improved blood glucose control in the hospital setting also appears to reduce the duration of hospital stay and the hospital costs (Ahmann, 2004). The purpose of this paper is to present a thorough descr r ole in the study, discuss what the student learned and problems that occurred, and make recomme ndations for students w ho may participate in this study in the future Background At the North Florida/ South Georgia Malcom Randall Veterans Affairs (VA) Medical Center a high rate of errors related to the delivery of sliding scale insulin were brought to awareness in February of 2009 by a routine mock Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) survey The mock JCAHO surveyor and a VA pharmacist came together to assess the medication safety of the high risk drug such as insul in. Ten patients were randomly selected to review the administration of insulin over a consecutive three day period
MANAGEMENT OF HYPOGLYCEMIA AND HYPERGLYCEMIA 4 The findings of this review revealed a 90% error rate with respect to at least one error of omission. Due to this finding a Diabetic Manag ement Wor k Group (DMWG) was established to improve the steps in ordering, documentation, and nursing administration of diabetic medications The multidisciplinary DMWG consisted of physicians, pharmacists, nurses, nurse educators, and informatics. The DMWG then proposed a clinical performance improvement process cha nge in February of 2009. T his process change was initiated in February of 2010. Purpose The purpose of this study was to examine the effects of a clinical performance improvement proce ss change on the administration and documentation of sliding scale insulin and the usage of oral glucose and IV dextrose. Hypotheses The hypotheses for this study were that 1) errors of omission of SSI orders would decrease after the process change (e.g., if insulin was ordered and required based upon SSI orders, the insulin will be given and documented in the medication record) and 2) the process change would lead to an increase in use and administration of oral glucose and a decrease in IV Dextrose administration. Methods Study Design A quantitative retrospective comparative design was used to conduct this study. Sample There was no direct contact with human subjects. Previously collected, de identified numerical, data w ere reviewed. According to the Institutional Review Board (IRB) the study was a non human subject research with no interventions or interactions with a living person; no
MANAGEMENT OF HYPOGLYCEMIA AND HYPERGLYCEMIA 5 identifiable private data or information obtained in a form associable with the individual; no individuals became participants as healthy individuals, control subjects, patients, or recipients of a test article; and the study did not involve human subjects on whose specimens an investigational device is used (Institutional Review Board, 2007 ) Procedures As part of phase one of thi s study physicians order of SSI medication was changed to be a scheduled dose medication for after meals and before bedtime order s instead of a PRN (as needed basis) medication order in the computerized medication record (BCMA). The process of administering SSI in the BCMA was changed for nursing staff and the nurses and providers were educated about this process change and glucose gel as options for hypoglycemia and there w as an improvement in the availability of glucose gel and glucagon in the Pyxis the medication dispensing machine As part of phase two of this study the process change of documentation was reviewed by comparing two sets of data previous ly collected in tw o time periods; one from June August 2009 and another from May July 2010. D ata including the frequency of administration of oral glucose and Dextrose IV, percentage of sliding scale insulin coverage indicated and administered, and percentage of sliding sca le insulin coverage indicated and not administered. The information was completely de identified, numerical data that were stored in a locked cabinet in a locked office room in the VA Medical Center. Quality improvement chart reviews were completed at rand om on patient charts from seven different units. Analysis We reviewed and analyzed nineteen charts from Unit A, eight charts from Unit B, four charts from Unit C, twelve charts from Unit D, eleven charts from Unit E, eight charts from Unit
MANAGEMENT OF HYPOGLYCEMIA AND HYPERGLYCEMIA 6 F, and five charts from Unit G for the months of 2009. We reviewed and analyzed seven charts from Unit A, seven charts from Unit B, eight charts from Unit C, six charts from Unit D, six charts from Unit E, five charts from Unit F, and five charts from Unit G for the months of 2010. We specifically analyzed the total number of chemsticks, the number of chemsticks within normal limits, frequency of coverage indicated and done, and frequency of coverage indicated and not done. We also reviewed the frequency of administration of IV dextrose and oral glucose on the seven units for the months of 2009 and the months of 2010. We then compared the data from the months of June, July, and August of 2009 to the months May, June, and July of 2010. Results For the months of 2009 the percentage of sliding scale insulin coverage indicated and not administered for the seven units was as follows: unit A 39%, unit B 28%, unit C 21%, unit D 19%, unit E 27%, unit F 21%, and unit G 9%. For the months of 2010 the percentage of sli ding scale insulin coverage indicated and not administered for the seven units was as follows: unit A 17%, unit B 3%, unit C 11%, unit D 7%, unit E 18%, unit F 11%, and unit G 8%. In 2009 oral glucose gel was only administered twice while oral glucose gel was administered 74 times in 2010 In 2009 IV dextrose was administered 169 times compared to 41 times in 2010 Based on the results it is evident that the process change led to an improvement in the administration and documentation of sliding scale ins ulin by decreasing errors of omission. This also led to a decrease in the use of IV dextrose and an increase in the use of oral glucose. Conclusions The process change was an effective way to impro ve administration of SSI to patients who had documented hyperglycemia and had ordered SS I Oral glucose administration was enhanced and IV dextrose administration was decreased. This is clinically important because
MANAGEMENT OF HYPOGLYCEMIA AND HYPERGLYCEMIA 8 Orienta tion. I also filled out multiple WOC forms and completed the WOC application i n or der to begin reviewing data Another role o f mine was learning about and understanding the IRB process. Dr. Citty an d Dr. Zumberg completed the IRB paperwork while I was able to review the forms and wai t for the IRB approval. We then waited for VA approv al so that we could present our study and our findings. Upon UF and VA IRB approval, I was able to present the study a t the Southern Nursing Research Society (SNRS) conferen ce with my student partner In November we submitted an abstract to SNRS and waited for an acceptance to attend the conference The abstract was reviewed and accepted under the Top Student Poster disc ussion session. My student partner and I then created the poster for the study and attended the SNRS conference in Jacksonville, Florida. In order to complete the po ster we created data charts using the results of our study. The discussion session consist ed of eleven poster displays including our poster. We stood with our poster for the first 30 minutes while answering questions and explaining our study. We were then seated in front with the other participants to begin the 60 minute discussion. The discussion was monitored by two moderators who asked questions specifically to each participant. The audience was also able to ask questions to gain a better unde rstanding of each project. Our poster was eligible for a student poster award and although we did not receive an award it was an honor and a great experience participating in the Top Student Poster discussion session and attending the conference. What I l earned Thr oughout my role in the study I was able to learn about the research process, how to obtain IRB approval and the procedures needed to implement a research study. I learned that education is very important and without education the results and f indings of our study would be
MANAGEMENT OF HYPOGLYCEMIA AND HYPERGLYCEMIA 9 en tirely dif ferent. If the nurses had not been educated about this proce ss change our results may not have shown a decrease in errors of omission and our evidence would suggest that the process change was an ineffective way to improve administration and documentation of SSI. I also gained time management skills and utilized these skills to successfully contrib ute to the study. I learned about sustainability and what makes a project sustainable. With a multidisciplinary approach and a policy change involving the entire hospital sustainability is more likely to occur. Through my review of literature I learned that about 34% of preventable adverse drug events occur at the administration step of the medication process (Bates et al. 1995). This gave me a better understanding of the significance of our project and the importance of research. When nurses make medication errors they violate the value to first do no harm and fail to uphold the trust that patients place in nurses (Wolf, 1989). Throughout my experience I learned the importance of decreasing errors o f omission and upholding patient safety. Problems There were a few problems that occurred throughout th e study and the time I was involved working on the study. We ran into mu ltiple issues with the VA process including problems with computer access, paperwork, and training sessions. The paperwork that needed to be completed was tedious and very time consuming The completion of these forms and the many online training sessions hi ndered me from beginning my role access so I was unable to review data in the computer system and had to wait for the data to be printed out by a RN in Nursing Informatics or any other member of the DMWG. There were also schedulin g conflicts that arose throughout the study. During the DMWG meetings some members call ed in because they were unable to attend the meeting in person. I had to miss class in order to attend a mandatory safety orientation so I could continue working as a WO C
MANAGEMENT OF HYPOGLYCEMIA AND HYPERGLYCEMIA 10 employee and stay involved with the study. Another issue brought to awareness was the reliability of our findings. It was mentioned in one of the meetings that so me of the data may have involved non diabetic patients. Our study focused specifically on di abetic patients and if we included non diabetic patients in our data our results could be incorrect or skewed. In Februar y our study was almost halted because of some VA guidelines requiring that Valerie and I receive computer access. This was a very stre ssful period because we had to quickly complete more paperwork and make sure we had everything done to continue with the study. We also did not receive VA approval until February 7 th This left us with little time to prepare our poster for the SNRS conference. Student Recommendations The first recommendation I would make to a student wishing to continue this project next year would be to start early. The paperwork that needs to be completed takes a long time and if this process is started quic kly the student can begin collecting and analyzing data much sooner. I would also suggest starting early so the student can prepare for an abstract and submit it to the SNRS by the deadline to be considered fo r attendance at the SNRS conference. T he student s should be interest ed in patient safety and control of hyperglycemia and hypoglycemia if they would like to participate in the study This study focuses on patient safety and decreasing errors of omission so if the student is interested in this topic they can contribute more and get excited about their involvement. They will also be enthused with the results that can give them a better understanding about the significance of the study and research overall. An other suggestion to the questions. Staying calm and using teamwork will decrease stress and help get everything accomplished. The final recommendation I have is to att end the SNRS conference. This is a
MANAGEMENT OF HYPOGLYCEMIA AND HYPERGLYCEMIA 11 wonderful opportunity and an amazing experience. The student will be able to mee t many role models who have made outstanding contributions to research and the nursing profession. Summary The DMWG was formed at the North Florida/South Georgia VAMC to improve the administration and documentation of SSI insulin and hypoglycemic medications. They initiated a d to have SSI be a scheduled medication order versus a PRN medication order in the BCMA. They also improved the availability of glucose gel and glucagon in the Pyxis hoping to decrease the use of IV dextrose. Previous collected data from the months June, J uly, and August 2009 (pre process change) was reviewed and compared to the previous collected data from the months May, June, and July of 2010 (post process change). After data analysis it was evident that t he process change was an effective way to improve administration and documentation of SSI, decrease the use of IV dextrose, and increase the use of oral glucose gel. Throughout my involvement in the study I was able to attend meetings, review data, create charts, and attend the SNRS conference. I learned about the research process, gained time management skills, and was able to make recommendations for future students to forest all any problems.
MANAGEMENT OF HYPOGLYCEMIA AND HYPERGLYCEMIA 12 References Ahmann, A. (2004). Reduction of hospital costs and length of stay by good control of blood glucose levels. Endocrine Practice 10 (2), 53 56. Retrieved from http://aace.metapress.com/content/lkrffgrd03nqmrwv/ Bates, D.W., Cullen, D.J., Laird, N., Peterson, L.A., Small, S.D., Servi, D., et al. (1995). Incidence of adverse drug events and potential adverse drug events. The Journal of the American Medical Association 274(1), 29 34. doi: 10.1001/jama.1995.03530010043033 Colliver, V. (2009). Retrieved from http://articles.sfgate.com/2009 10 28/news/17185347_1_medication errors integrated nurse leadership program ucsf program Institutional Review Board. (2007). I ntroductory questionnaire: Non human, exempt, t raining g rant, & center projects. Unpublished man uscript, Department of Research, University of Florida, Gainesville, Florida. Kalisch, B.J., Landstrom, G., & Williams R.A. (2009). Missed nursing care: Errors of omission. Nursing Outlook 57(1), 3 9. doi:10.1016/j.outlook.2008.05.007 Koproski, J., Pret to, Z., & Poretsky, L. (1997). Effects of an int ervention by a diabetes team in hospitalized patients with diabetes Diabetes Care 20 1553 1555. doi: 10.2337/diacare.20.10.1553 Moghissi, E.S., Korytkowski, M.T., DiNardo, M., Einhorn, D., Hellman, R., Hirsch, I.B., et al. (2009). American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 32 1119 1131. doi: 10.2337/dc09 9029 Wolf, Z.R. (1989). Medication errors and nursing responsibility. Holistic Nursing Practice 4(1),
MANAGEMENT OF HYPOGLYCEMIA AND HYPERGLYCEMIA 13 8 17. Retrieved from http://journals.lww.com/hnpjournal/Citation/1989/11000/Medication_errors_and_nursing _responsibility.5.aspx