Transcript Quality of Care Initiative blood glucose 2010

ABSTRACT
Objective:
The primary objective was to evaluate the timing of our current in-patient
process between BG monitoring, insulin administration and bedside meal
delivery. A second objective was to create workflows that would allow for
this process to be completed within a 30 minute window. Third objective
was to create protocols to guide staff with the most current evidence based
practice.
• Nurse Driven process of BG monitoring, meal delivery ,and insulin
50
45
44
Study
Baseline
40
37
35
30
n
6
7
25
20
15
10
3
2
10
5
0
Mean
(minutes)
Standard
Deviation
(minutes)
43.67
24.45
Baseline
Baseline
9/2/09 to 9/10/09
09/02/09 to
09/10/09
4th
Awareness
Time Study
04/12/10
to 04/15/10
04/12/10
to
04/15/10
Nurse5thDriven
Time Study
07/26/10
to 08/05/10
07/26/10
to
08/05/10
Difference
Between
Baseline and Nurse
Driven
10.75
7.17
32.94
20.57
Blood glucose to insulin being administered
120%
97%
100%
80%
Baseline
9/2/09 to 9/10/09
65%
Awareness
4th
Time Study
04/12/10 to 04/15/10
40%
39%
Nurse
5th
timeDriven
study
07/26/10 to 08/5/10
39%
22%
22%
3%
3.
4.
5.
6.
ADA position statement. (2010) Standards of Medical Care in Diabetes-2010. Diabetes Care.33(1). S11-51.
Moghissi, ES, et.al. (2009). American Association of Clinical Endocrinologists and American Diabetes Association Consensus
Statement on Inpatient Glycemic Control. Endocrine Practice. 15(4). 1-17.
Maynard, G., Umpierrez, G.(2008) Introduction: Overview of efforts and lessons learned. Journal of Hospital Medicine. 3 (5).
S1-S75.
Potter, PA & Perry, AG (2008). Fundamentals of Nursing Seventh Edition. Mosby: St. Louis, Missouri.
Clement, S. et al. (2004) Management of Diabetes and Hyperglycemia in Hospital: Diabetes Care. 27(2). 553-591.
Levetan C, et al. Impact of Pramlintide on Glucose Fluctuations and Postprandial Glucose, Glucagon, and Triglyceride
Excursions Among Patients with type 1 Diabetes Intensively Treated with Insulin Pumps. Diabetes Care 2003; 26:1-8.
• The process measure improvement s listed above also resulting in
outcomes improvement with a decrease in mean CBG and increase in
percent of glucose readings within target range
<0.000
1
LIMITATIONS
The limitations to this study are as follows:
1. The time in motion studies took place over 5 days and BG numbers
were utilized as the n value.
2. Only a sub acute unit was studied not generalizable to other units.
3. Study completed in an Academic Level 1 Trauma medical center
and results can not be generalized to other centers.
4. Staff were aware of when the study was conducted.
5. Study tools were rudimentary and not precise. Cell phones used
for timing.
0%
0%
ACKNOWLEDGEMENTS
% <=30 minutes
% 31 - 60 minutes
1.
2.
3.
% >= 61 minutes
4.
5.
6.
METHODS
1.
2.
administration coupled with education, policies, and process changes
resulted in significant improvement in timing between BG monitoring and
insulin administration and near 100% adherence to guidelines
13%
20%
Results:
We found a number of discrepancies with BG timing, meal tray delivery and
insulin administration. Staff obtained BGs >30 minutes prior to meal 49%
of the time, ranging from 166 minutes before meal to 98 minutes after meal.
Meal timing was inconsistent; delivery to floor varied by 15-30 minutes each
day, followed by tray audits taking ≥15 minutes on average. Outcomes
measures for these same time periods showed a decrease in mean BG
from 160.40 to 150.64. Other significant results shown in graphics to right.
REFERENCES
Pvalue*
Nurse Driven
60%
Method:
This was a quality improvement workflow project on an adult inpatient unit
where approximately one-third of patients receive insulin. We used time-inmotion studies and process mapping to quantitate and define our current
process and to assist in creating effective interventions. We designed and
instituted interventions including standardization of processes and meal
delivery times. We developed a standardized nursing protocol for insulin
delivery and BG monitoring. In the last stage we instituted nurse driven
processes including glucose monitoring, meal delivery, and insulin
administration. Process and outcomes measures were collected over one
year.
CONCLUSIONS
Mean Time Between Blood Glucose to
Insulin Administration
Minutes
Background:
We investigated the timing problems associated with insulin administration,
blood glucose (BG) monitoring and meal tray delivery on a sub-acute
medical surgical unit in the only Academic Medical Center, Level 1 Trauma
Center in the state of New Mexico. It was noted that BG monitoring did not
coincide with meal delivery. Insulin administration was not coordinated with
meal delivery and or BG monitoring and often would occur greater than 30
minutes after the delivery of the meal tray. There were no protocols in
place for standards of practice regarding BG timing and insulin
administration. We believed these process discrepancies were resulting in
worse BG outcomes.
RESULTS
Study
Baseline
n
Mean (mg/dL)
Standard
Deviation
(mg/dL)
5494
160.40
75.82
Nurse Driven
4896
150.64
67.12
Difference
Between
Baseline and
Nurse Driven
9.76
P-value*
95% CI
(mg/dL)
99% CI
(mg/dL)
<0.0001
(7.01, 12.51)
(6.15, 13.37)
Figure 2: Discharge Clinic Visit Status
Yvette Sena, Operation Management Specialist, University of New Mexico Medical Group, Quality & Clinical Process Improvement.
Margaret Saiz Program Planning Manager, University of New Mexico Medical Group, Quality & Clinical Process Improvement
J Rush Pierce Jr. MD MPH, Associate Professor, Section of Hospital Medicine, Department of Internal Medicine, University of New
Mexico School of Medicine.
Cristina Murray-Kresnan, MS, Research Assistant Professor of Internal Medicine, University of New Mexico Health Sciences Center
Biostatistical support provided by the University of New Mexico Clinical & Translational Science Center (CTSA 1ULRR031977-01)
The management and staff of 4 West sub-acute medical surgical unit at the University of New Mexico Hospital, pictured below