As highlighted in our last blog, the need to improve our glycemic management practices within the inpatient setting is clear. It’s better for both the patient and hospital, but the challenge comes with implementing quality improvement initiatives. Throughout the EndoTool User Group Meeting, five elements to drive adoption were identified as the keys to success in your glycemic management optimization initiatives: data, champions, education, standardization and review of processes.
The first step to any quality improvement project is data. As Dr. Fogel, Medical Director of OR Services at the Carilion Clinic, stated, “if you don’t know where you are, you don’t know where to go, and you don’t know how to get there.” Hospitals need to track their performance on blood glucoses in target range, time to achieve target glucose range and rates of hypoglycemia, among other glucometrics.
It also was highly encouraged to regularly publicize this data with everyone on the staff to encourage positive care practices, such as timeliness of glucose checks. As Dr. Burgess, Founder and Inventor of EndoTool, pointed out, 80% of low blood glucose readings occur when the blood glucose was checked more than five minutes late. To make the metrics more meaningful to staff, he suggested that hospitals start tracking the patient days between hypoglycemic events. For example, a drop of hypoglycemia from .9% of blood glucose readings to .3% of blood glucose readings may not appear to be so significant to some. However, if it is presented as a drop from one hypoglycemic event every 111 patient days to 1 hypoglycemic event every 360 patient days, that is easily understandable to everyone and becomes more patient-centric.
With the data to know how you are performing and what needs to be done, the only way to make that achievable is to have champions supporting the initiative to improve glycemic management. With the heavy lift at hand, one champion is not enough. It needs to be a collaborative effort among a number of key roles. A glycemic optimization committee is advised to help in driving the initiative, but there also needs to be a champion for each department and unit. Also, getting nursing leadership’s support is imperative. As Dr. Fogel mentioned during his session, the one nurse who has the clout and reputation both in the hospital and unit will make a big difference in achieving successful adoption.
The roles needed to be involved in implementation:
- Project Manager
- Clinical Lead
- Education Lead
- Physician Champion
- Nursing Leadership
- Medical Director
- Safety and Quality Improvement
- Diabetes RN/Educator
- Clinical Pharmacist
- Registered Dietitian
- Nutrition Services
- Lab Supervisor
- Clinical Informaticist
- Nursing Champion From Each Unit
- Medical Director From Each Unit
The hardest component of any new quality improvement initiative is the implementation. Once you have the data, plan, and champions on board, you need to put it all into action, and that requires a significant amount of education, especially for diabetes management.
With glycemic management often not part of core curriculum for medical or nursing students, there is a gap in knowledge in the best practices of care, and as a result, methods such as sliding scale insulin remain common because it’s easy and has been historically used. To overcome the knowledge deficit, attendees suggested mandatory competency tests to ensure all healthcare providers have a sufficient understanding of appropriate diabetes care. Additionally, resources such as short videos on how to order EndoTool, tip cards, and interactive case studies have been successful. For training, it also helps to have peers lead the session, such as physician to physician, to stress the importance and answer questions specific to their role.
4. Standardization of Workflow
If there is a snafu with implementation, it’s often due to discrepancies in workflow. Proper glycemic management requires a systematic approach, particularly with subcutaneous insulin, where there needs to be even more coordination with the food delivery, the blood glucose check and delivery of bolus and correction insulin. The education will help instill the standardization, but another major contributor is integration and interfacing with the hospital electronic medical record (EMR). During a panel session, Scott Bates, RN, MS, BSN from Orangeburg Regional Medical Center, who utilizes Cerner, and April Willis, RN, MSN from CaroMont Health, who uses Epic, discussed how further integrating and interfacing EndoTool with their EMR significantly improved the workflow and aided in nurse satisfaction by removing the double documentation.
5. Review of Processes
Once you’ve implemented the quality improvement initiative, the job is not done. It’s time to look back at the data to see if you’ve moved the bar and determine why you progressed or need continued improvement in certain areas. To truly determine where you stand, Monarch Clinical Services Specialist , Chris Santry, RN, MSN, CCRN, suggested setting smart goals, meaning goals that are Specific, Measurable, Achievable, Relevant, and Time-based. With these goals and data at hand, you can benchmark and continue improvement efforts, and it is recommended that you regularly review the data and goals. During a nursing leadership panel featuring Lisa Clement-Bryant, MSN, RN, CDE, CPT from CaroMont Health, RaShaye Freeman, DNP, FNP-BC, CDE, ADM-BC from HCA and Cynde Adorno, BSN, RN, CCRN from Grand Strand Medical Center, they recommend at least monthly team meetings with the clinical leads to review and continue to set new goals.
So while quality improvement is challenging, it’s not impossible. More hospitals are making glycemic management initiatives a priority