Apr 20, 2020
Improving the care of patients with diabetes in Alberta hospitals — part 1
Take away messages:
- Diabetes management in hospital is complex, and requires a multidisciplinary approach with the patients participating in the decision making and care planning.
- Practice change requires an implementation or knowledge translation approach, addressing unit or site specific barriers and facilitators.
- Data (including audit and feedback) provides a powerful tool to identify a care gap, and demonstrate the impact of practice change.
What was the problem?
Approximately 20% of all adult patients in Alberta hospitals have either type 1 or type 2 diabetes. While Diabetes Canada recommends a blood glucose (BG) of 5–10 mmol/L for most patients with diabetes while in hospital, 2014 point-of-care testing (POCT) data revealed that over a third of BG tests in Alberta hospitals were above 10 mmol/L.
BG that is too high, or hyperglycemia, increases the risk of complications in hospital, including post-operative infections, pneumonia, diabetic ketoacidosis (DKA), and delayed wound healing. It also puts the patient at risk for long-term complications. In the same year (2014), a province-wide patient survey found that patients with diabetes were less satisfied with their hospital stay than patients without diabetes.
One cause of hyperglycemia in hospital is the common practice of prescribing subcutaneous sliding scale insulin (SSI). SSI does not prevent hyperglycemia; instead, it reactively addresses the patient’s high BG after it has occurred. Other known contributing factors to hyperglycemia include the discoordination of diabetes medication administration relative to BG testing and mealtime, and the overtreatment of hypoglycemia.
As in other hospitals across Canada and the United States, clinicians in Alberta hospitals have tolerated hyperglycemia, perhaps because the harm to the patient is not immediately evident, or perhaps because the patient’s other acute illnesses take precedence. This tolerance of hyperglycemia is very confusing for patients, as they are taught to keep their BG within range to avoid complications.
What did Alberta do?
In 2015, the Diabetes, Obesity and Nutrition Strategic Clinical Network (DON SCN)™ launched the Inpatient Diabetes Management Initiative (Figure 1 [PDF, 154.4 KB]), developed in collaboration with patients, provincial pharmacy, Nutrition and Food Services, provincial lab POCT, and multidisciplinary health care providers in zone operations. The provincial initiative was a multifaceted quality improvement approach, aimed at standardizing how diabetes is managed in hospital and improving glycemic management for hospitalized patients with diabetes.
Basal bolus insulin therapy
The initial priority was to implement basal bolus insulin therapy (BBIT), a method of ordering subcutaneous insulin injections that mimics the normal physiologic secretion of insulin, aiming to achieve target BG levels safely. This approach is proactive and tailored to the patient’s individual needs. For more than 16 years, Diabetes Canada has recommended BBIT as the preferred method for ordering subcutaneous insulin in hospital.
The provincial implementation strategy for BBIT was based on learnings from an attempted implementation in Calgary in 2012 and insights from other hospitals/jurisdictions across Canada. In 2012, an endocrinology fellow interested in improving the care of hospital patients with diabetes, as part of her residency and fellowship research projects and subsequent master’s thesis, attempted to implement BBIT in Calgary hospitals by creating an electronic BBIT order set and providing several education sessions. This practice change was initially adopted but was not sustained.
Did you know?
- 1 in 5 patients in hospital have diabetes
- 90% of these patients have type 2 diabetes
- 10% of these patients have type 1 diabetes
- 40% of all patients with diabetes admitted to hospital use insulin to manage their diabetes at home
- Even those patients not on insulin at home may benefit from insulin therapy in hospital
Focus groups conducted following the implementation identified several barriers to the practice change. In one focus group interview, a nurse who had learned about BBIT shared that she had asked the attending physician to order BBIT for a patient, and the request was not well received, because the physician felt at liberty to use subcutaneous SSI.
In 2014, a national environmental scan was conducted to gain insights from other Canadian hospitals that had implemented BBIT. Interestingly, the barriers to implementation shared by other hospitals were very similar to those identified following the Calgary implementation.
The provincial implementation strategy was developed guided by implementation (or knowledge translation) scientists. Knowledge translation (KT) is the science of moving evidence and research into everyday clinical practice. The implementation strategy includes a staged approach with activities suggested pre-implementation, during implementation, and post-implementation.
The strategy includes site readiness assessment and site-based champions from each of three disciplines—nurses, prescribers (including nurse practitioners), and pharmacists—who provide peer-to-peer education and address concerns as they arise. They are supported by their local administrative champions. As well, teams were encouraged to assess individual site, unit, or program barriers and facilitators to the practice change and address each barrier.
Sites were also encouraged to retire any pre-existing subcutaneous SSI order sets. The strategy further involves audit feedback, with pre- and post-implementation data that were shared with the whole team. Numerous resources to support this practice change were co-created by the DON SCN™ inpatient team and the early adopter sites, and were housed and made available online (see Additional Resources, below).
Prior to and after the implementation at early adopter sites, common barriers and facilitators were identified through interviews with the various multidisciplinary site champions. These barriers were mapped to specific solutions, andew website to assist new sites with their implementation.
Over the past four years, DON SCN™ has supported multidisciplinary teams in hospitals across Alberta to implement this clinical practice change, and the majority of hospitals have now implemented BBIT and retired SSI ordering practices. The outcome data has been very positive for the sites that are fully implemented.
Outcomes include a significant increase in BBIT ordering by 2.4 times above baseline, significant decreases in hyperglycemia (without increasing hypoglycemia), and a significant decrease in length of stay in hospital. Implementation science suggests that if you can successfully sustain a practice change for at least 18 months, the change is fully implemented and sustainable. All of the early adopter sites have demonstrated this sustained practice change. In fact, a recent data pull for one of the early adopter groups that implemented BBIT three years ago demonstrates a sustained practice change.
Glycemic management policy and procedures for hypo- and hyperglycemia management
Another aspect of the provincial initiative was the creation of provincial governance documents. Prior to this initiative, most hospitals in Alberta had a document in place to direct the management of hypoglycemia, but processes varied greatly and there was no formal process to guide the treatment of hyperglycemia (prior to the patient having DKA).
Type 1 Diabetes (T1 DM)
- Most often autoimmune in nature; the pancreas produces very little to no insulin
- These patients always require basal insulin
- At risk for diabetic ketoacidosis (DKA)
- At significant risk for hypoglycemia
Type 2 Diabetes (T2 DM)
- A combination of insulin resistance and insulin deficiency
- The pancreas produces some insulin, but the cells in the body fail to respond to the insulin properly (insulin resistance)
- Most patients will benefit from insulin supplementation in hospital
In 2016, a provincial multidisciplinary team (including nurses in many different roles), led by DON SCN™, developed a provincial policy for adult glycemic management, as well as procedures for both hyper- and hypoglycemia management. These procedures primarily focus on early recognition and treatment. The nursing professional associations were also consulted and provided input for the governance documents.
Simultaneously, the DON SCN™ collaborated with provincial lab POCT to have the alerts on all glucose meters in Alberta hospitals changed to align with the procedures. There are now alerts when the patient’s BG is less than 4.0 or greater than 18.0 mmol/L instead of only at critically low or high lab values of 2.5 and 25.1 mmol/L, respectively. The policy and procedures have been in effect since September 2017, with minor revisions in 2018. They have been instrumental in standardizing in-hospital diabetes management, including identifying BBIT as the most effective way to order subcutaneous insulin therapy.
Guidelines for safe management of insulin pump therapy (IPT) in hospital
Another dimension of the multifaceted initiative was the development of guidelines for safe management of insulin pump therapy (IPT) in hospital. Many patients with type 1 diabetes use IPT to manage their diabetes. Insulin pumps use only rapid-acting insulin, so if they are disconnected or turned off, patients require insulin within two hours to prevent hyperglycemia and/or DKA. The guidelines largely focus on supporting patients to continue to use their IPT device in hospital when safe and appropriate, as well as ensuring patient safety if the pump is stopped for any reason.
After the guidelines were published, a website was co-created with patients to support both patients and clinicians in the management of IPT. The guidelines and the website enable patients to self-advocate and prepare for diagnostic tests or planned admission to hospital.
The initiative also included
- a DKA protocol for emergency room and inpatients;
- making the carbohydrate content of Alberta Health Services menu items available to patients;
- patient-specific dispensing of insulin (a high-alert medication);
- a simplified insulin formulary; and
- the development of perioperative and diabetes in pregnancy guidelines (with complimentary provincial order sets being developed).
The initiative has furthermore led to the development of a pediatric glycemic management policy with procedures (which will mirror the existing adult governance documents).
Nurses, in numerous roles, were involved in, and contributed to, every aspect of this improved diabetes management in-hospital QI initiative. Clinical nurse educators (CNEs) across the province embraced the change and assisted the DON SCN™ with the development of nursing educational resources. CNEs also played a key role in implementing and educating other nurses about BBIT, the glycemic management policy and procedures, glucose meter alerts, and other aspects of this multifaceted QI initiative. Nurse managers and leaders endorsed and supported the changes.
Alberta’s Provincial Diabetes Inpatient Initiative (Figure 2 [PDF, 385.1 KB]) could not have been possible without the involvement of nurses from across the province and a multidisciplinary approach. Acute care nurses are now equipped and empowered to support their patients to achieve their recommended BG targets while in hospital.
For more information about this initiative, please feel free to contact the DON SCN at: email@example.com.