Monitoring, Meals, and Medications: A Pilot Study to Improve the Coordination of Inpatient Diabetes Care

Background/Significance: National guidelines for diabetes care in the hospital include recommendations to coordinate blood glucose monitoring, meal delivery, and medication administration (ADA, 2018; Umpierrez et al, 2012). Ideally, blood glucose monitoring should occur prior to meal delivery; insulin should be administered within 30-60 minutes of blood glucose monitoring (Kulasa & Juang, 2017). Many factors in the hospital setting make such recommendations difficult to achieve such as a lack of communication between nursing and dietary staff, variable meal delivery times, patients’ inability to communicate with staff, lack of staff knowledge about the clinical importance of coordinated diabetes care, and other clinical priorities during meal times that cause delayed glucose monitoring and/or meal delivery (Engle, Ferguson, & Fields, 2016; Freeland, Penprase, & Anthony, 2011; Gerard & Ritchie, 2017; Kaisen, Parkosewich, & Bonito, 2018). However, if these challenges are not managed, uncoordinated diabetes care may increase risks for hypoglycemia and hyperglycemia (Eiland, Goldner, Drincic, & Desouza 2014; Kulasa & Juang, 2017).

An evaluation to assess the timeliness of glucose monitoring in relationship to insulin administration was completed in February 2018. This revealed opportunities for improvement across multiple medical and surgical non-critical care units. Additionally, staff were dissatisfied with the existing communication mechanisms which were inconsistently used and unreliable.

Purpose of Project: The purpose of this quality improvement project was to pilot new strategies aimed at improving the coordination of glucose monitoring, meal delivery, and insulin administration for hospitalized, adult patients with diabetes.

Methods: A pilot study was conducted on a 32-bed adult transplant unit in June 2018. This unit was selected due to the high volume of patients receiving blood glucose monitoring and insulin as well as the willingness of staff to pilot a process change. An interdisciplinary team representing nursing and dietary staff identified root causes that were contributing to the lack of coordinated diabetes care. Staff were surveyed to understand perceptions related to workflow process efficiency, communication between unit staff and tray delivery staff, and frequency of tray delivery directly to patients.

Results: A new workflow was implemented during two weeks in June 2018. Tray delivery staff communicated directly with unit staff before delivering meals to patients. Unit staff used the available technology to monitor tray delivery status in order to anticipate timing of tray delivery. Unit staff were educated about expectations for coordination and timing of blood glucose monitoring prior to meal delivery and insulin administration within 30-60 minutes of blood glucose monitoring based on whether insulin was given before or after the meal. Clinical outcomes will be shared specific to timing of blood glucose monitoring in relationship to meals and timing between blood glucose monitoring and insulin administration pre-pilot, during the pilot, and post-pilot. Staff survey data will be shared which showed significant positive changes in staff perceptions.

Conclusions/Implications:A number of positive changes resulted from this pilot. The new process implemented improved staff perceptions about communication and process efficiency. Staff became more cognizant of when the meal tray would be delivered in order to coordinate blood glucose monitoring; staff were asked to repeat the monitoring if there was a delay longer than 30 minutes. This added to the workflow burden of staff and staff reported a negative impact on patient satisfaction. In some cases, staff would perform glucose monitoring after the meal was delivered. Because nurses, nursing assistants, health unit coordinators, and tray delivery staff all participated in the new process, it was important to get feedback from all team members before, during, and after the pilot. Their feedback reflected their need for reinforcement about role responsibilities and education about timing expectations. They also identified needed Improvements in the tray delivery software to more accurately identify which patients need blood glucose monitoring; this work is in progress. Given the success of the pilot, both in terms of clinical outcomes and staff satisfaction, this pilot was expanded to other units and is now implemented hospital-wide.