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Flemons K, Cameron A, Dossett L, Helmle KE, McKeen J, Ruzycki SM. Barriers to High-quality Postoperative Glycemic Management by Surgical Teams: A Theory-informed Qualitative Analysis. Can J Diabetes 2023; 47:560-565. [PMID: 37196982 DOI: 10.1016/j.jcjd.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/24/2023] [Accepted: 05/06/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE Our aim in this study was to identify the barriers to following recommendations for postoperative glycemic management among surgical team members. METHODS We conducted semistructured interviews with surgical team members guided by 2 theoretical frameworks for understanding the barriers and drivers of health-care behaviours: the Theoretical Domains Framework and the Consolidated Framework for Implementation Research. Interview data were coded deductively by 2 study team members. RESULTS Sixteen surgical team members from 7 surgical disciplines at a single hospital participated in this investigation. The most important barriers to management of postoperative hyperglycemia were knowledge of glycemic targets, belief about consequences of hyper- and hypoglycemia, available resources to manage hyperglycemia, adaptability of usual insulin regimens to complex postoperative patients, and skills to initiate insulin. CONCLUSIONS Interventions to reduce postoperative hyperglycemia are unlikely to be effective unless they use implementation science to address local barriers to high-quality management among surgical team members, including setting and systems-level barriers.
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Affiliation(s)
- Kristin Flemons
- W21C, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anna Cameron
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lesly Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Karmon E Helmle
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Julie McKeen
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shannon M Ruzycki
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Ruzycki SM, Harrison TG, Enns E, McKeen J, Helmle K, Cameron A. Quality gaps in screening and monitoring for postoperative hyperglycemia in a Canadian hospital: a retrospective cohort study. BMJ Open Diabetes Res Care 2021; 9:e002445. [PMID: 34711544 PMCID: PMC8557293 DOI: 10.1136/bmjdrc-2021-002445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/18/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Evidence-based preoperative, intraoperative and postoperative glycemic management may reduce poor surgical outcomes. Previous studies suggest that quality gaps in perioperative glycemic management may be common. RESEARCH DESIGN AND METHODS This retrospective cohort study used administrative health and laboratory data from a single center to estimate quality gaps in perioperative glycemic management in patients with and without diabetes between April 2019 and March 2020. We examined the proportion of patients with preoperative hemoglobin A1c (HbA1c) measurement, postoperative point-of-care testing (POCT) for glucose, hyperglycemia, and basal bolus insulin regimens. We compared the median length of stay (LOS) in patients with and without postoperative hyperglycemia, adjusted for age and sex. RESULTS There were 6576 patients in our cohort; 1165 (17.8%) had diabetes. Most patients with diabetes had an HbA1c measured prior to surgery (n=697, 59.8%). Postoperatively, 16.9% of patients with diabetes had no POCT monitoring (n=197) and 65.7% had hyperglycemia (n=636). Only 35.9% of patients who received insulin had a basal bolus insulin regimen (n=229). Patients with diabetes who had postoperative hyperglycemia had a longer median LOS compared with those who did not have postoperative hyperglycemia (8.4 days (95% CI 7.5 to 9.4) and 6.7 days (95% CI 6.3 to 7.1), respectively). In patients without diabetes, median LOS was 7.4 days (95% CI 4.4 to 10.4) for those with hyperglycemia and 5.2 days (95% CI 5.1 to 5.4) for those with in-target glucose. CONCLUSIONS Quality gaps in perioperative glycemic management include measurement of blood glucose after surgery and treatment of postoperative hyperglycemia. These gaps may contribute to longer LOS.
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Affiliation(s)
- Shannon M Ruzycki
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Tyrone G Harrison
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Edwin Enns
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Julie McKeen
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karmon Helmle
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anna Cameron
- Department of Obstetrics and Gynecology, Cumming School of Medicine, Calgary, Alberta, Canada
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Hitchen SA, Lan NSR, Hort AL, Rankin JM, Fegan PG, Yeap BB. Managing inpatient hyperglycaemia and initiating sodium-glucose cotransporter 2 inhibitor therapy in the setting of diabetes and acute coronary syndrome. Intern Med J 2021; 51:428-432. [PMID: 33738945 DOI: 10.1111/imj.15245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/30/2020] [Accepted: 09/17/2020] [Indexed: 12/01/2022]
Abstract
We previously showed that implementing algorithms for managing diabetes in acute coronary syndrome was associated with improved inpatient glycaemic control and increased sodium-glucose cotransporter 2 (SGLT2) inhibitor prescriptions. The present study performed 1 year later found that inpatient hyperglycaemia had relapsed to pre-intervention rates, although SGLT2 inhibitor prescriptions remained increased. We discuss the challenges of improving inpatient glycaemic control.
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Affiliation(s)
- Sarah A Hitchen
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Pharmacy, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Nick S R Lan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Adam L Hort
- Department of Pharmacy, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - P Gerry Fegan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Bu B Yeap
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia
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Khan AA, Shahzad A, Rose S, Al Mohanadi DHSH, Zahid M. Quality improvement project for improving inpatient glycaemic control in non-critically ill patients admitted on medical floor with type 2 diabetes mellitus. BMJ Open Qual 2020; 9:bmjoq-2020-000982. [PMID: 32792342 PMCID: PMC7430318 DOI: 10.1136/bmjoq-2020-000982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/04/2020] [Accepted: 07/21/2020] [Indexed: 12/18/2022] Open
Abstract
A significant number of patients admitted to the medical floor have type 2 diabetes mellitus (DM). Lack of a standardised inpatient hyperglycaemia management protocol leads to improper glycaemic control adding to morbidity in such patients. American Diabetes Association, in its 2019 guidelines, recommends initiation of a regimen consisting of basal insulin (long-acting insulin) or basal plus correctional insulin for non-critically ill hospitalised patients with poor or no oral intake. A combination of basal insulin, bolus (short-acting premeal or prandial) insulin and correctional scale insulin is recommended for inpatient hyperglycaemia management in non-critical patients with type 2 DM who have proper oral intake. Baseline data of 100 patients with diabetes admitted to Hamad General Hospital Doha, Qatar, showed that although insulin was used in the majority of patients, there was lack of uniformity in the initiation of insulin regimen. Adequate glycaemic control (7.8–10 mmol/L) was achieved in 45% of patients. Using Plan–Do–Study–Act (PDSA) model of improvement, a quality improvement project was initiated with the introduction of a standardised inpatient hyperglycaemia management protocol aiming to achieve 50% compliance to protocol and improvement in inpatient glycaemic control from baseline of 45% to 70%. Interventions for change included development of a standardised inpatient hyperglycaemia management protocol and its provision to medical trainees, teaching sessions for trainees and nurses, active involvement of medical consultants for supervision of trainees to address the fear of hypoglycaemia, regular reminders/feedbacks to trainees and nurses about glycaemic control of their patients and education about goals of diabetes management during hospitalisation for patients with diabetes. Overall, glycaemic control improved significantly with target glycaemic control of 70% achieved in 4 of the 10 PDSA cycles without an increase in the number of hypoglycaemic episodes. We conclude that development of a standardised inpatient insulin prescribing protocol, educational sessions for medical trainees and nurses about goals of diabetes management during hospitalisation, regular reminders to healthcare professionals and patient education are some of the measures that can improve glycaemic control of patients with type 2 DM during inpatient stay.
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Affiliation(s)
- Adeel Ahmad Khan
- Department of Internal Medicine, Hamad Medical Corporation, Doha 3050, Qatar
| | - Aamir Shahzad
- Department of Internal Medicine, Hamad Medical Corporation, Doha 3050, Qatar
| | - Samman Rose
- Department of Internal Medicine, Hamad Medical Corporation, Doha 3050, Qatar
| | | | - Muhammad Zahid
- Department of Internal Medicine, Hamad Medical Corporation, Doha 3050, Qatar
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María María MA, Ramos A, Martínez Roldán MJ, Pujol Giménez I, Pérez A. Implementation of an inpatient hyperglycemia management program incorporating a nurse consultant. ACTA ACUST UNITED AC 2019; 67:461-468. [PMID: 31706975 DOI: 10.1016/j.endinu.2019.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 07/23/2019] [Accepted: 07/25/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND AIMS The efficacy and safety of inpatient hyperglycemia management protocols using basal-bolus regimens have been widely demonstrated, but their implementation is insufficient. The aim of the study was to assess implementation and to establish the efficacy and safety of inpatient hyperglycemia management protocol based on a basal-bolus regimen and the incorporation of a nurse consultant. MATERIAL AND METHODS Evaluation was performed at 10 hospital units. Data were retrospectively reviewed during hospital stay and 90 days after discharge in 400 patients after protocol implementation and 200 patients before implementation. The degree of satisfaction of professionals was assessed using a questionnaire 12 months after implementation. RESULTS The proportion of patients with basal-bolus regimens upon admission was higher in the postimplementation group (58% vs. 9%, P<0.001). Mean pre-prandial and bedtime blood glucose levels during admission were lower in the postimplementation group (164±41mg/L vs. 196±50mg/dL, P<0.001). After implementation, there were less patients with blood glucose levels >300mg/dL (36.3% vs. 50.5%, P<0.001) and more patients with values <70mg/dL (15% vs. 9%, P=0.040). Insulin addition and intensification was the main change in treatment at discharge, and a significant HbA1c reduction was seen three months after discharge in the postimplementation phase (P=0.04). The professionals assigned the protocol a score of 4.5 on a 1 to 5 scale. CONCLUSIONS Incorporation of a nurse consultant expert in diabetes as key component of a hyperglycemia management program ensures that a majority of patients admitted to hospital for hyperglycemia receive treatment with a basal-bolus regimen and improves blood glucose control during hospital stay and after discharge.
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Affiliation(s)
- Miguel A María María
- Servicio de Endocrinología y Nutrición, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Analía Ramos
- Servicio de Endocrinología y Nutrición, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - M José Martínez Roldán
- Servicio de Endocrinología y Nutrición, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Isabel Pujol Giménez
- Servicio de Endocrinología y Nutrición, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Antonio Pérez
- Servicio de Endocrinología y Nutrición, Hospital de la Santa Creu i Sant Pau, Barcelona, España; Departamento de Medicina, Universitat Autònoma de Barcelona, Bellaterra, España; CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), España.
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