Rosa Matonti RN MSN CNS CDE, Susan Hoeppner RN BSN, Kendall Rogers MD CPE FACP FHMUniversity of New Mexico Health Sciences Center, Albuquerque, New Mexico

Quality of Care Initiative: Blood glucose timing, food delivery and insulin administration

• Nurse Driven process of BG monitoring, meal delivery ,and insulin 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

• 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

Figure 2: Discharge Clinic Visit Status

ABSTRACT CONCLUSIONS

LIMITATIONSThe 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.

METHODS

RESULTS

ACKNOWLEDGEMENTS1. Yvette Sena, Operation Management Specialist, University of New Mexico Medical Group, Quality & Clinical Process Improvement.2. Margaret Saiz Program Planning Manager, University of New Mexico Medical Group, Quality & Clinical Process Improvement3. J Rush Pierce Jr. MD MPH, Associate Professor, Section of Hospital Medicine, Department of Internal Medicine, University of New

Mexico School of Medicine.4. Cristina Murray-Kresnan, MS, Research Assistant Professor of Internal Medicine, University of New Mexico Health Sciences Center5. Biostatistical support provided by the University of New Mexico Clinical & Translational Science Center (CTSA 1ULRR031977-01)6. The management and staff of 4 West sub-acute medical surgical unit at the University of New Mexico Hospital, pictured below

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.

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.

Method:This was a quality improvement workflow project on an adult inpatient unit where approximately one-third of patients receive insulin. We used time-in-motion 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.

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.

Blood glucose to insulin being administered

39% 39%

22%

65%

22%13%

97%

3% 0%0%

20%

40%

60%

80%

100%

120%

% <=30 minutes % 31 - 60 minutes % >= 61 minutes

Baseline9/2/09 to 9/10/09

4th Time Study04/12/10 to 04/15/10

5th time study07/26/10 to 08/5/10

Baseline9/2/09 to 9/10/09

4th Time Study

04/12/10 to 04/15/10

5th Time Study

07/26/10 to 08/05/10

0

5

10

15

20

25

30

35

40

45

50

44

37

10

Mean Time Between Blood Glucose to Insulin Administration

Min

ute

s

REFERENCES1. ADA position statement. (2010) Standards of Medical Care in Diabetes-2010. Diabetes Care.33(1). S11-51.2. Moghissi, ES, et.al. (2009). American Association of Clinical Endocrinologists and American Diabetes Association Consensus

Statement on Inpatient Glycemic Control. Endocrine Practice. 15(4). 1-17.3. Maynard, G., Umpierrez, G.(2008) Introduction: Overview of efforts and lessons learned. Journal of Hospital Medicine. 3 (5).

S1-S75.4. Potter, PA & Perry, AG (2008). Fundamentals of Nursing Seventh Edition. Mosby: St. Louis, Missouri.5. Clement, S. et al. (2004) Management of Diabetes and Hyperglycemia in Hospital: Diabetes Care. 27(2). 553-591.6. 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.

Study n Mean (mg/dL)

Standard Deviation (mg/dL) P-value*

95% CI (mg/dL)

99% CI (mg/dL)

Baseline 5494 160.40 75.82Nurse Driven 4896 150.64 67.12Difference Between Baseline and Nurse Driven

9.76 <0.0001 (7.01, 12.51) (6.15, 13.37)

Study nMean

(minutes)

Standard Deviation (minutes)

P-value*

Baseline

67

43.67 24.45

Nurse Driven

32

10.75 7.17

Difference Between Baseline and Nurse Driven 32.94 20.57 <0.000

1

Nurse Driven

07/26/10 to 08/05/10

Awareness

04/12/10 to 04/15/10

Baseline09/02/09 to

09/10/09

Awareness

Nurse Driven