Feb 08, 2021
Improving the care of patients with diabetes in Alberta hospitals — part 2
- Hyperglycemia is common in hospitals and increases the risk of complications for patients with diabetes. Patient feedback advocated for a change in practice.
- The implementation of basal bolus insulin therapy was a challenging practice change as traditional subcutaneous sliding scale insulin had been a long-standing, entrenched practice.
- Key elements for successful implementation included a robust knowledge translation strategy, including partnerships with early adopter sites, identification of site based barriers and facilitators, site-based multidisciplinary champions to provide peer-to-peer education and support, a site-based executive sponsor to support the team, standardized resources, as well as audit and feedback data to support the practice change.
Alberta Health Services (AHS) is a provincial health system that has 98 acute care rural and urban hospitals, with 8,483 inpatient beds collectively. Over the past five years, most of these hospitals have participated in a provincial initiative led by the Diabetes, Obesity and Nutrition Strategic Clinical Network (DON SCN), to improve glycemic management for their patients with diabetes. The multifaceted initiative was highlighted on the Canadian Nurse website on April 20, 2020.
- One in five patients in Alberta hospitals has type 1 or type 2 diabetes.
- Over 30 per cent of blood glucose (BG) results measured in Alberta hospitals in 2014 were above the recommended in-hospital target of 5 to 10 mmol/L (for most patients).
- High BG increases the risk of complications (such as postoperative infections, pneumonia, diabetic ketoacidosis and prolonged stay in hospital).
The provincial initiative
Diabetes care in hospital is complex. Making change requires a multifaceted, multidisciplinary, system-wide quality improvement approach. The DON SCN inpatient diabetes management initiative included many components: implementation of basal bolus insulin therapy (BBIT) in place of traditional subcutaneous sliding scale insulin, guidelines for safe management of insulin pump therapy, safe management of diabetic ketoacidosis, diabetes-specific nutritional support, insulin formulary and dispensing changes, a glycemic management policy with procedures for both hypoglycemia and hyperglycemia and perioperative diabetes management guidelines.
Survey finds patients with diabetes less satisfied
Part of the foundational work of the DON SCN was learning how patients with diabetes viewed their in-hospital care. Surveys were sent to over 2,800 patients with diabetes discharged from all hospitals in the province during the month of June 2014; 672 (26 per cent) patients completed the survey and shared their experience. The DON SCN learned that patients with diabetes are less satisfied with their in-hospital care than patients without, and they requested improved medication and glycemic management. This survey informed the development of the provincial initiative.
Key elements for successful implementation of BBIT
The implementation of BBIT was a challenging practice change as traditional subcutaneous sliding scale insulin had been a long-standing, entrenched practice. Here are eight factors for this initiative’s success:
Early-adopter sites’ clinical team members also assisted with the development of additional educational resources for both prescribers and nursing staff.
1. Begin with a knowledge translation strategy
The DON SCN team collaborated with knowledge translation (KT) experts to develop an evidence-based implementation strategy. KT is the science of moving research into the practice setting, closing the gaps between what we know and what we do. The DON SCN used learnings from previous attempted implementations of BBIT in the province and a national e-scan of barriers and facilitators to inform this strategy.
This KT approach supported the development of a provincial BBIT implementation strategy that was an iterative process, with early-adopter sites contributing to the development and revision of the BBIT order set, creation of educational resources, identification of barriers and facilitators to the practice change and development of specific tools to overcome identified barriers.
2. Develop standardized resources
A provincial BBIT order set (in electronic and paper format) was developed by a working group of multidisciplinary content experts from across the province (prescribers, pharmacists and nurses) and informed by best evidence. The order set and accompanying forms were tested and revised by the first early-adopter sites’ front-line staff and multidisciplinary teams, providing feedback related to clarity and usability. Data demonstrated the order set to be safe and effective. Early-adopter sites’ clinical team members also assisted with the development of additional educational resources for both prescribers and nursing staff. A provincial glycemic management policy suite was developed supporting recognition and management of both hyperglycemia and hypoglycemia and promoting the use of BBIT.
3. Identify and partner with early-adopter sites
The DON SCN team partnered and collaborated with self-identified early-adopter sites across Alberta to support individual sites in their implementation, co-develop tools and resources and further refine the provincial implementation and sustainability strategy. Early-adopter sites included a large hospitalist program across four large urban teaching hospitals, three medium-sized suburban hospitals and two small rural hospitals, spanning four health zones and two health authorities.
Joy, a registered nurse and patient safety and quality consultant at one early-adopter site, reflected on her site’s implementation experience: “We wanted to ensure our implementation was successful. It was important to not underestimate the system-wide impacts of this change. Multidisciplinary engagement was key; site champions were important to provide peer-to-peer education and address any issues that arose. The investment of site nurse educators to provide initial and ongoing staff education, a strong physician champion and senior director leadership representing this practice change helped set the strategic direction of this widespread change and [were] considered invaluable.”
4. Identify a senior leader (executive sponsor) to support the site champions
Senior leaders played a key role in supporting and encouraging their teams, facilitating successful and sustained practice change. They ensured that the project had been thoroughly discussed and that all team members were aware of the efforts required to fulfil the entire process. This ensured that their teams were prepared for and adequately resourced to move through the three stages of implementation (pre-implementation, implementation and post-implementation).
5. Assess readiness for change
A readiness assessment supported the team(s), or leaders of early-adopter sites, in identifying this implementation project as a priority for the site and the commitment of the team to implement change. As teams reviewed their readiness, they could apply change management principles (e.g., building awareness) to engage with the local stakeholders to ensure readiness if areas of concern were identified in the readiness assessment.
6. Identify multidisciplinary site champions to provide peer-to-peer education and support
Sites were encouraged to form local multidisciplinary teams responsible for implementing the practice change, including site champions (nurses, pharmacists and physicians) who were local opinion leaders. Each local team participated in pre-implementation activities, including a train the trainer (TTT) session led by the provincial team. The TTT session included a review of local baseline data, guidelines and evidence for BBIT, expert and previous site implementation experience, available resources and protocols, and identified site-specific barriers and facilitators and evidence-informed tools available to address each. The TTT session imparted expertise and confidence in site champions so that they would facilitate peer-to-peer education and training for their sites.
7. Assess local barriers and facilitators
The provincial team supported the sites in identifying their perceived barriers and facilitators and in creating solutions to overcome each identified barrier. These unique site-based barriers were added to the list of common ones identified through previous implementations in the province and a national e-scan and in the literature.
Using an evidence-based framework with the support of KT experts, each barrier was mapped to possible strategies to overcome the barrier. New barriers drove micro plan-do-study-act cycles, informing co-development and revision of tools. These were made available for all sites to use and share via a website that linked to resources.
Addressing site/unit-specific barriers was essential. For example, it will not likely be helpful to provide education on how to use an order set to an individual who does not believe in the practice change. In this situation, peer-to-peer education around the evidence behind why BBIT is best practice may be more impactful.
8. Collect and review data.
KT science supports the use of audit data feedback as a facilitator to implementing and successfully sustaining practice change. Early-adopter sites collected baseline audit data (i.e., the sites identified the care gap and increased initial engagement) and then collected additional data over 18 months post-implementation. Data was populated onto a dashboard and accessed by local implementation team members (nurses, physicians, pharmacists, leaders and allied health professionals). Infographics highlighting outcomes were developed by the DON SCN team for site champions to share with front-line colleagues, leaders and patients. Data analysis over the 18 months was used to celebrate successes and identify any practice regression.
Audit data across all early-adopter sites demonstrated successful uptake and sustained use of BBIT over the 18 months. Provincially, BBIT ordering increased 2.4 times above baseline, with significant decreases in hyperglycemia and no increase in hypoglycemia. One program, using an electronic health record, was able to demonstrate a significant decrease in length of stay in hospital.
All early-adopter sites were surveyed after the implementation and were overall satisfied with the experience. Multidisciplinary participants indicated that 97 per cent were “very satisfied or satisfied” with the implementation strategy and process. Eighty-one per cent reported BBIT as being “very easy or easy to use,” which was remarkable as most respondents were non-diabetes specialist providers. Finally, 95 per cent responded that BBIT was being used frequently or always at their site.
Learnings from the early-adopter sites are being shared across the province of Alberta. Over 75 per cent of all 98 acute care sites have now implemented BBIT, reflecting the success of this implementation strategy.
The implementation of BBIT in lieu of the common practice of subcutaneous sliding scale insulin was a complex practice change. It required more than an order set and education. Provincially, it was important to engage and collaborate with content experts, patients, front-line multidisciplinary providers and administrators from across the province to support this practice change. The provincial glycemic management policy endorsing the use of BBIT, developed as part of the multifaceted provincial initiative, supported the spread of BBIT beyond early-adopter sites.
The learnings from this initiative continue to inform BBIT implementation in Alberta, as well as the implementation of other elements of the broader provincial initiative. These learnings are highly generalizable and can serve as a road map for other practice change initiatives.