One of the barriers to the safe management of inpatients with hyperglycemia is the lack of coordination between bedside blood glucose (BBG) Testing, insulin administration, and food delivery. This results in potential for mismatch between glucose levels and supplemental insulin dosage and for mistimed nutritional insulin in relation to nutritional intake; both increase the risk for hypoglycemia.
To identify the causes for lack of coordination between BBG testing, insulin administration, and food delivery and to pilot‐test an initiative to improve this coordination on a general medicine floor.
Our diabetes Ql team first mapped current processes for coordinating these events. A gap analysis revealed several causes for lack of coordination: (1) nurse assistants performed BBG testing on a set schedule regardless of when patients ordered meals, (2) the trigger for notification of food tray arrival depended on physicians ordering each patient a diabetic diet, and (3) food delivery personnel often failed to notify clinical personnel of food tray arrival in an appropriate way (ringing the call light or not al all), even if a prompt were present on the “meal ticket.” Using CQI methods, we developed, pilot‐tested, evaluated, and refined several steps to improve this situation: (1) a new diet order sheet was created that included a box (to be completed by Ihe night nurse‐in‐charge) for all patients ordered BBG testing; (2) either that box or an order for a diabetic diet now triggered a “notify unit clerk” prompt on each meal ticket; (3) food delivery personnel were trained to notify the unit clerk and not to ring the call light when prompted by the meal ticket; (4) instructional videos were used to train nurse assistants to delay BBG testing if patients did not want lo order a meal at the time of routine testing; and (5) nurses were trained on the overall goals of coordination and how to manage various situations. The nurse educators on the floor also provided continuous feedback and education to nursing staff. To evaluate the impact of this pilot, volunteers were placed on Ihe floor on randomly selected days lo observe the liming of food delivery and notification, if any. Data from electronic sources were used to determine the limes of insulin administration and BBG testing. Perfect timing was defined as SBG testing < 1 hour before a meal (and not after}, supplemental insulin within 1 hour of BBG testing, and nutritional insulin from 20 minutes before to 30 minutes after food delivery. From January through July 2009, the rate of perfect timing increased from 41% to 68% of patient meals.
Our analysis revealed several causes of lack of coordination involving several personnel. A multidisciplinary and multifactorial solution has shown promise in improving coordination of BBG testing, insulin administration, and food delivery.
J. Schnipper, Brigham & Women's Hospital, employment; E, Swain, Brigham & Women's Hospital, employment; J. Kemnitz, Brigham & Women's Hospital, employment; P. Aylward, Brigham & Women's Hospital, employment; J. Elder, Brigham & Women's Hospital, employment; K, McManus, Brigham & Women's Hospital, employment; K, Purdy‐Reilly, Brigham & Women's Hospital, employment; K, Alexander, Brigham & Women's Hospital, employment; R. Zaremski, Brigham & Women's Hospital, employment.
To cite this abstract:Schnipper J, Zaremski R, Swain E, Kemnitz J, Aylward P, Elder J, McManus K, Purdy‐Reilly K, Smith C, Szumita P, Tur‐chin A. An Initiative to Improve Coordination of Bedside Blood Glucose Testing, Insulin Administration, and Food Delivery. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 191. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/an-initiative-to-improve-coordination-of-bedside-blood-glucose-testing-insulin-administration-and-food-delivery/. Accessed May 23, 2019.