The work described here won the Best Abstract award at the Pharmacy Together 2019 conference.
Variable-rate intravenous insulin infusions (VRIII) are used to maintain glycaemic control for surgical patients with diabetes missing two or more meals. The safe transfer from VRIII to regular subcutaneous insulin is essential for high quality diabetes care and accurate documentation provides assurance that this has occurred and supports future glycaemic management. However, safe transfer requires improvement nationally and issues with transition have been identified locally by audits, incident reports and informally by staff.
Trust guidelines and training are in place to ensure safe transitions. This project was undertaken on two elective orthopaedic wards at a large, acute teaching hospital where VRIIIs are commonly required.
Scoping and analysis of the problem was done by mapping the process from recovery to the ward with stakeholders. Information gathered was used to develop a driver diagram of potential interventions. Key stakeholders were the medicines safety team, nursing staff from wards and theatres recovery, diabetes specialist nurses (DSN) and electronic patient record (EPR) nurse educators. Orthopaedic nurses felt there were no issues with VRIII transition, but information about subcutaneous insulin was needed.
Trying to implement change was difficult when the staff did not recognise the importance of documentation
Baseline data was collected retrospectively from EPR and following each intervention between May and December 2018, until 10 data points were achieved for each cycle. This showed wide variation in documentation of key information with no indication of when VRIIIs were being discontinued. A gap in knowledge and education around documentation was identified.
Interventions were developed collaboratively with stakeholders, introduced and tested using Plan- Do-Study-Act cycles.
The first intervention was to display a poster about subcutaneous insulin in the clinical area to address a knowledge gap perceived by nursing staff. The second intervention involved delivering teaching sessions at nursing handovers to ensure discontinuation of VRIII was documented.
To measure improvement, a scoring system was developed to measure safety of VRIII transition documentation.
Points were given, subtracted or neutral for documentation of:
- decision to stop
- time stopped
- independent check of rate change to zero
- meal and other diabetes medicines given one hour before stopped.
There was a maximum score of 6 and a minimum score of -3. These were plotted on a run chart.
There was no difference in median score from baseline after intervention one. The range of scores suggested variation in the way staff members document VRIII discontinuation. Teaching sessions were shown to have an impact on completeness of documentation. During the sessions, nurses suggested reasons for the problems in documenting the stop times, such as staffing and time pressures and queried the need for the mandated independent check of rate change to zero.
Overall, the project did result in some improvement in VRIII documentation; however significant areas for improvement were identified. Trying to implement change was difficult when the staff did not recognise the importance of documentation. A limitation of the study was the small sample size, but this was sufficient to highlight issues. Feedback from nurses has provided insight around future training needs.
Clare Crowley & Cate Leon, Oxford University Hospitals NHS Foundation Trust
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Competing interest statement:
The author declares: support from Oxford University Hospitals NHS Foundation Trust and Cardiff University for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.