The work described here was presented at the Pharmacy Together 2019 conference.
Inpatients with diabetes may require variable-rate intravenous insulin infusions (VRIII) to treat hyperglycaemia. These infusions require frequent monitoring and adjustment to achieve effective glycaemic control and avoid patient harm. Historically, this was prompted by documenting on locally designed bespoke paper proformas, but these have since been replaced by an electronic prescribing, monitoring and administration (ePMA) system. The safe and appropriate use of VRIII requires improvement both locally and nationally. Local safety concerns about VRIII documentation warranted investigation which led to a study undertaken in an adult emergency assessment unit of a large, multi-site acute teaching hospital.
Stakeholder engagement, observation and process mapping revealed VRIII practice issues and areas for improvement. Stakeholders included: medical, nursing, pharmacy staff; the inpatient diabetes team; and, managers and ePMA teams.
It was discovered that different sections within ePMA were used to record infusion rates and that identifying when VRIIIs were stopped was problematic. Unfamiliarity with the correct processes for documentation was a contributing factor.
The targets for improving the quality and accuracy of VRIII documentation were exceeded
A driver diagram detailing potential interventions and scored for achievability and impact guided selected interventions. Scoring tools were developed to grade the quality, accuracy and location of VRIII documentation within ePMA. Baseline data were collected, entered into a pre-piloted Excel spreadsheet, and analysed.
The interventions which aimed to standardise electronic documentation were:
- ‘Espresso’ teaching sessions: quick, opportunistic ward-based teaching for nurses, describing how to document rate-changes on ePMA
- VRIII administration ‘hints and tips guide’: shared with staff and attached to the ward ePMA computers
The interventions were developed and tested using the Plan-Do-Study-Act cycles. Stakeholders were actively involved throughout. Each intervention was performed over two weeks during June 2018 and October 2018. Data were collected and analysed following each intervention.
The measurements for improvement were an increase in VRIII documentation score by 50 percent for a) quality and b) accuracy. All infusion rates were recorded in the agreed location of ePMA.
The targets for improving the quality and accuracy of VRIII documentation were exceeded. All rate-changes were recorded in the recommended location on ePMA. Changes resulted in a clearer representation of patients’ VRIII requirements, enabling accurate assessment of insulin use with implications for ongoing management. Although 100 percent of VRIII stop times were documented, only 65 percent were recorded using the agreed method. Staff expressed reluctance to document the infusion rate as zero.
Some improvements previously achieved through the VRIII paper proformas were lost with the transition to ePMA. Standardising ePMA practice in this project increased the quality and accuracy of VRIII documentation. It is imperative that the implementation of ePMA for VRIII is supported by adequate training for front-line users which remains readily accessible. Further work is required to encourage correct documentation of zero-rate when stopping VRIII.
Cate Leon & Clare Crowley, Oxford University Hospitals NHS Foundation Trust
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Competing interest statement:
The author declares: support from Cardiff University School of Pharmacy and Oxford University Hospitals NHS Foundation Trust 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.