Performing an Institutional Assessment of Current Care

One of the first steps in improving care is a thorough survey of your current care environment, order sets, methods for assessing and tracking glycemic control, and a variety of other factors. This section provides a framework for such an assessment. Again, you may wish to focus on selected portions of the assessment at first, but eventually, essentially all these items need to be assessed and improved on in order to achieve optimal care.

• Assessment item 1: Institutional support
• Assessment item 2: Presence of a multidisciplinary team to address issues?
• Assessment item 3: Reliable data flow and metrics
• Assessment item 4: Standardized order sets for insulin (subcutaneous and infusion)
• Assessment item 5: Nutritional dietary system
• Assessment item 6: Diabetes self-management
• Assessment item 7: Hypoglycemia, insulin safety, and cultural issues
• Assessment item 8: Algorithms, protocols, and policies
• Assessment item 9: Transitions-in-care issues
• Assessment item 10: Educational issues

Note: You might find it helpful to use process mapping when you do your assessment of selected areas of interest. See the Process Flow Mapping section for more information and examples.

Assessment item 1: Institutional support

• Are buy-in from administration and a communication/medical staff committee reporting structure defined and in place?
• Do you have the resources available for forming a team and supporting its efforts in formulating order sets, protocols, educational programs, and metrics to optimize the care of the inpatient with hyperglycemia?
• Do you have an executive staff sponsor?

A team working on an improvement effort this large is doomed to fail without the recognition by hospital administration and medical staff committees of the importance of glycemic control and prevention of hypoglycemia. If you haven't already done so, Institutional Support will assist you in enrolling the administration in your cause and in defining the medical staff entities your team needs to report to.

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Assessment item 2: Presence of a multidisciplinary team to address issues?

• Have you formed a truly multidisciplinary team or steering committee that works on the front lines of health care delivery, as outlined in the First Steps section? If not, do so now! You won't be able to complete the survey without the knowledge of representatives from all disciplines.

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Assessment item 3: Reliable data flow and metrics

• Point-of-care (POC) glucose testing, recording, and storage and retrieval issues (separate assessments may be needed for critical care and non-critical care areas).
• Does your institution have a robust bedside glucose monitoring quality control program with the parameters outlined here? (see Table 10 in Clement et al.)
• Is the methodology for acquiring and recording POC glucose tests standardized and reliable across different wards?
• Are POC glucose test results recorded and quickly available to the prescribing physician across all wards?
• Is POC glucose information available electronically, or is it recorded on paper? Is it recorded in the medication administration record, the bedside record, the permanent record, or lab data?
• Do your bedside glucose devices allow for identification of provider and patient via bar coding?
• Are your POC glucose results downloaded in a timely manner to the centralized lab database?
• Does your institution have any reports summarizing glycemic control or hypoglycemic event rates for all populations of inpatients (critical care, wards, perioperative settings)? Are the metrics reliable enough and descriptive enough to be actionable?
• Do you have metrics and reports describing the frequency and severity of hypoglycemic events that are based on glucose testing, not just incident reporting and D50 use?

Help on data flow, formulating metrics, and presenting data is available in Track Performance.

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Assessment item 4: Standardized order sets for insulin (subcutaneous and infusion)

• What order sets/protocols for insulin administration and glucose monitoring already exist?
• An institution will frequently have dozens of order sets of varying quality. At times, order sets designed to facilitate the care of the perioperative patient, the stroke patient, or other special populations will have sliding-scale insulin orders embedded in them. To truly standardize and optimize insulin usage, all insulin orders should be created using your standardized forms. Understanding what is already in place and who "owns" each order set/protocol will enable you to approach the stakeholders and register their support.
• Does your subcutaneous order form specifically encourage the use of scheduled basal, long-acting, or intermediate-acting insulins?
• Does your order form specifically encourage the use of scheduled nutritional (prandial) insulin?
• Does your order form standardize the administration of correction dose insulin?
• Is there a choice of standard scales to use based on insulin sensitivity?
• Is the q HS scale for correction dose modified downward from q AC dosing to prevent nocturnal hypoglycemia?
• Does your form conform to National Patient Safety Goals (making it compliant with the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]), spelling out units and eliminating trailing zeros?
• Does your form provide specific guidance for the timing of insulin administration with regard to tray/nutritional delivery?
• Does your form include or refer to a standardized hypoglycemia protocol?

Intensive insulin infusion order set/protocol

Is there a standardized intensive insulin infusion regimen used in your critical care units? Is it standardized and used throughout the institution, or is it at least standardized for each type of unit and patient?

If YES:

• Is it in computerized physician order entry (CPOE) or handwritten form?
• Are calculations and application of mathematical rules automated or translated into tabular form and algorithmic, or are the nurses expected to make these calculations?
• Does your insulin infusion order set clearly state the glycemic target?
• Are general guidelines for when to start and stop an insulin infusion embedded in the order set?
• Are general guidelines for dosing insulin infusions embedded in the order set?
• Does your insulin infusion order set include instructions for standard insulin infusion concentrations?
• Does your insulin infusion order set allow for differing sensitivity to insulin, making adjustments based on both current glucose value and the rate of change (dynamic scale) of the glucose values?
• Does your form conform to National Patient Safety Goals (rendering them JCAHO compliant), spelling out units and eliminating trailing zeros?
• Does your form include or refer to a standardized hypoglycemia protocol?
• What is the level of nursing and physician acceptance of and enthusiasm for the order set? How do you know?
• Do you have "smart" insulin infusion pumps applied with insulin infusions?
• Are guidelines for the transition from infusion to subcutaneous insulin regimens embedded in the insulin infusion order set?
• Are insulin infusion solutions labeled and prepared in the centralized medical center pharmacy?

Several examples of subcutaneous and infusion insulin order sets/protocols, along with guidelines for successful implementation, are provided in the Reliable Interventions and Clinical Tools sections.

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Assessment item 5: Nutritional dietary system

• What is the status of the nutritional/dietary system for hyperglycemic patients at your institution?
• Is there a routine process for addressing the special needs of inpatients with diabetes? Is there an accepted way of ordering a diabetic diet? Do meals delivered to all patients on insulin have consistent carbohydrate content? Is the timing of tray delivery/administration reliable and linked appropriately to POC glucose testing and insulin administration? Are there safeguards in place to prevent patients from being deprived of food/nutrition after receiving nutritional insulin (such as being sent for dialysis or testing) or from holding nutritional insulin for unexpected cessation of nutritional calories? Are nighttime snacks available?

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Assessment item 6: Diabetes self-management

• Does your institution have a program that allows carefully selected patients to self-manage their diabetes in the hospital?

See Table 5 in Clement et al.

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Assessment item 7: Hypoglycemia, insulin safety, and cultural issues

• Does your institution have a standardized hypoglycemia protocol? Is this protocol directed at the prevention of hypoglycemia and the recognition of risk factors for hypoglycemia in addition to the treatment for hypoglycemia?
• Does your hypoglycemia protocol address when to repeat the finger stick to measure blood glucose (BG), when to send a blood glucose specimen to the laboratory, and when to call the doctor/nurse-practitioner/physician assistant?
• How does your organization define hypoglycemia? How does it define severe hypoglycemia?
• How often do patients who have had an episode of hypoglycemia suffer repeat episodes?
• Has your hospital evaluated and worked on its "culture of safety" ? Would nurses be comfortable questioning an insulin dose or regimen they believed might be dangerous, or for that matter, would they feel comfortable pushing physicians for more aggressive insulin therapy in poorly controlled patients? Do physicians respond appropriately to questions and concerns from nurses? Does the culture vary in different parts of the hospital? How do you know?
• Are endocrinologists readily available? If so, how interested are they in aggressive consultation for hyperglycemic inpatients? Are hospitalists capable and willing to fill this role?
• Does your institution have bar coding to assist in preventing errors in the administration of insulin?
• Are pharmacists participating in physician rounds or surveillance of insulin-prescribing patterns?
• Is CPOE available at your institution?
• Are there mechanisms to trigger action/investigation for severe hypoglycemia, sustained hyperglycemia, or inpatient development of ketoacidosis or hyperglycemic hyperosmolar states?
• Have you gone through the "Safe Use of Insulin" document?

American Society of Health System Pharmacists and the Hospital and Health System Association of Pennsylvania. Recommendations for safe use of insulin in hospitals. 2005. Available at www.premierinc.com.
Accessed December 23, 2006.

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Assessment item 8: Algorithms, protocols, and policies

• Do you have algorithms, protocols, and policies available to assist caregivers in managing special situations and ordering appropriate insulin regimens for each situation? (All these items are covered in Reliable Interventions, so don't panic if you don't have most of them in place now.)
  • Calculating insulin dosages
    • Do you provide widespread guidance in estimating the total daily dose of subcutaneous insulin a patient needs or assistance in adjusting insulin.
  • Recommended insulin regimens for patients with different forms of nutritional intake
    • Do you have institutional guidelines for preferred specific insulin regimens for the:
      • NPO patient?
      • Patient eating meals or on bolus tube feedings?
      • Patient on TPN? Nocturnal TPN?
      • Patient on continuous or nocturnal enteral tube feedings?
    • Are your institutional guidelines for these scenarios available at the point of care, or are they embedded in your order sets?
    • Do nurses understand and embrace their role in coordinating bedside glucose testing, delivering nutrition, and administering insulin?
    • Does your nursing staff have guidance/protocols for managing common bedside issues such as what to do when the nutritional source is interrupted or a patient is unable to eat a meal?
    • Is there pharmacy oversight or standardization of insulin orders in patients receiving TPN?
    • Do you monitor the quality of glycemic control in any of these patients?
  • Transitioning from an infusion to a subcutaneous insulin regimen
    • Do you have guidance/protocols for transitioning patients from an infusion insulin regimen to a subcutaneous insulin regimen? Are they embedded in the order set?
  • Patients in other special situations: caring for perioperative patients and patients receiving high-dose steroids
    • Periprocedural Care
      • How does your institution address glycemic control in patients undergoing procedures and operations?
      • Do your insulin order sets or perioperative order sets encourage basal insulin throughout the perioperative period?
      • Are insulin infusions encouraged or mandated for hyperglycemic patients whose perioperative NPO status is expected to be prolonged?
      • Are dextrose-containing solutions routinely provided for NPO perioperative patients?
      • How aware are your surgeons and anesthesiologists of the need for good glycemic control?
      • Do you have any methods for assessing the quality of glycemic control in the perioperative setting?
    • Glucocorticoids
      • Has your medical center developed guidelines for hyperglycemic patients receiving large doses of steroids (chemotherapy regimens and post-transplant regimens, for example)?
      • Are these guidelines incorporated into order sets for chemotherapy/transplant regimens that include large steroid boluses?
      • Do you have any data/reports assessing the glycemic control of post-transplant or chemotherapy patients receiving large steroid boluses?
  • HbA1C values and prompts for monitoring glucose
    • Are HbA1C values routinely obtained (if none from the previous 30 days) to help guide insulin therapy? Is there a prompt for ordering HbA1C in insulin order sets?
    • Are all patients admitted screened for hyperglycemia by laboratory test or bedside glucose monitoring? Is glucose monitoring routine for perioperative patients and patients entering critical care areas?

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Assessment item 9: Transitions-in-care issues

Patients move quickly through the spectrum of health care environments. The care process, resources, and personnel often differ dramatically between the home, the emergency department, the general medical/ surgical ward, and the OR and post-op environments, and each transition in care presents a challenge to provide patients with consistent, high-quality, safe therapy and education tailored to their individual needs.

• Who does peri-op orders (pre-op, in OR, post-op, back to floor)?
• Is there diabetes teaching before discharge (more under 12)?
• Is there assurance that the medical regimen on discharge is tailored to the patient, that the patient can afford and understand it, that bedside glucose meter machines/strips are covered by the patient's insurance, and that the patient has defined follow-up?
• Are patients without diabetes dx who have random high BG/stress-induced hyperglycemia known/followed up?
• Is there communication with PCP?
• How do you identify patients who need translation of verbal and written instructions?
• How is med reconciliation handled at these interfaces?

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Assessment item 10: Educational issues

• Do you have a comprehensive patient diabetes education process in place?
• Is there a template in place for ordering diabetes self-management education (DSME) materials for patients?
• Is CDE available and what is its role?
• Do you have weekend teaching?
• Does your program utilize the general principles of diabetes self-management education outlined in "Management of diabetes and hyperglycemia in hospitals," by Clement et al.?
• Do you routinely assess the learner as part of the educational process?
• Do you include information on community resources and further outpatient education if needed?
• Is up-to-date and comprehensive written information provided as appropriate?
• Do you have a reliable method to educate the patient whose primary language is not English?
• Is there a certification/training program for nurses providing DSME?
• Have you considered implementing a diabetes resource nurse program to help extend the reach of diabetes education in your hospital?

Implementation strategies and further resources for DSME are provided in the Reliable Interventions> Comprehensive Educational Programs section

Staff education and certification

• Do you have a complete educational/certification program in place for care of the inpatient with hyperglycemia, rational insulin therapy, and prevention/treatment of hyperglycemia?
• Is it widely available via intra- or Internet access?
• Is it interactive in the form of learner-based modules?
• Are the modules tailored to the nurses? Tailored to physicians and other providers?
• If yours is a teaching institution, is education appropriately targeted at house staff?
• Does your program address institution-specific order sets as well as general principles?
• Is there mandatory participation by key providers?
• Is the educational program case based?
• Is there any method for tracking participation or competence/understanding of the most important concepts?

Pharmacy issues

• Do pharmacists critically review all insulin orders? Do pharmacists call physicians when insulin orders are irrational or deviate from the protocol? Does the MAR distinguish basal, nutritional, and corrective insulin and give instructions that assist the providers in delivering each of these appropriately? Have you gone through the "Safe Use of Insulin" document?
• Have steps been taken to ensure that insulin nomenclature and abbreviations don't cause medical errors? (N might represent NPH or Novolog, for example, and L might represent Lantus or lispro) What steps have been taken to avoid improper mixing of insulin types? (Lantus, for example, should not be mixed with other types of insulin.)

Reliable Interventions> Comprehensive Educational Programs is designed to assist you in successfully building, implementing, and tracking the results of a comprehensive educational program.

An alternative method for assessing your institutions guidelines and processes for administering inpatient insulin is available courtesy of the Georgia Hospital Association and the Partnership for Health & Accountability Diabetes Special Interest Group at the above link.

Performing an institutional assessment can be daunting at first. Remember, you don't have to fix or assess everything at once.

Download the Institutional Assessment of Your Current Practice Task Sheet.

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