Running Head: QUALITY IMPROVEMENT 1

Leadership Strategy Analysis Quality Improvement

Belinda Bonter

Mindi Groenendyk

Amanda Hubbard

Julie Walker

Ferris State University

QUALITY IMPROVEMENT 2

Abstract
The following paper addresses a clinical need at a local healthcare facility. The need is in
reference to the time period between morning blood glucose checks and the subsequent dosing
and administration of insulin. Evidence will show that insulin should be dosed and administered
within an hour after this check and within thirty minutes of the meal. This timing is important
for prevention of complications such as hyperglycemia and hypoglycemia. Ideas for how such a
change could be implemented and the team that should be involved are also presented in this
paper. Finally, the authors also explain how such a change will have a positive impact on patient
outcomes and how this plan can be evaluated.
Keywords: insulin administration, blood glucose levels, timing

QUALITY IMPROVEMENT 3

Quality Improvement
At every inpatient hospital today, blood glucose monitoring is performed for all diabetic
patients. Each organization and unit establishes a policy by which blood glucose levels are
checked and by which insulin is administered. This paper discusses a scenario in which too great
a time exists between blood glucose checking and the dosing and administration of insulin. The
authors establish evidence for this clinical need and discuss the strategies by which this process
can and should be improved.
Clinical Need
The timing of insulin administration is based on the type of insulin being given. Most of
the time, in acute care settings, sliding scale insulin (SSI) is given just prior to meals in order to
help reduce blood glucose levels after food is consumed. However, in some facilities glucose
levels are checked an hour or two before the meal, and insulin is dosed upon this information.
Checking blood glucose levels two hours before administering insulin can be deadly. In two
hours, blood glucose levels can change rapidly in some patients. The safety of the patient could
be compromised by dosing insulin based on a two hour old blood glucose level. Checking blood
glucose (BG) levels just before administration of insulin can decrease the safety issues associated
with insulin administration.
In a study done by Trotter, Conaway, and Burns (2013), The study demonstrated timing
of blood glucose measurement does affect the required SSI dose. The closer the blood glucose
was obtained to the patient's meal time, the lower the glucose value (lower insulin requirement).
Results suggest BG value and insulin dose administration should be accomplished immediately
prior to meal time. BG levels checked right before insulin administration showed that less
insulin was required than when the glucose readings were taken an hour or more before the
QUALITY IMPROVEMENT 4

insulin was administered. Had the insulin been given based on a BG reading done too far in
advance of the meal, a patient could have an adverse reaction because of too much insulin given.
As stated in the article by Lampe, Penoyer, Hadesty, Bean, and Chamberlain (2014), if
BG testing is performed too far before the nurse gives the insulin, the dose may be insufficient
for glycemic control and can lead to hyperglycemia or hypoglycemia, (pg. 166). This is
considered a medication error if insulin is given and an adverse event happens based on a BG
level that was outside of the recommended time frame. It was found in this study that the ideal
timing for BG testing was within one hour prior to the meal, (Lampe et al. 2014, pg. 166).
When the investigators of this study used a thirty minute time window that was recommended in
another study, 87% of the blood sugar checks were done outside of that 30 minute window
(Lampe et al. 2014, pg. 166).
With the BG timings being so far in advance of insulin dosing, the diabetic patient is
facing detrimental effects. High and low blood sugars can be seen based on BG levels done too
far in advance. This is a patient safety issue that can be corrected by following guidelines
recommended by the type of insulin being given to the patient.
Interdisciplinary Team
Investigating any clinical issue will require other disciplines to become involved. In this
scenario, the interdisciplinary team should consist of a staff nurse, the nursing director of the
unit, the medical director of the unit, a pharmacist, and a member of nutrition services. These
team members should meet together to share each ones concerns and ideas regarding this
matter.
The concerned staff nurse should be included due to his or her hands-on experience with
this issue. The nursing director will have concerns about how changing times of the blood
QUALITY IMPROVEMENT 5

glucose checks will impact his or her staff routines. Further, both the nursing director and the
medical director are responsible for the patients outcomes. The medical director may have to
write new orders depending on the policy of the organization. Additionally, he or she will
continue to monitor hemoglobin A1C for each diabetic patient that is under his or her care for the
long term. This will ensure that blood glucose levels are being maintained at a stable level.
A pharmacist should be involved in this quality improvement process. Different types of
insulin have varying times of onset, peak, and duration. The pharmacist will be a great resource
for the specific type(s) of insulin being administered at this facility. Finally, nutrition services
should also be included. This is important due to blood glucose being impacted by snacks and
meals. Staff must ensure that the morning fasting blood glucose level is truly fasting and does
not conflict with the timing of snacks or meals being delivered by nutrition services.
Data Collection
A fishbone diagram is an effective method of summarizing a brainstorming session,
(Yoder-Wise, 2011, p.399). In determining poor outcomes as a part of the significant amount of
time between glucose checks and administration of insulin, the fish bone diagram was selected to
see complications or effects of the clinical problem indicated in diagram 1. Diagram 2 indicates
some strategies in fishbone structure to improve the issue. Some further data collection may be
requiring a flow chart. A flow chart could be used to document blood glucose measurement
timing and the amount of insulin at meal time over a certain period. The interdisciplinary team
looks at all the possible poor outcomes and possible strategies to improve the problem. One
strategy is selected while continuing to collect data. During the data collection period, evaluation
continues to see if the appropriate outcomes are met (Yoder-Wise, 2011).

Diagram 1
QUALITY IMPROVEMENT 6

Patients get hypoglycemia Increased chance for complications


Harder time to control blood sugars


Too much time between blood glucose checks and insulin administration and dosing


Overall dissatisfaction with hospital Increased Death Rates


Increased hospital stay


More money out of patients pockets




Diagram 2

Nurses check their own blood sugars for accuracy Hire more staff


Educate nurse Techs


Too much time between blood glucose checks and insulin administration


Review Compliance with the protocol of timing of sugars


Better communication about workload of blood sugars so they get
done at the appropriate time and not too soon.

Outcomes
The goal of every diabetic individual is to have good blood glucose control.
Unfortunately, many diabetics do not follow the proper timing when checking their blood sugars
and taking insulin. If a patient is on a rapid acting type insulin, which is often used for sliding
scale checks, it should be injected within 15 minutes before a meal or directly after the meal
QUALITY IMPROVEMENT 7

(American Diabetes Association, 2014). The ultimate outcomes for the patients would be for the
person to test per their individual plan, and if using sliding scale insulin, to administer it per
these recommended guidelines. The interval from time of insulin injection and eating a meal
should be about 30 minutes, if the meal is eaten right away this results in a delayed
hypoglycemic event (American Diabetes Association, 2014). By following the recommended
guidelines it may decrease the episodes of hypoglycemia, which in turn will lead to better
glucose control.
Implementation
Many factors play into the importance of correct timing of glucose checks as well
appropriate insulin administration based on the glucose level. Data suggest that the most
common causes of both hypoglycemia and hyperglycemia are deficiencies in the use and
monitoring of insulin therapy, (American Society of Health-System Pharmacists, 2004, p.9). It
is critical to come up with measures to be certain accurate blood sugars are being obtained at the
appropriate time. Some strategies to improve and correct the improper timing of blood sugar
checks are measures such as reviewing compliance and data that shows when the blood glucose
checks were done. Upon reviewing such information, the director of nursing for the unit should
follow up with any individuals not following the protocol. Another strategy to improve
monitoring is caregiver competency for nursing assistants and nurses. This may involve further
education on the importance of timed blood sugar checks and the consequences of inaccurate
blood sugars. Caregivers should also be informed of appropriate and inappropriate results in
order to know when an emergency exists. The organization should also define time limits in
which it is unsafe to administer insulin after a given period of time. After such time, the blood
QUALITY IMPROVEMENT 8

sugar check must be repeated to ensure safe administration of insulin (American Society of
Health-System Pharmacists, 2004).
Evaluation
Every diabetic patient needs to have good documentation about not only their blood
sugars, but also the amount of insulin received, and time of day along with any symptoms that
they may be feeling. The American Association of Diabetes (2014) recommends keeping a diary
or journal so that the diabetic care team is aware of everything that occurs in case something
needs to be changed. In order to properly evaluate the changing of when blood sugars are
checked and when patients receiving their insulin, the outcome standards need to be followed.
Documentation on each patient that receives sliding scale insulin needs to be reviewed after a
one-month time frame to see any correlation with the recommended techniques for monitoring
and insulin control.
Scholarship
The aforementioned clinical problem and strategies reflect that there is abundant
evidence regarding the timing of blood glucose checks as related to insulin dosing and
administration. In order to ensure a high standard of care, the facility can adjust the timing of
blood glucose checks to be within one hour of the meal, as recommended by Lampe et. al (2014).
The interdisciplinary team can use various means at their disposal to ensure that outcomes within
the facility are improving. Many facilities take advantage of electronic medication
administration records (EMAR), and these software programs offer reports that can be
periodically reviewed. The team can review not only the results of the blood glucose checks, but
also the time at which the check was performed. Further, the team can then review insulin
dosing based on the blood glucose check.
QUALITY IMPROVEMENT 9

Conclusion
This paper has shown that there is supporting evidence for a change to be made in the
timing of blood glucose checks at this facility. Strategies have been presented to assist staff
members in making this change. An interdisciplinary team will be established in order to trouble
shoot the new policy and evaluate it over time. It is clear that a facility that desires to provide a
high standard of care and deliver positive outcome would certainly be interested in quality
improvement in this area.

QUALITY IMPROVEMENT 10

References
American Diabetes Association (2014). Diabetes care: insulin administration. Retrieved from
http://care.diabetesjournals.org/content/27/suppl_1/s106.full
American Society of Health-System Pharmacists. (2004). Recommendations for Safe Use of
Insulin in Hospitals (pp. 1-41). Retrieved from http://www.ashp.org/s_ashp/
docs/files/Safe_Use_of_Insulin.pdf
Lampe, J., Penoyer, D., Hadesty, S., Bean, A., & Chamberlain, L., 2014. Timing is
everything: Results to an observational study of mealtime insulin practices. Clinical
Nurse Specialist, 28(3), 161-167. doi:10.1097/NUR.0000000000000045
Trotter, B., Conaway, M., & Burns, S., 2013. Relationship of glucose values to sliding scale
insulin (correctional insulin) dose delivery and meal time in acute care patients with
diabetes mellitus. MedSurg Nursing, 22(2), 99-105.
Yoder-Wise, P. S. (2011). Leading and Managing in Nursing (5th Ed.). St. Louis, MO: Elsevier.