Overcoming Barriers on the Way to Evidence-Based Practice

Results

Eight patients were treated in accordance with the protocol within 30 days, and none experienced hypoglycemia. The team was unable to place 30 patients on the insulin protocol within one month. There was an unexpected decline in the admission of patients to the unit who were being treated with an anti-diabetic agent. Additionally, the medical staff was reluctant to consistently treat patients in accordance with the protocol. That potential barrier had been identified prior to the implementation of the pilot and addressed through education of the medical staff. However, the team underestimated the medical staff’s resistance to relinquishing use of the SSI protocol. The use of SSI has survived for > 70 years, through many generations of physicians (Kitabchi & Nyenwe, 2007). It is relatively easy for patients and clinical staff to learn and follow. The cultural change required for the staff to adopt the change in practice could not be realized within the 30-day period with eight patients.

Barriers to smooth adoption of the evidence-based protocol included lack of familiarity with the protocol, lack of experience in managing patients being treated with concomitant use of glucocorticoids, concerns about discharging patients on an insulin protocol that is not the community standard, and lack of confidence in the nursing staff’s ability to consistently implement the protocol.

Despite slow adoption, four months after implementation of the pilot, the nursing and medical staff leadership at the Center adopted the evidence-based insulin protocol for all inpatients and eliminated the use of the sliding-scale orders. Nonetheless, some providers continue to use only the nutritional part of the order set, thus rendering it a sliding scale. Four months after full implementation, the rate of hypoglycemia at the Center went from an average of 15% to 11%.

Conclusions

Umpierrez et al. call SSI “a medical myth; a concept that we were taught that is easy to remember, but just plain wrong: a reflex action passed down from attending physician to resident to students despite a lack of scientific evidence” (Umpierrez, 2007). Getting past “this is the way it has always been done” in light of the best evidence continues to be a challenge. Although compelling evidence and education was provided to a team of dedicated medical staff who participated in the pilot project, changing engrained behavior was difficult. Time is necessary for awareness, knowledge, and motivation to impact acceptance and change beliefs and practices. Ongoing multidisciplinary leadership support, integrated clinical decision support tools within the medical record, ongoing process monitoring, and staff education is vital to the full adoption of the evidence-based insulin protocol.

Reducing hypoglycemia depended in part on identifying and mitigating barriers that may have contributed to failure to reach the project goal. One barrier that was not amenable was having a dedicated endocrinologist readily available for consultation. This delayed the medical staff’s acquisition of skills and confidence to effectively manage patients on the protocol. In order to have a successful glycemic control processes, the Society for Hospital Medicine’s Glycemic Control Task Force recommends that a dedicated glycemic management team be established to track improvements in processes and glycemic outcomes. Given the complex effects of diabetes therapies on cancer risk and cancer progression, having the resources of a dedicated multidisciplinary diabetes team would be beneficial to patients and staff in preventing malglycemia in an oncology setting. The Center is currently considering this recommendation.

The use of the Six Sigma methodology was an essential aid in detecting and validating the root causes of the incidence of hypoglycemia. Providers believed that the primary origins of hypoglycemia were related to use of corticosteroids and nutritional imbalances that cancer patients often experience. Demonstrating that sliding-scale protocol and variability in glucose monitoring were contributing factors required rigorous measurement and systematic, validated analysis of baseline data. Process control measures that quickly identify and control process variation are equally important to validate root cause and sustain improvement results. While the reduction in hypoglycemia at the Center has been substantial, a significant gap still remains. Future efforts need to focus on complete eradication of hypoglycemia and hyperglycemia.