Exploring the use of variable rate intravenous insulin infusion in hospital: A hierarchical taskanalysis

ABSTRACT

Introduction: Variable rate intravenous insulin infusion(VRIII) is a cornerstone treatment for controlling elevatedblood glucose (BG) in inpatients who are missing meals,and/or have a critical illness. VRIII can cause serious harmto patients if used incorrectly. Traditional approaches toimproving safety have focused on identifying errors, thenfinding solutions to prevent future recurrence. Such approaches fail to fully take into account the complex adaptive nature of healthcare systems, which cannot be controlledsolely by standards or procedures. The Resilient Health Care(RHC) approach proposes that understanding the variabilityin healthcare practitioners' everyday work e.g. a physical andcognitive activity directed toward achieving a specific goal, iskey to enhancing patient safety (1). There are a considerablenumber of studies on using RHC to enhance safety, however,no studies to date have researched resilience in the use ofVRIII.Aim: This study sought to comprehensively understand,within a RHC framework, how VRIIIs are used in the clinicalenvironment.Methods: A qualitative observational study was conducted in a Vascular Surgery Unit. A purposive sample of twoinpatients and all healthcare practitioners caring for VRIIIaspects for these patients were recruited. The researcher video-recorded healthcare practitioners while prescribing,administering and monitoring VRIII. The video data werethen transcribed and inductively coded to construct a deepunderstanding of the use of VRIII. A hierarchical task analysis (HTA) which is a core human factors approach (2) wasused to represent the actual task for the use of VRIII.Results: Twenty-two hours of video recordings of 10healthcare practitioners were used to develop the final HTAwith a top-level goal of controlling elevated BG using VRIII.The HTA clearly illustrated the complexity of using VRIIIsby highlighting more than 100 practical activities to achievethe goal. The observed challenges were mainly related tolack of knowledge e.g. the co-prescription of appropriateconcurrent IV fluids, and system and technology problemse.g. the need for frequent BG monitoring. The analysis ofthe video data identified various strategies that healthcarepractitioners used to respond to variability in work includingknowledge, standardising practice e.g. the using of ready-toadminister insulin infusions, and context-dependent adaptations including asking available colleagues to countersign administration and assigning the monitoring task to other staffwhen the nurses were busy. Most of the observed adaptationshad positive outcomes in terms of patient care delivery.Conclusion: This study was the first to have exploredhow 'work is done' in reference to the use of VRIII usingHTA. The study was limited by time, the Covid-19 pandemicand number of participants. However, the developed HTAprovided detailed tasks and, by highlighting when and howadaptations were used, systematically presented the processas it was actually done. Future work will focus on using thedata from this study to model RHC in the use of VRIII in away that allows the study site to better enhance patient safety.