Implementation of a screening program to detect previously undiagnosed dysglycemia in hospitalized patients.

OBJECTIVE: Many people with dysglycemia are unaware that they have the condition. We conducted a study to determine whether a screening program for hospitalized patients could identify new cases of unrecognized dysglycemia and affect the actions of attending care providers during hospitalization. METHODS: We measured A1C in 466 participants with no history of diabetes who had been admitted to hospital for coronary heart disease or elective joint replacement surgery. Participants with A1C <6.0% were considered normoglycemic and those with A1C ≥6.0% were considered dysglycemic. Notifications to care providers were placed on the charts of participants who had dysglycemia, along with recommendations for in-hospital monitoring and care. Oral glucose tolerance tests were completed 6 weeks post-hospitalization for participants with dysglycemia and a subsample of participants who were normoglycemic. Sensitivity and specificity of in-hospital dysglycemia criteria were calculated. Provider practices were determined by chart review. RESULTS: In-hospital dysglycemia was present in 10.4% of patients with coronary heart disease and 11.4% of participants with elective joint replacement surgery. Attending care providers took few of the recommended actions, despite the chart notification of dysglycemia; glucose monitoring occurred <30% of the time. The in-hospital dysglycemia criterion of ≥6% demonstrated moderate sensitivity (47.5%) and high specificity (96.2%) in detecting dysglycemia based on oral glucose tolerance tests. CONCLUSIONS: Dysglycemia was a relatively common finding in patients with no history of diabetes who had been admitted for coronary heart disease or elective joint replacement surgery. The in-hospital A1C screening criteria generated a high level of false-negative tests, and a chart notification had limited effects on the practices of attending care providers. Future studies examining lower A1C thresholds and the barriers to and facilitators of attending care providers' behaviours are warranted.

Using standardized insulin orders to improve patient safety in a tertiary care centre.

OBJECTIVE: To standardize insulin prescribing practices for inpatients, improve management of hypoglycemia, reduce reliance on sliding scales, increase use of basal-bolus insulin and improve patient safety. METHODS: Patients with diabetes were admitted to 2 pilot inpatient units followed by corporate spread to all insulin-treated patients on noncritical care units in a Canadian tertiary care multicampus teaching hospital. Standardized preprinted insulin and hypoglycemia management orders, decision support tools and multidisciplinary education strategies were developed, tested and implemented by way of the Model for Improvement and The Ottawa Model for Research Process. Clinical and balance measures were evaluated through statistical process control. RESULTS: Patient safety was improved through a reduction in hypoglycemia and decreased dependence on correctional scales. Utilization of the preprinted orders approached the target of 70% at the end of the test period and was sustained at 89% corporately 3 years post-implementation. CONCLUSIONS: The implementation of a standardized, preprinted insulin order set facilitates best practices for insulin therapy, improves patient safety and is highly supported by treating practitioners. The utilization of formal quality-improvement methodology promoted efficiency, enhanced sustainability, increased support among clinicians and senior administrators, and was effective in instituting sustained practice change in a complex care centre.

Facilitating specialist to primary care transfer with tools for transition: a quality of care improvement initiative for patients with type 2 diabetes.

The epidemic of diabetes has increased pressure on the whole spectrum of the healthcare system including specialist centres. The authors' own specialist centre at The Ottawa Hospital has 20,000 annual visits for diabetes, 80% of which are follow-up visits. Since it is a tertiary facility, managers, administrators and clinicians would like to increase their ability to see newly referred patients and decrease the number of follow-up visits. In order to discharge appropriate diabetes patients, the authors decided it was essential to strengthen the transition process to decrease both the pressure on the centre and the risk for discontinuity of diabetes care after discharge.

Transition from specialist to primary diabetes care: a qualitative study of perspectives of primary care physicians.

BACKGROUND: The growing prevalence of diabetes and heightened awareness of the benefits of early and intensive disease management have increased service demands and expectations not only of primary care physicians but also of diabetes specialists. While research has addressed issues related to referral into specialist care, much less has been published about the transition from diabetes specialists back to primary care. Understanding the concerns of family physicians related to discharge of diabetes care from specialist centers can support the development of strategies that facilitate this transition and result in broader access to limited specialist services. This study was undertaken to explore primary care physician (PCP) perspectives and concerns related to reassuming responsibility for diabetes care after referral to a specialized diabetes center. METHODS: Qualitative data were collected through three focus groups. Sessions were audio-taped and transcribed verbatim. Data were coded and sorted with themes identified using a constant comparison method. The study was undertaken through the regional academic referral center for adult diabetes care in Ottawa, Canada. Participants included 22 primary care physicians representing a variety of referral frequencies, practice types and settings. RESULTS: Participants described facilitators and barriers to successful transition of diabetes care at the provider, patient and systems level. Major facilitators included clear communication of a detailed, structured plan of care, ongoing access to specialist services for advice or re-referral, continuing education and mentoring for PCPs. Identified provider barriers were gaps in PCP knowledge and confidence related to diabetes treatment, excessive workload and competing time demands. Systems deterrents included reimbursement policies for health professionals and inadequate funding for diabetes medications and supplies. At the PCP-patient interface, insufficient patient confidence or trust in PCP's ability to manage diabetes, poor motivation and "non-compliance" emerged as potential patient barriers to transition. Incongruence between PCP attitudes and expectations related to diabetes self-management and those of patients who had attended a multidisciplinary specialist center was also observed. CONCLUSION: This study underlines the breadth of PCP concerns related to transition of diabetes care and the importance of this topic to them. While tools that promote timely information flow and care planning are cornerstones to successful transition, and may be sufficient for some practitioners, appropriately resourced decision support and education strategies should also be available to enhance PCP capacity and readiness to resume diabetes care after referral to a specialist center. Characteristics of the patient-care provider relationship that impact discharge were identified and are worthy of further research.