Barriers to High-quality Postoperative Glycemic Management by Surgical Teams: A Theory-informed Qualitative Analysis.

OBJECTIVE: Our aim in this study was to identify the barriers to following recommendations for postoperative glycemic management among surgical team members. METHODS: We conducted semistructured interviews with surgical team members guided by 2 theoretical frameworks for understanding the barriers and drivers of health-care behaviours: the Theoretical Domains Framework and the Consolidated Framework for Implementation Research. Interview data were coded deductively by 2 study team members. RESULTS: Sixteen surgical team members from 7 surgical disciplines at a single hospital participated in this investigation. The most important barriers to management of postoperative hyperglycemia were knowledge of glycemic targets, belief about consequences of hyper- and hypoglycemia, available resources to manage hyperglycemia, adaptability of usual insulin regimens to complex postoperative patients, and skills to initiate insulin. CONCLUSIONS: Interventions to reduce postoperative hyperglycemia are unlikely to be effective unless they use implementation science to address local barriers to high-quality management among surgical team members, including setting and systems-level barriers.

Implementation of a Multidisciplinary Educational Strategy Promoting Basal-Bolus Insulin Therapy Improves Glycemic Control and Reduces Length of Stay for Inpatients With Diabetes.

IN BRIEF "Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc. (ACP), and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an initiative to increase the use of basal-bolus insulin therapy for hyperglycemia in an inpatient setting and to evaluate its effects on patient outcomes compared to sliding-scale insulin therapy.

Knowledge Translation to Optimize Adult Inpatient Glycemic Management With Basal Bolus Insulin Therapy and Improve Patient Outcomes.

OBJECTIVES: To develop and evaluate a Basal Bolus Insulin Therapy (BBIT) Knowledge Translation toolkit to address barriers to adoption of established best practice with BBIT in the care of adult inpatients. METHODS: This study was conducted in 2 phases and focused on the hospitalist provider group across 4 acute care facilities in Calgary. Phase 1 involved a qualitative evaluation of provider and site specific barriers and facilitators, which were mapped to validated interventions using behaviour change theory. This informed the co-development and optimization of the BBIT Knowledge Translation toolkit, with each tool targeting a specific barrier to improved diabetes care practice, including BBIT ordering. In Phase 2, the BBIT Knowledge Translation toolkit was implemented and evaluated, focusing on BBIT ordering frequency, as well as secondary outcomes of hyperglycemia (patient-days with BG >14.0 mmol/L), hypoglycemia (patient-days with BG <4.0 mmol/L), and acute length of stay. RESULTS: Implementation of the BBIT Knowledge Translation toolkit resulted in a significant 13% absolute increase in BBIT ordering. Hyperglycemic patient-days were significantly reduced, with no increase in hypoglycemia. There was a significant, absolute 14% reduction in length of stay. CONCLUSIONS: The implementation of an evidence-informed, multifaceted BBIT Knowledge Translation toolkit effectively reduced a deeply entrenched in-patient diabetes care gap. The resulting sustained practice change improved patient clinical and system resource utilization outcomes. This systemic approach to implementation will guide further scale and spread of glycemic optimization initiatives.

Qualitative Evaluation of the Barriers and Facilitators Influencing the Use of an Electronic Basal Bolus Insulin Therapy Protocol to Improve the Care of Adult Inpatients With Diabetes.

OBJECTIVES: A qualitative evaluation of the perceived impact of a new evidence-informed electronic basal bolus insulin therapy order set on clinical workflow and practice, and exploration of potential barriers and facilitators to electronic basal bolus insulin order set uptake and use in acute care facilities for various acute care team members. METHODS: We conducted 9 semistructured focus groups with multidisciplinary nursing staff (n=22), resident trainees (n=24) and attending physicians (n=23) involved in the delivery of inpatient diabetes care at 3 adult acute care facilities. The domains of inquiry included impact on workload, perceived impact on patient care and discipline-specific barriers and facilitators to use, including care-providers' needs, comfort and competencies, contributions from the clinical environment and efficacy of communication. The interviews were transcribed and analyzed using a content analysis approach. RESULTS: Several major themes emerged from the focus group discussions, including impact of education, information technology/user interface, workflow, organizational issues and practices, and perceived outcomes. Barriers and facilitators were identified relating to each theme. CONCLUSIONS: The outcomes highlight the complex interplay between educational, organizational and technical themes and the significance of employing a systemic approach to support the implementation of electronic inpatient glycemic-management protocols within complex social organizations.

Analysis of mitochondrial DNA in microfluidic systems.

Abnormalities in mitochondrial function play a major role in many human diseases. It is often of critical importance to ascertain what proportion of the mitochondria within a cell, or cells, bear a given mutation (the mitochondrial "demographics"). In this work, a rapid, novel, on-chip procedure was used, in which a restriction enzyme was employed to excise a mitochondrial DNA (mtDNA) sequence from plasmid DNA that acted as a prototypical mitochondrial genome. The DNA was then denatured, reassembled to form duplexes, fluorescently labelled and analysed. This method was able to differentiate between a homogeneous population and a heterogeneous population. Using a microfluidic chip, the method could be performed in about 45 min, even without robotics or multiplexed operation, whereas conventional methods of analysis require days to perform. This method may ultimately form the basis for a means of characterizing the mitochondrial demographics of a single cell.

Tissue localization of the copper chaperone ATOX1 and its potential role in disease.

ATOX1 is a cytoplasmic copper chaperone that interacts with the copper-binding domain of the membrane copper transporters ATP7A and ATP7B. ATOX1 has also been suggested to have a potential anti-oxidant activity. This study investigates the tissue-specific localization of the mouse homolog, Atox1, in mouse liver and kidney. Immunohistochemical studies in the liver localize the copper chaperone to hepatocytes surrounding both hepatic and central veins. In the kidney, Atox1 is localized to the cortex and the medulla. Cortex immunostaining is specific to glomeruli in both the juxtamedullary and cortical nephrons. Expression in the medulla appears to be associated with the loops of Henle. These data suggest that localized regions in the liver and kidney express Atox1 and have a role in copper homeostasis and/or anti-oxidant protection. Twenty-seven patients with Wilson disease-like phenotypes and two patients with Menkes disease-like phenotypes were screened for ATOX1 mutations with no alterations detected. The human phenotype resulting from mutations in ATOX1 remains unidentified.