Quality improvement project for improving inpatient glycaemic control in non-critically ill patients admitted on medical floor with type 2 diabetes mellitus

Abstract

A significant number of patients admitted to the medical floor have type 2 diabetes mellitus (DM). Lack of a standardised inpatient hyperglycaemia management protocol leads to improper glycaemic control adding to morbidity in such patients. American Diabetes Association, in its 2019 guidelines, recommends initiation of a regimen consisting of basal insulin (long-acting insulin) or basal plus correctional insulin for non-critically ill hospitalised patients with poor or no oral intake. A combination of basal insulin, bolus (short-acting premeal or prandial) insulin and correctional scale insulin is recommended for inpatient hyperglycaemia management in non-critical patients with type 2 DM who have proper oral intake. Baseline data of 100 patients with diabetes admitted to Hamad General Hospital Doha, Qatar, showed that although insulin was used in the majority of patients, there was lack of uniformity in the initiation of insulin regimen. Adequate glycaemic control (7.8–10 mmol/L) was achieved in 45% of patients. Using Plan–Do–Study–Act (PDSA) model of improvement, a quality improvement project was initiated with the introduction of a standardised inpatient hyperglycaemia management protocol aiming to achieve 50% compliance to protocol and improvement in inpatient glycaemic control from baseline of 45% to 70%. Interventions for change included development of a standardised inpatient hyperglycaemia management protocol and its provision to medical trainees, teaching sessions for trainees and nurses, active involvement of medical consultants for supervision of trainees to address the fear of hypoglycaemia, regular reminders/feedbacks to trainees and nurses about glycaemic control of their patients and education about goals of diabetes management during hospitalisation for patients with diabetes. Overall, glycaemic control improved significantly with target glycaemic control of 70% achieved in 4 of the 10 PDSA cycles without an increase in the number of hypoglycaemic episodes. We conclude that development of a standardised inpatient insulin prescribing protocol, educational sessions for medical trainees and nurses about goals of diabetes management during hospitalisation, regular reminders to healthcare professionals and patient education are some of the measures that can improve glycaemic control of patients with type 2 DM during inpatient stay.