Research Article
Perceptions, Barriers, and Knowledge of Inpatient Glycemic Control: A Survey of Health Care Workers
Journal of Pharmacy Practice 1-7 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190014566309 jpp.sagepub.com
Regine Beliard, PharmD1,2, Karina Muzykovsky, PharmD3,4, William Vincent III, PharmD5, Bupendra Shah, PhD4, and Evangelia Davanos, PharmD3,4
Abstract Objectives: To assess knowledge and perceptions of health care workers regarding optimal care for patients with hyperglycemia and identify commonly perceived barriers for the development of a hospital-wide education program. Research Design and Methods: A cross-sectional design was utilized to survey health care workers involved in managing hyperglycemia in an urban, community teaching hospital. Each health care worker received a survey specific to their health care role. Results: Approximately 50% of questions about best clinical practices were answered correctly. Correct responses varied across disciplines (n, mean + standard deviation [SD]), that is, physicians (n ¼ 112, 53% + 26%), nurses (n ¼ 43, 52% + 35%), pharmacists (n ¼ 20, 64% + 23%), dietitians (n ¼ 5, 48% + 30%), and patient care assistants (n ¼ 12, 38% + 34%). Most health care workers perceived hyperglycemia treatment to be very important and that sliding scale insulin was commonly used because of convenience but not efficacy. Conclusion: Knowledge regarding hyperglycemia management was suboptimal across a sample of health care workers when compared to clinical best practices. Hyperglycemia management was perceived to be important but convenience seemed to influence the management approach more than efficacy. Knowledge, perceptions, and barriers seem to play an important role in patient care and should be considered when developing education programs prior to implementation of optimized glycemic protocols. Keywords hyperglycemia, survey, diabetes, inpatient, education
Background The results of recent clinical trials demonstrate that tight glycemic control may increase mortality in critically ill and noncritically ill patients, therefore resulting in a shift of glycemic targets in both of these populations.1,2 Although the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) have published an updated consensus statement on inpatient glycemic control, its implementation has been slow and has met resistance possibly due to systematic and perceived barriers.3 There are some studies evaluating the perceptions, barriers, and knowledge of health care workers regarding inpatient hyperglycemia management; however, there are no studies that examine perceptions, barriers, and knowledge of health care workers in accordance with new inpatient glycemic goals.3-11 These studies revealed that most nurses and residents require additional education in order to provide optimal care to patients with diabetes, that educational programs should emphasize inpatient treatment strategies for glycemic control, and that the most commonly reported barrier to ideal management was lack of knowledge about insulin treatment options. One study conducted by Derr et al evaluated insulin-related knowledge
among health care workers in internal medicine but did not associate these responses with an evaluation of perceptions and barriers toward inpatient management of hyperglycemia.11 Since the publication of the consensus guidelines, there are no studies evaluating the perceptions and knowledge of multiple health care workers including pharmacists, dietitians, and patient care assistants who are involved in the management of inpatient hyperglycemia.1 Prior studies have also not compared health care worker perceptions on current management
1 Department of Clinical and Administrative Sciences, Notre Dame of Maryland University, School of Pharmacy, Baltimore, MD, USA 2 Johns Hopkins Community Physicians, Greater Dundalk, Baltimore, MD, USA 3 Department of Pharmacotherapy, The Brooklyn Hospital Center, Brooklyn, NY, USA 4 Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY, USA 5 Department of Pharmacy, Boston Medical Center, Boston, MA, USA
Corresponding Author: Regine Beliard, Department of Clinical and Administrative Sciences, Notre Dame of Maryland University, School of Pharmacy, Baltimore, MD 21210, USA. Email: [email protected]
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techniques in comparison to published guidelines while also attempting to understanding the barriers that health care workers face when treating inpatient hyperglycemia. With constantly changing recommendations, there is currently no literature assessing current management techniques in comparison with recent guidelines.
Research Design and Methods Study Objectives The purpose of this study was to assess the knowledge and perceptions of medical and pharmacy residents, attending physicians, nurses, pharmacists, dietitians, and patient care assistants in regard to the management of inpatient hyperglycemia with regard to the most current consensus statement. Additionally, the study sought to identify common barriers and evaluate current treatment modalities in order to provide guidance for the development of a hospital-wide education program focused on management of inpatient hyperglycemia prior to developing and implementing a glycemic quality improvement project focused on a basal-bolus insulin protocol for noncritically ill patients.
Study Design A cross-sectional design was utilized to survey physicians, nurses, pharmacists, dietitians, and patient care assistants involved in managing hyperglycemia in the inpatient setting of a 450-bed, community teaching, urban hospital. Each survey consisted of questions specifically pertaining to the job functions of each health care worker, the perceived importance of managing hyperglycemia, the perceived comfort related to managing hyperglycemia, barriers to optimal care of patients with hyperglycemia and assessment of knowledge in comparison to clinical best practices. Survey questions were piloted with a health care worker from each discipline for face and content validity prior to hospital-wide survey dissemination. Paper surveys were approved by the institutional review board and administered during departmental meetings from December 2011 to April 2012. Completed surveys were collected and entered in a Microsoft Excel database and subsequently analyzed using SPSS version 19.0. Descriptive and bivariate analyses were conducted and are reported.
Survey Development Five unique surveys were designed specifically for physicians, pharmacists, nurses, dietitians, and patient care assistants (Supplemental Surveys S1-5). Surveys incorporated questions assessing the perceived burden of diabetes mellitus (4 items), the perceived importance of the treatment of hyperglycemia (4 items), perceived comfort of managing hyperglycemia (4 items), perceived barriers that may prevent optimal care of inpatient hyperglycemia (13-18 items), and knowledge-based questions (7-13 questions). Items and questions related to perceived barriers and knowledge were tailored to each health care
worker’s role in the management of inpatient hyperglycemia, with common themes for all health care workers to enable comparison. Knowledge questions were obtained from the AACE/ ADA Consensus Statement2 published in 2009 and were assessed on a correct/incorrect basis. Questions pertaining to the importance of treatment of hyperglycemia were assessed using a 4-item scale with a 5-point Likert-type importance measurement (1, not at all important to 5, very important), whereas questions pertaining to comfort in treating patients with hyperglycemia were assessed using a 4-item scale with a 5-point Likert-type comfort measurement (1, not at all comfortable to 5, very comfortable). Items related to barriers were assessed using 13 to 18 questions, specific to each health care worker’s job function using a 5-point Likert-type significant measurement (1, not at all significant to 5, very significant).
Target Study Participants Eligible participants included medical and surgical residents, medical fellows, attending physicians, staff pharmacists, pharmacy residents, clinical pharmacists, nurses, dietitians, and patient care assistants. Obstetrics/gynecology and pediatric physicians, students, pediatric and dialysis nurses, and the pilot study group were excluded from participating in the study. Hardcopy surveys were distributed during grand rounds, noon conferences, and departmental meetings. Participants were not provided with a time constraint to complete the survey. A survey proctor was present to ensure that participants did not use outside resources or consult with fellow participants when completing the survey. Study participants were provided an incentive of a small breakfast, lunch, or snack, which was funded by The Brooklyn Hospital Center Pharmacotherapy research fund.
Statistical Analysis Descriptive statistics were utilized to analyze the study data. Reliability and internal consistency of the perceptions and barriers were determined using Cronbach’s alpha (a) with a value of .6 or greater being desirable.12 Statistical analysis was performed using IBM SPSS Statistics Software v19.0. The data are presented as mean and a range of 1 standard deviation. Exploratory factor analysis (EFA) was used in the barriers section to determine what proportion of total barriers was captured by assessing the number of items that are interrelated. Capturing at least 30% to 40% of a concept was desirable.
Results Study Population Demographics A total of 185 health care workers participated in the study (Table 1). Of a possible 336 total physician respondents, 112 (33%) surveys were completed by residents, fellows, and attendings within family medicine, internal medicine, surgery, and emergency medicine departments. The majority (54%) of respondents belonged to the internal medicine department. Of
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Table 1. Health care worker demographics. Demographics
Physicians, n ¼ 112
Age 22-35 80 (71.4) 36-50 18 (16.1) >50 9 (8) Unknown 5 (4.5) Gender Male 70 (62.5) Female 31 (27.7) Unknown 11 (9.8) Health care role Attending 12 (10.7) All second year fellows 1 (0.9) All first year residents 68 (60.7) All second year residents 22 (19.6) All third year residents 28 (25) All fourth year residents 4 (3.6) All fifth year residents 1 (0.9) Specialty Internal medicine 61 (54.5) Surgery 21 (18.8) Emergency medicine 13 (11.6) Family medicine 11 (9.8) Pulmonary medicine 1 (0.9) Cardiology 1 (0.9) Previous experience with basal/bolus insulin protocol Yes 45 (40.2) No 62 (55.4) Unknown 0 Unita N/A Med/surg PACU CPCU/CCU MICU SICU ED
Nurses, n ¼ 43
Pharmacists, n ¼ 20
7 (16.3) 19 (44.2) 10 (23.3) 7 (16.3)
14 (70) 1 (5) 0 2 (10)
1 1 2 1
1 (2.3) 37 (86) 5 (11.6) N/A
6 (30) 12 (60) 2 (10) N/A
0 5 (100) 0 N/A
9 (75) 3 (25) 0 N/A
N/A
N/A
N/A
N/A
5 (11.6) 32 (74.4) 0
6 (30) 12 (60) 0 N/A
2 (40) 3 (60) 0
0 9 (75) 3 (25)
1 (20) 0 1 (20) 0 1 (20) 0
10 (83.4) 0 1 (8.4) 1 (8.4) 1 (8.4) 2 (16.7)
31 (72.1) 1 (2.3) 6 (14) 1 (2.3) 2 (4.6)
Dietitians, n ¼ 5 (20) (20) (40) (20)
PCAs, n ¼ 12 2 4 2 4
(16.7) (33.4) (16.7) (33.4)
Abbreviations: PCA, patient care assistant; Med/Surg, medical/surgical; PACU, postanesthesia care unit; CPCU, cardiac progressive care unit; CCU, coronary care unit; MICU, medical intensive care unit; SICU, surgical intensive care unit; ED, emergency department; N/A, not applicable. a May select more than 1 unit.
a possible 107 total nurse respondents, 43 (40%) surveys were completed among nurses working with patients in the general medicine and surgery units, the surgical and medical intensive care units, and the cardiac and cardiopulmonary units. Of a total of 34 pharmacists, 20 (59%) employed by the hospital completed the survey. All 5 (100%) dietitians employed by the institution completed the survey. Finally, 12 (12%) of the 100 patient care assistants completed the survey.
Health Care Workers’ Knowledge of Glycemic Management No health care worker answered all questions correctly. Figure 1 depicts the portion of questions answered correctly on an average by each group of health care workers for all questions asked in each survey.
Figure 1. Mean knowledge scores among all health care workers.
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Among the physicians and nurses, questions frequently answered incorrectly pertained to the definition of hypoglycemia, the preprandial blood glucose goal, and the optimal medication regimen for patients admitted to the hospital as per the 2009 consensus statement.1 Questions frequently answered incorrectly by pharmacists pertained to the preprandial blood glucose goal, the blood glucose value threshold for initiating insulin therapy, and the fastest treatment modality for hypoglycemia. Dietitians frequently answered questions incorrectly pertaining to the optimization of bolus insulin for elevated postprandial blood glucose values, the blood glucose value threshold for initiating insulin therapy, and the components of meal planning as per the Diabetes Nutrition Recommendations for Healthcare Institutions published by the ADA.13 Finally, patient care assistants frequently answered questions incorrectly relating to the definition of hypoglycemia, the postprandial blood glucose goal, and the timing of finger sticks in relation to insulin administration (Table 2).
Perceived Importance of Care The Cronbach’s a for the 4-item perceived importance of care scale was .7 or greater in all surveys except the nurse survey (a for perceived importance of care for physicians ¼ .7, pharmacists ¼ .7, dietitians ¼ .8, patient care assistants ¼ .7, and nurses ¼ .43). The lowest mean total score on the perceived importance of care scale (out of 20) was obtained for patient care assistants (physicians: 18 + 2, pharmacists: 19 + 1, dietitians: 18 + 1, and patient care assistants: 14 + 1).
Perceived Comfort of Providing Care The Cronbach’s a for the 4-item perceived comfort of providing care scale was .7 or greater for physicians and pharmacists but somewhat lower for nurses (a for perceived comfort of providing care in the physician survey ¼ .7, in the pharmacist survey ¼ .9, and nurse survey ¼ .6). The mean total score on the perceived comfort of providing care scale (out of 20) was higher among physicians than pharmacists (physicians: 16 + 3 and pharmacists 15 + 4).
Opinions of Sliding Scale Insulin Sixty percent of physicians believed that sliding scale insulin was commonly used because it is the most convenient method of managing hyperglycemia. Thirty-four percent of physicians felt that sliding scale was commonly used because it is the most effective method of managing hyperglycemia and 22% felt that its use was reinforced during training at this particular institution. Nurses felt that sliding scale insulin was commonly used because it is the most effective method of managing hyperglycemia, with 54% of respondents believing so. Forty-four percent of nurses felt that sliding scale insulin was the more convenient method of managing hyperglycemia and 12% felt that its use was reinforced at this institution. Sixty percent of pharmacists believed that sliding scale insulin was commonly
Table 2. Questions Frequently Answered Incorrectly.a
Questions answered incorrectly Physicians, n ¼ 112 Definition of hypoglycemia Reference: Supplemental survey 1, Question 1 Preprandial blood glucose goal Reference: Supplemental survey 1, Question 2 Optimal medication regimen Reference: Supplemental survey 1, Question 9 Nurses, n ¼ 43 Definition of hypoglycemia Reference: Supplemental survey 2, Question 1 Pre-prandial blood glucose goal Reference: Supplemental survey 2, Question 2 Optimal medication regimen Reference: Supplemental survey 3, Question 9 Pharmacists, n ¼ 20 Pre-prandial blood glucose goal Reference: Supplemental survey 3, Question 2 Blood glucose to initiate insulin Reference: Supplemental survey 3, Question 7 Fastest treatment for hypoglycemia Reference: Supplemental survey 3, Question 8 Dietitians, n ¼ 5 Optimizing insulin for postprandial blood glucose Reference: Supplemental survey 4, Question 4 Blood glucose to initiate insulin Reference: Supplemental survey 4, Question 7 Components of meal planning Reference: Supplemental survey 4, Question 12 Patient care assistants, n ¼ 12 Definition of hypoglycemia Reference: Supplemental survey 5, Question 1 Postprandial blood glucose goal Reference: Supplemental survey 5, Question 3 Timing of finger sticks Reference: Supplemental survey 5, Question 4
Percentage of those who answered incorrectly 83.9 78.6 45.5
72 95.2 88
70 45 50
100 80 60
91.6 91.6 66.6
a
Questions left blank were considered incorrect.
used because it is the most convenient method of managing hyperglycemia. Thirty percent of pharmacists believed that sliding scale insulin was the most effective method of managing hyperglycemia and 20% believed that its used was reinforced at the institution.
Barriers to Care The top 5 barriers to optimal care reported by physicians included prolonged nil per os (NPO) status, lack of educational reinforcement to the patient, unpredictable timing of patient procedures, lack of coordination between meal delivery and insulin administration, and lack of a standardized basal-bolus insulin protocol (a ¼ .9; EFA 32%). Nurses believed the top barriers to optimal care included prolonged NPO status, unpredictable changes in patient diet and mealtimes, lack of prompt delivery of medications from the pharmacy, lack of educational
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reinforcement to the patient, and lack of coordination between meal delivery and insulin administration (a ¼ .9; EFA 38%). Pharmacists believed that the lack of a standardized basalbolus insulin protocol, lack of coordination between meal delivery and insulin administration, shift changes and crosscoverage leading to inconsistent management, prolonged NPO status, and lack of educational reinforcement to the patient were the top barriers to care (a ¼ 0.8; EFA 36%). Although the Cronbach’s a and EFA were not significant for the dietitian survey, these health care workers believed that barriers to care included the priority of care placed on more acute patient issues, risk of causing hypoglycemia, incorrect and/or no diet orders placed in patient’s medical record, patients not in the hospital long enough to control blood glucose, and unpredictable changes in patient’s diet and mealtimes. Finally, patient care assistants believed that the top barriers to care included lack of coordination between meal delivery and finger-stick times, unpredictable changes in patient diet and mealtimes, priority being placed on more acute patient issues, risk of causing hypoglycemia, and unpredictable timing of patient procedures leading to not obtaining glucose finger sticks at the correct time (a ¼ 0.9; EFA unable to determine).
Conclusion Despite recent updates to the AACE/ADA Consensus Statement, response to reform current clinical practices to reflect recent literature has been slow and often meets resistance possibly due to systematic and perceived barriers.1 There have been numerous publications emphasizing the importance of focusing on hyperglycemia management in the hospital, but it is clear that there are many obstacles that are faced when implementing programs geared at optimizing glycemic control.4,14 These obstacles are likely partly due to the lack of quality evidence regarding management of hyperglycemia in noncritically ill patients and lack of knowledge of health care workers that care for patients with hyperglycemia.1 Guidelines for inpatient management of hyperglycemia were first published in 2004 by the American College of Endocrinology.15 Blood glucose targets for noncritically ill patients were supported by data from prospective observational studies.1 Extrapolated data from critically ill patients were used for recommendations in noncritically ill patients in the 2006 American Clinical Endocrinologist/ADA consensus statement.16 Tight glycemic control was encouraged until the results of the Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation (NICE-SUGAR) trial in 2009, which revealed that increased mortality was observed in critically ill patients managed this way.2 Discrepancy in study results may have been attributed to differences in measurement and reporting of blood glucose values, study participants, glycemic variability, and/or nutrition support.1 In 2009, the AACE and the ADA joined forces to create an updated consensus statement to address the results of newer studies and extrapolate these results to noncritically ill patients.1 Repeated changes in glycemic goals and methods of management within
the past 10 years may attribute to a lack of acceptance of recent guidelines among the medical community. Identifying the knowledge deficits and perceptions of health care workers in regard to hyperglycemia management may also help to explain why there is a slow response to reform current clinical practice. It is likely beneficial to consider the perceptions, barriers, and knowledge of those caring for patients with hyperglycemia in order to develop a meaningful and targeted hospital-wide education program prior to implementing optimized glycemic protocols involving basal-bolus insulin methods. There have been studies that assess these components in physicians, nurses, and mid-level practitioners, but to our knowledge there are no data assessing these components in regard to the entire multidisciplinary team caring for patients with hyperglycemia when using the 2009 consensus statement as a guide.3,6-17 This survey helps provide important information regarding knowledge and perceptions of health care workers on the provision of optimal care to patients with hyperglycemia. This information will be important for the successful development and implementation of a structured insulin protocol for noncritically ill patients at The Brooklyn Hospital Center by highlighting specific educational and systematic barriers that need to be addressed through educational efforts. From a clinical perspective, because every discipline did not score a 100% on the knowledge portion of the survey, we can conclude that there is a lack of knowledge among all health care workers in regard to inpatient glycemic management. Previous studies show similar results for a lack of overall knowledge, with mean scores of 71% and 59% for house staff physician residents and 66% and 47% for nurses.7,9,11 From a research perspective, physicians, nurses, and pharmacists obtained a higher score than the mean of all health care workers, therefore we can conclude that they are more knowledgeable. Dietitians and patient care assistants obtained a score lower than the mean of all health care workers and therefore are less knowledgeable. According to survey results, although many health care workers successfully recognized the signs and symptoms of hyperglycemia and hypoglycemia, they were unable to correctly identify definition of hypoglycemia and frequently answered questions incorrectly that pertained to the recommended optimal treatment regimen for patients. An alternative question frequently answered incorrectly pertained to the definition of the preprandial blood glucose goal in noncritically ill patients. We can conclude that health care workers are able to appropriately identify signs and symptoms of hyperglycemia and hypoglycemia, although many are unable to define the blood glucose concentration that indicates hypoglycemia and many do not appropriately treat these symptoms or treat patients with recommended treatment goals in mind. Comparatively, in a validated survey administered to nurses and house staff residents, questions averaging less than 50% correct pertained to the fasting plasma glucose criterion for diagnosis of diabetes, insulin pharmacokinetics, and treatment of severe hypoglycemia.9 The survey conducted by Derr et al found results similar to our study where residents and nurses
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frequently answered questions incorrectly pertaining to the definition of hypoglycemia.11 Results of our study reiterate some of the commonly identified knowledge deficits and illustrate that a lack of knowledge is not only evident among residents and nurses, but among pharmacists, dietitians, and patient care assistants as well. The basal-bolus method of insulin administration for the treatment of hyperglycemia has been shown to be a proactive and effective approach to glycemic control as opposed to the reactive sliding scale method.18,19 Many previous studies indicate that health care workers believe that the treatment of hyperglycemia in noncritically ill patients was somewhat important or very important, although these studies do not assess why health care workers believe that sliding scale insulin, a proven ineffective method of management, is often used.3,6,8,17,18 Assessing these perceptions may help educators understand whether suboptimal care is a result of hospital culture and/or a lack of knowledge. Interestingly, despite the majority of health care workers believing that the treatment of hyperglycemia is very important, more than 50% of physicians and pharmacists also believed that sliding scale insulin was used most frequently out of convenience as opposed to efficacy. Although we were unable to determine how important nurses believed the treatment of hyperglycemia was, it was dismaying to discover that greater than 50% of nurses believed that sliding scale insulin was the most effective method of treating hyperglycemia. The discordance in optimal medication use and actual medication use provides an opportunity for quality improvement and education to dispel beliefs to those who may believe sliding scale insulin is the optimal treatment method of choice. The most commonly cited barriers and their corresponding perceived significance helps target systematic weaknesses that may benefit from crucial examination prior to the implementation of a glycemic quality improvement project. Results of this survey clearly express the need for a systematic method of coordinating care, including assessing blood glucose values and providing insulin relative to meals. Unlike previous studies, surveying the entire multidisciplinary team while creating a validated survey tailored to the specific job function of a health care worker helps provide valuable insight on what to target within each department to optimize glycemic control.3,6,7,8,10,17 Results of this survey will be used to tailor education for each health care discipline and anticipate potential barriers to care. One limitation of this study was the survey length. Many respondents commented on the length of time required to complete the survey and as a result, test fatigue may have occurred and caused an inaccurate assessment of true results and perceptions to care. Despite conducting a pilot survey and assessing the length of time required for the completion of the survey, we underestimated the survey time required for the general population. During survey administration, proctors were unable to answer questions regarding survey content or terminology. The verbiage of the survey was not tailored to health care worker average literacy level and this could have led to
falsely low results. During the development of survey questions, authors were unaware that patient care assistants were provided with very limited access to protected health information in the electronic medical record. With limited access to patient medical records, patient care assistances may not have been able to accurately answer questions pertaining to burden of care. Finally, it was difficult to reach each health care worker from every discipline. Obtaining the majority of health care workers from each discipline would have provided a more robust sample size to draw large-scale conclusions regarding this institution. The results of this study help voice the opinions of health care workers invested in the care of patient with hyperglycemia, assess current knowledge regarding the care of patients with hyperglycemia as it pertains to individual health care role, and assist in pinpointing what education is needed for a hospital-wide education program in order to secure successful implementation of a basal-bolus insulin protocol. Although there is a lack of knowledge among all health care workers regarding hyperglycemia management when compared to clinical best practices, this survey has highlighted the most important areas to focus on and provides a platform to successfully create targeted education programs prior to optimizing current glycemic protocols. Supplemental Material The online data supplements are available at http://jpp.sagepub.com/ supplemental.
Authors’ Note This work was supported by The Brooklyn Hospital Pharmacotherapy Research Fund. No potential conflicts of interest relevant to this article were reported. RB was a co-investigator for this study and was responsible for conception and design of the study in addition to data collection, analysis and was the primary writer for this manuscript. ED was the primary investigator for this study as was responsible for oversight of study design, data collection, and manuscript review and editing. KM and WV were responsible for oversight of study design and manuscript review and editing. BS was responsible for oversight of study design, statistical analysis, and manuscript review and editing.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologist and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Diabetes Care. 2009;32(6):1119-1131. 2. Finfer S, Chittock DR, Su SY, et al. (NICE-SUGAR Study Investigators). Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-1297.
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3. Cook CB, McNaughton DA, Braddy CM, et al. Management of inpatient hyperglycemia: assessing perceptions and barriers to care among resident physicians. Endocr Pract. 2007;13(2): 117-124. 4. Klonoff DC. Hospital diabetes: why quality of care matters to both patients and hospitals. J Diabetes Sci Technol. 2011;5(1): 1-4. 5. Cook CB, Elias B, Kongable GL, et al. Diabetes and hyperglycemia quality improvement efforts in hospital in the United States: current status, practice variation, and barriers to implementation. Endocr Pract. 2010;16(2):219-230. 6. Cheekati V, Osburne RC, Jameson KA, et al. Perceptions of resident physicians about management of inpatient hyperglycemia in an urban hospital. J Hosp Med. 2009;4(1):E1-E8. 7. Latta S, Alhosaini MN, Al-Solaiman Y, et al. Management of inpatient hyperglycemia: assessing knowledge and barriers to better care among residents. Am J Ther. 2011;18(5): 355-365. 8. El-Kebbi IM, Ziemer DC, Gallina DL, et al. Diabetes in urban African-Americans. XV. Identifications of barriers to provider adherence to management protocols. Diabetes Care. 1999; 22(10):1617-1620. 9. Rubin DJ, Moshang J, Jabbour SA. Diabetes knowledge: are resident physicians and nurses adequately prepared to manage diabetes? Endocr Pract. 2007;13(1):17-21. 10. Giangola J, Olohan K, Longo J, et al. Barriers to hyperglycemia control in hospitalized patients: a descriptive epidemiologic study. Endocr Pract. 2008;14(7):813-819.
11. Derr RL, Sivanandy MS, Bronich-Hall L, et al. Insulin-related knowledge among health care professionals in internal medicine. Diabetes Spectrum. 2007;20:177-185. 12. Tavakol M, Dennick R. Making sense of Cronbach’s alpha. Int J Med Educ. 2011;2:53-55. 13. Schafer RG, Bohannon B, Franz MJ, et al. Diabetes nutrition recommendations for health care institutions. Diabetes Care. 2004; 27(1):S55-S57. 14. Cook CB, Elias B, Kongable GL, et al. Diabetes and hyperglycemia quality improvement efforts in hospital in the United States: a current status, practice variation and barriers to implementation. Endocr Pract. 2010;16(2):219-230. 15. Garber AJ, Moghissi ES, Bransome ED Jr, et al. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract. 2004;10(suppl 2):4-9. 16. ACE/ADA Task Force on Inpatient Diabetes. American College of Endocrinology and American Diabetes Association consensus statement on inpatient diabetes and glycemic control: a call to action. Diabetes Care. 2006;29:1955-1962. 17. Cook CB, Jameson KS, Hartsell ZC, et al. Beliefs about hospital diabetes and perceived barriers to glucose management among inpatient midlevel practioners. Diabetes Educ. 2008;34(1):75-83. 18. Hirsch IB. Sliding scale insulin – time to stop sliding. JAMA. 2009;301(2):213-214. 19. Umpirrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 Trial). Diabetes Care. 2011;30(9):2181-2186.
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Perceptions, Barriers, and Knowledge of Inpatient Glycemic Control: A Survey of Health Care Workers
Journal of Pharmacy Practice 1-7 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190014566309 jpp.sagepub.com
Regine Beliard, PharmD1,2, Karina Muzykovsky, PharmD3,4, William Vincent III, PharmD5, Bupendra Shah, PhD4, and Evangelia Davanos, PharmD3,4
Abstract Objectives: To assess knowledge and perceptions of health care workers regarding optimal care for patients with hyperglycemia and identify commonly perceived barriers for the development of a hospital-wide education program. Research Design and Methods: A cross-sectional design was utilized to survey health care workers involved in managing hyperglycemia in an urban, community teaching hospital. Each health care worker received a survey specific to their health care role. Results: Approximately 50% of questions about best clinical practices were answered correctly. Correct responses varied across disciplines (n, mean + standard deviation [SD]), that is, physicians (n ¼ 112, 53% + 26%), nurses (n ¼ 43, 52% + 35%), pharmacists (n ¼ 20, 64% + 23%), dietitians (n ¼ 5, 48% + 30%), and patient care assistants (n ¼ 12, 38% + 34%). Most health care workers perceived hyperglycemia treatment to be very important and that sliding scale insulin was commonly used because of convenience but not efficacy. Conclusion: Knowledge regarding hyperglycemia management was suboptimal across a sample of health care workers when compared to clinical best practices. Hyperglycemia management was perceived to be important but convenience seemed to influence the management approach more than efficacy. Knowledge, perceptions, and barriers seem to play an important role in patient care and should be considered when developing education programs prior to implementation of optimized glycemic protocols. Keywords hyperglycemia, survey, diabetes, inpatient, education
Background The results of recent clinical trials demonstrate that tight glycemic control may increase mortality in critically ill and noncritically ill patients, therefore resulting in a shift of glycemic targets in both of these populations.1,2 Although the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) have published an updated consensus statement on inpatient glycemic control, its implementation has been slow and has met resistance possibly due to systematic and perceived barriers.3 There are some studies evaluating the perceptions, barriers, and knowledge of health care workers regarding inpatient hyperglycemia management; however, there are no studies that examine perceptions, barriers, and knowledge of health care workers in accordance with new inpatient glycemic goals.3-11 These studies revealed that most nurses and residents require additional education in order to provide optimal care to patients with diabetes, that educational programs should emphasize inpatient treatment strategies for glycemic control, and that the most commonly reported barrier to ideal management was lack of knowledge about insulin treatment options. One study conducted by Derr et al evaluated insulin-related knowledge
among health care workers in internal medicine but did not associate these responses with an evaluation of perceptions and barriers toward inpatient management of hyperglycemia.11 Since the publication of the consensus guidelines, there are no studies evaluating the perceptions and knowledge of multiple health care workers including pharmacists, dietitians, and patient care assistants who are involved in the management of inpatient hyperglycemia.1 Prior studies have also not compared health care worker perceptions on current management
1 Department of Clinical and Administrative Sciences, Notre Dame of Maryland University, School of Pharmacy, Baltimore, MD, USA 2 Johns Hopkins Community Physicians, Greater Dundalk, Baltimore, MD, USA 3 Department of Pharmacotherapy, The Brooklyn Hospital Center, Brooklyn, NY, USA 4 Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY, USA 5 Department of Pharmacy, Boston Medical Center, Boston, MA, USA
Corresponding Author: Regine Beliard, Department of Clinical and Administrative Sciences, Notre Dame of Maryland University, School of Pharmacy, Baltimore, MD 21210, USA. Email: [email protected]
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techniques in comparison to published guidelines while also attempting to understanding the barriers that health care workers face when treating inpatient hyperglycemia. With constantly changing recommendations, there is currently no literature assessing current management techniques in comparison with recent guidelines.
Research Design and Methods Study Objectives The purpose of this study was to assess the knowledge and perceptions of medical and pharmacy residents, attending physicians, nurses, pharmacists, dietitians, and patient care assistants in regard to the management of inpatient hyperglycemia with regard to the most current consensus statement. Additionally, the study sought to identify common barriers and evaluate current treatment modalities in order to provide guidance for the development of a hospital-wide education program focused on management of inpatient hyperglycemia prior to developing and implementing a glycemic quality improvement project focused on a basal-bolus insulin protocol for noncritically ill patients.
Study Design A cross-sectional design was utilized to survey physicians, nurses, pharmacists, dietitians, and patient care assistants involved in managing hyperglycemia in the inpatient setting of a 450-bed, community teaching, urban hospital. Each survey consisted of questions specifically pertaining to the job functions of each health care worker, the perceived importance of managing hyperglycemia, the perceived comfort related to managing hyperglycemia, barriers to optimal care of patients with hyperglycemia and assessment of knowledge in comparison to clinical best practices. Survey questions were piloted with a health care worker from each discipline for face and content validity prior to hospital-wide survey dissemination. Paper surveys were approved by the institutional review board and administered during departmental meetings from December 2011 to April 2012. Completed surveys were collected and entered in a Microsoft Excel database and subsequently analyzed using SPSS version 19.0. Descriptive and bivariate analyses were conducted and are reported.
Survey Development Five unique surveys were designed specifically for physicians, pharmacists, nurses, dietitians, and patient care assistants (Supplemental Surveys S1-5). Surveys incorporated questions assessing the perceived burden of diabetes mellitus (4 items), the perceived importance of the treatment of hyperglycemia (4 items), perceived comfort of managing hyperglycemia (4 items), perceived barriers that may prevent optimal care of inpatient hyperglycemia (13-18 items), and knowledge-based questions (7-13 questions). Items and questions related to perceived barriers and knowledge were tailored to each health care
worker’s role in the management of inpatient hyperglycemia, with common themes for all health care workers to enable comparison. Knowledge questions were obtained from the AACE/ ADA Consensus Statement2 published in 2009 and were assessed on a correct/incorrect basis. Questions pertaining to the importance of treatment of hyperglycemia were assessed using a 4-item scale with a 5-point Likert-type importance measurement (1, not at all important to 5, very important), whereas questions pertaining to comfort in treating patients with hyperglycemia were assessed using a 4-item scale with a 5-point Likert-type comfort measurement (1, not at all comfortable to 5, very comfortable). Items related to barriers were assessed using 13 to 18 questions, specific to each health care worker’s job function using a 5-point Likert-type significant measurement (1, not at all significant to 5, very significant).
Target Study Participants Eligible participants included medical and surgical residents, medical fellows, attending physicians, staff pharmacists, pharmacy residents, clinical pharmacists, nurses, dietitians, and patient care assistants. Obstetrics/gynecology and pediatric physicians, students, pediatric and dialysis nurses, and the pilot study group were excluded from participating in the study. Hardcopy surveys were distributed during grand rounds, noon conferences, and departmental meetings. Participants were not provided with a time constraint to complete the survey. A survey proctor was present to ensure that participants did not use outside resources or consult with fellow participants when completing the survey. Study participants were provided an incentive of a small breakfast, lunch, or snack, which was funded by The Brooklyn Hospital Center Pharmacotherapy research fund.
Statistical Analysis Descriptive statistics were utilized to analyze the study data. Reliability and internal consistency of the perceptions and barriers were determined using Cronbach’s alpha (a) with a value of .6 or greater being desirable.12 Statistical analysis was performed using IBM SPSS Statistics Software v19.0. The data are presented as mean and a range of 1 standard deviation. Exploratory factor analysis (EFA) was used in the barriers section to determine what proportion of total barriers was captured by assessing the number of items that are interrelated. Capturing at least 30% to 40% of a concept was desirable.
Results Study Population Demographics A total of 185 health care workers participated in the study (Table 1). Of a possible 336 total physician respondents, 112 (33%) surveys were completed by residents, fellows, and attendings within family medicine, internal medicine, surgery, and emergency medicine departments. The majority (54%) of respondents belonged to the internal medicine department. Of
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Table 1. Health care worker demographics. Demographics
Physicians, n ¼ 112
Age 22-35 80 (71.4) 36-50 18 (16.1) >50 9 (8) Unknown 5 (4.5) Gender Male 70 (62.5) Female 31 (27.7) Unknown 11 (9.8) Health care role Attending 12 (10.7) All second year fellows 1 (0.9) All first year residents 68 (60.7) All second year residents 22 (19.6) All third year residents 28 (25) All fourth year residents 4 (3.6) All fifth year residents 1 (0.9) Specialty Internal medicine 61 (54.5) Surgery 21 (18.8) Emergency medicine 13 (11.6) Family medicine 11 (9.8) Pulmonary medicine 1 (0.9) Cardiology 1 (0.9) Previous experience with basal/bolus insulin protocol Yes 45 (40.2) No 62 (55.4) Unknown 0 Unita N/A Med/surg PACU CPCU/CCU MICU SICU ED
Nurses, n ¼ 43
Pharmacists, n ¼ 20
7 (16.3) 19 (44.2) 10 (23.3) 7 (16.3)
14 (70) 1 (5) 0 2 (10)
1 1 2 1
1 (2.3) 37 (86) 5 (11.6) N/A
6 (30) 12 (60) 2 (10) N/A
0 5 (100) 0 N/A
9 (75) 3 (25) 0 N/A
N/A
N/A
N/A
N/A
5 (11.6) 32 (74.4) 0
6 (30) 12 (60) 0 N/A
2 (40) 3 (60) 0
0 9 (75) 3 (25)
1 (20) 0 1 (20) 0 1 (20) 0
10 (83.4) 0 1 (8.4) 1 (8.4) 1 (8.4) 2 (16.7)
31 (72.1) 1 (2.3) 6 (14) 1 (2.3) 2 (4.6)
Dietitians, n ¼ 5 (20) (20) (40) (20)
PCAs, n ¼ 12 2 4 2 4
(16.7) (33.4) (16.7) (33.4)
Abbreviations: PCA, patient care assistant; Med/Surg, medical/surgical; PACU, postanesthesia care unit; CPCU, cardiac progressive care unit; CCU, coronary care unit; MICU, medical intensive care unit; SICU, surgical intensive care unit; ED, emergency department; N/A, not applicable. a May select more than 1 unit.
a possible 107 total nurse respondents, 43 (40%) surveys were completed among nurses working with patients in the general medicine and surgery units, the surgical and medical intensive care units, and the cardiac and cardiopulmonary units. Of a total of 34 pharmacists, 20 (59%) employed by the hospital completed the survey. All 5 (100%) dietitians employed by the institution completed the survey. Finally, 12 (12%) of the 100 patient care assistants completed the survey.
Health Care Workers’ Knowledge of Glycemic Management No health care worker answered all questions correctly. Figure 1 depicts the portion of questions answered correctly on an average by each group of health care workers for all questions asked in each survey.
Figure 1. Mean knowledge scores among all health care workers.
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Among the physicians and nurses, questions frequently answered incorrectly pertained to the definition of hypoglycemia, the preprandial blood glucose goal, and the optimal medication regimen for patients admitted to the hospital as per the 2009 consensus statement.1 Questions frequently answered incorrectly by pharmacists pertained to the preprandial blood glucose goal, the blood glucose value threshold for initiating insulin therapy, and the fastest treatment modality for hypoglycemia. Dietitians frequently answered questions incorrectly pertaining to the optimization of bolus insulin for elevated postprandial blood glucose values, the blood glucose value threshold for initiating insulin therapy, and the components of meal planning as per the Diabetes Nutrition Recommendations for Healthcare Institutions published by the ADA.13 Finally, patient care assistants frequently answered questions incorrectly relating to the definition of hypoglycemia, the postprandial blood glucose goal, and the timing of finger sticks in relation to insulin administration (Table 2).
Perceived Importance of Care The Cronbach’s a for the 4-item perceived importance of care scale was .7 or greater in all surveys except the nurse survey (a for perceived importance of care for physicians ¼ .7, pharmacists ¼ .7, dietitians ¼ .8, patient care assistants ¼ .7, and nurses ¼ .43). The lowest mean total score on the perceived importance of care scale (out of 20) was obtained for patient care assistants (physicians: 18 + 2, pharmacists: 19 + 1, dietitians: 18 + 1, and patient care assistants: 14 + 1).
Perceived Comfort of Providing Care The Cronbach’s a for the 4-item perceived comfort of providing care scale was .7 or greater for physicians and pharmacists but somewhat lower for nurses (a for perceived comfort of providing care in the physician survey ¼ .7, in the pharmacist survey ¼ .9, and nurse survey ¼ .6). The mean total score on the perceived comfort of providing care scale (out of 20) was higher among physicians than pharmacists (physicians: 16 + 3 and pharmacists 15 + 4).
Opinions of Sliding Scale Insulin Sixty percent of physicians believed that sliding scale insulin was commonly used because it is the most convenient method of managing hyperglycemia. Thirty-four percent of physicians felt that sliding scale was commonly used because it is the most effective method of managing hyperglycemia and 22% felt that its use was reinforced during training at this particular institution. Nurses felt that sliding scale insulin was commonly used because it is the most effective method of managing hyperglycemia, with 54% of respondents believing so. Forty-four percent of nurses felt that sliding scale insulin was the more convenient method of managing hyperglycemia and 12% felt that its use was reinforced at this institution. Sixty percent of pharmacists believed that sliding scale insulin was commonly
Table 2. Questions Frequently Answered Incorrectly.a
Questions answered incorrectly Physicians, n ¼ 112 Definition of hypoglycemia Reference: Supplemental survey 1, Question 1 Preprandial blood glucose goal Reference: Supplemental survey 1, Question 2 Optimal medication regimen Reference: Supplemental survey 1, Question 9 Nurses, n ¼ 43 Definition of hypoglycemia Reference: Supplemental survey 2, Question 1 Pre-prandial blood glucose goal Reference: Supplemental survey 2, Question 2 Optimal medication regimen Reference: Supplemental survey 3, Question 9 Pharmacists, n ¼ 20 Pre-prandial blood glucose goal Reference: Supplemental survey 3, Question 2 Blood glucose to initiate insulin Reference: Supplemental survey 3, Question 7 Fastest treatment for hypoglycemia Reference: Supplemental survey 3, Question 8 Dietitians, n ¼ 5 Optimizing insulin for postprandial blood glucose Reference: Supplemental survey 4, Question 4 Blood glucose to initiate insulin Reference: Supplemental survey 4, Question 7 Components of meal planning Reference: Supplemental survey 4, Question 12 Patient care assistants, n ¼ 12 Definition of hypoglycemia Reference: Supplemental survey 5, Question 1 Postprandial blood glucose goal Reference: Supplemental survey 5, Question 3 Timing of finger sticks Reference: Supplemental survey 5, Question 4
Percentage of those who answered incorrectly 83.9 78.6 45.5
72 95.2 88
70 45 50
100 80 60
91.6 91.6 66.6
a
Questions left blank were considered incorrect.
used because it is the most convenient method of managing hyperglycemia. Thirty percent of pharmacists believed that sliding scale insulin was the most effective method of managing hyperglycemia and 20% believed that its used was reinforced at the institution.
Barriers to Care The top 5 barriers to optimal care reported by physicians included prolonged nil per os (NPO) status, lack of educational reinforcement to the patient, unpredictable timing of patient procedures, lack of coordination between meal delivery and insulin administration, and lack of a standardized basal-bolus insulin protocol (a ¼ .9; EFA 32%). Nurses believed the top barriers to optimal care included prolonged NPO status, unpredictable changes in patient diet and mealtimes, lack of prompt delivery of medications from the pharmacy, lack of educational
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reinforcement to the patient, and lack of coordination between meal delivery and insulin administration (a ¼ .9; EFA 38%). Pharmacists believed that the lack of a standardized basalbolus insulin protocol, lack of coordination between meal delivery and insulin administration, shift changes and crosscoverage leading to inconsistent management, prolonged NPO status, and lack of educational reinforcement to the patient were the top barriers to care (a ¼ 0.8; EFA 36%). Although the Cronbach’s a and EFA were not significant for the dietitian survey, these health care workers believed that barriers to care included the priority of care placed on more acute patient issues, risk of causing hypoglycemia, incorrect and/or no diet orders placed in patient’s medical record, patients not in the hospital long enough to control blood glucose, and unpredictable changes in patient’s diet and mealtimes. Finally, patient care assistants believed that the top barriers to care included lack of coordination between meal delivery and finger-stick times, unpredictable changes in patient diet and mealtimes, priority being placed on more acute patient issues, risk of causing hypoglycemia, and unpredictable timing of patient procedures leading to not obtaining glucose finger sticks at the correct time (a ¼ 0.9; EFA unable to determine).
Conclusion Despite recent updates to the AACE/ADA Consensus Statement, response to reform current clinical practices to reflect recent literature has been slow and often meets resistance possibly due to systematic and perceived barriers.1 There have been numerous publications emphasizing the importance of focusing on hyperglycemia management in the hospital, but it is clear that there are many obstacles that are faced when implementing programs geared at optimizing glycemic control.4,14 These obstacles are likely partly due to the lack of quality evidence regarding management of hyperglycemia in noncritically ill patients and lack of knowledge of health care workers that care for patients with hyperglycemia.1 Guidelines for inpatient management of hyperglycemia were first published in 2004 by the American College of Endocrinology.15 Blood glucose targets for noncritically ill patients were supported by data from prospective observational studies.1 Extrapolated data from critically ill patients were used for recommendations in noncritically ill patients in the 2006 American Clinical Endocrinologist/ADA consensus statement.16 Tight glycemic control was encouraged until the results of the Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation (NICE-SUGAR) trial in 2009, which revealed that increased mortality was observed in critically ill patients managed this way.2 Discrepancy in study results may have been attributed to differences in measurement and reporting of blood glucose values, study participants, glycemic variability, and/or nutrition support.1 In 2009, the AACE and the ADA joined forces to create an updated consensus statement to address the results of newer studies and extrapolate these results to noncritically ill patients.1 Repeated changes in glycemic goals and methods of management within
the past 10 years may attribute to a lack of acceptance of recent guidelines among the medical community. Identifying the knowledge deficits and perceptions of health care workers in regard to hyperglycemia management may also help to explain why there is a slow response to reform current clinical practice. It is likely beneficial to consider the perceptions, barriers, and knowledge of those caring for patients with hyperglycemia in order to develop a meaningful and targeted hospital-wide education program prior to implementing optimized glycemic protocols involving basal-bolus insulin methods. There have been studies that assess these components in physicians, nurses, and mid-level practitioners, but to our knowledge there are no data assessing these components in regard to the entire multidisciplinary team caring for patients with hyperglycemia when using the 2009 consensus statement as a guide.3,6-17 This survey helps provide important information regarding knowledge and perceptions of health care workers on the provision of optimal care to patients with hyperglycemia. This information will be important for the successful development and implementation of a structured insulin protocol for noncritically ill patients at The Brooklyn Hospital Center by highlighting specific educational and systematic barriers that need to be addressed through educational efforts. From a clinical perspective, because every discipline did not score a 100% on the knowledge portion of the survey, we can conclude that there is a lack of knowledge among all health care workers in regard to inpatient glycemic management. Previous studies show similar results for a lack of overall knowledge, with mean scores of 71% and 59% for house staff physician residents and 66% and 47% for nurses.7,9,11 From a research perspective, physicians, nurses, and pharmacists obtained a higher score than the mean of all health care workers, therefore we can conclude that they are more knowledgeable. Dietitians and patient care assistants obtained a score lower than the mean of all health care workers and therefore are less knowledgeable. According to survey results, although many health care workers successfully recognized the signs and symptoms of hyperglycemia and hypoglycemia, they were unable to correctly identify definition of hypoglycemia and frequently answered questions incorrectly that pertained to the recommended optimal treatment regimen for patients. An alternative question frequently answered incorrectly pertained to the definition of the preprandial blood glucose goal in noncritically ill patients. We can conclude that health care workers are able to appropriately identify signs and symptoms of hyperglycemia and hypoglycemia, although many are unable to define the blood glucose concentration that indicates hypoglycemia and many do not appropriately treat these symptoms or treat patients with recommended treatment goals in mind. Comparatively, in a validated survey administered to nurses and house staff residents, questions averaging less than 50% correct pertained to the fasting plasma glucose criterion for diagnosis of diabetes, insulin pharmacokinetics, and treatment of severe hypoglycemia.9 The survey conducted by Derr et al found results similar to our study where residents and nurses
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frequently answered questions incorrectly pertaining to the definition of hypoglycemia.11 Results of our study reiterate some of the commonly identified knowledge deficits and illustrate that a lack of knowledge is not only evident among residents and nurses, but among pharmacists, dietitians, and patient care assistants as well. The basal-bolus method of insulin administration for the treatment of hyperglycemia has been shown to be a proactive and effective approach to glycemic control as opposed to the reactive sliding scale method.18,19 Many previous studies indicate that health care workers believe that the treatment of hyperglycemia in noncritically ill patients was somewhat important or very important, although these studies do not assess why health care workers believe that sliding scale insulin, a proven ineffective method of management, is often used.3,6,8,17,18 Assessing these perceptions may help educators understand whether suboptimal care is a result of hospital culture and/or a lack of knowledge. Interestingly, despite the majority of health care workers believing that the treatment of hyperglycemia is very important, more than 50% of physicians and pharmacists also believed that sliding scale insulin was used most frequently out of convenience as opposed to efficacy. Although we were unable to determine how important nurses believed the treatment of hyperglycemia was, it was dismaying to discover that greater than 50% of nurses believed that sliding scale insulin was the most effective method of treating hyperglycemia. The discordance in optimal medication use and actual medication use provides an opportunity for quality improvement and education to dispel beliefs to those who may believe sliding scale insulin is the optimal treatment method of choice. The most commonly cited barriers and their corresponding perceived significance helps target systematic weaknesses that may benefit from crucial examination prior to the implementation of a glycemic quality improvement project. Results of this survey clearly express the need for a systematic method of coordinating care, including assessing blood glucose values and providing insulin relative to meals. Unlike previous studies, surveying the entire multidisciplinary team while creating a validated survey tailored to the specific job function of a health care worker helps provide valuable insight on what to target within each department to optimize glycemic control.3,6,7,8,10,17 Results of this survey will be used to tailor education for each health care discipline and anticipate potential barriers to care. One limitation of this study was the survey length. Many respondents commented on the length of time required to complete the survey and as a result, test fatigue may have occurred and caused an inaccurate assessment of true results and perceptions to care. Despite conducting a pilot survey and assessing the length of time required for the completion of the survey, we underestimated the survey time required for the general population. During survey administration, proctors were unable to answer questions regarding survey content or terminology. The verbiage of the survey was not tailored to health care worker average literacy level and this could have led to
falsely low results. During the development of survey questions, authors were unaware that patient care assistants were provided with very limited access to protected health information in the electronic medical record. With limited access to patient medical records, patient care assistances may not have been able to accurately answer questions pertaining to burden of care. Finally, it was difficult to reach each health care worker from every discipline. Obtaining the majority of health care workers from each discipline would have provided a more robust sample size to draw large-scale conclusions regarding this institution. The results of this study help voice the opinions of health care workers invested in the care of patient with hyperglycemia, assess current knowledge regarding the care of patients with hyperglycemia as it pertains to individual health care role, and assist in pinpointing what education is needed for a hospital-wide education program in order to secure successful implementation of a basal-bolus insulin protocol. Although there is a lack of knowledge among all health care workers regarding hyperglycemia management when compared to clinical best practices, this survey has highlighted the most important areas to focus on and provides a platform to successfully create targeted education programs prior to optimizing current glycemic protocols. Supplemental Material The online data supplements are available at http://jpp.sagepub.com/ supplemental.
Authors’ Note This work was supported by The Brooklyn Hospital Pharmacotherapy Research Fund. No potential conflicts of interest relevant to this article were reported. RB was a co-investigator for this study and was responsible for conception and design of the study in addition to data collection, analysis and was the primary writer for this manuscript. ED was the primary investigator for this study as was responsible for oversight of study design, data collection, and manuscript review and editing. KM and WV were responsible for oversight of study design and manuscript review and editing. BS was responsible for oversight of study design, statistical analysis, and manuscript review and editing.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologist and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Diabetes Care. 2009;32(6):1119-1131. 2. Finfer S, Chittock DR, Su SY, et al. (NICE-SUGAR Study Investigators). Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-1297.
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Beliard et al
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3. Cook CB, McNaughton DA, Braddy CM, et al. Management of inpatient hyperglycemia: assessing perceptions and barriers to care among resident physicians. Endocr Pract. 2007;13(2): 117-124. 4. Klonoff DC. Hospital diabetes: why quality of care matters to both patients and hospitals. J Diabetes Sci Technol. 2011;5(1): 1-4. 5. Cook CB, Elias B, Kongable GL, et al. Diabetes and hyperglycemia quality improvement efforts in hospital in the United States: current status, practice variation, and barriers to implementation. Endocr Pract. 2010;16(2):219-230. 6. Cheekati V, Osburne RC, Jameson KA, et al. Perceptions of resident physicians about management of inpatient hyperglycemia in an urban hospital. J Hosp Med. 2009;4(1):E1-E8. 7. Latta S, Alhosaini MN, Al-Solaiman Y, et al. Management of inpatient hyperglycemia: assessing knowledge and barriers to better care among residents. Am J Ther. 2011;18(5): 355-365. 8. El-Kebbi IM, Ziemer DC, Gallina DL, et al. Diabetes in urban African-Americans. XV. Identifications of barriers to provider adherence to management protocols. Diabetes Care. 1999; 22(10):1617-1620. 9. Rubin DJ, Moshang J, Jabbour SA. Diabetes knowledge: are resident physicians and nurses adequately prepared to manage diabetes? Endocr Pract. 2007;13(1):17-21. 10. Giangola J, Olohan K, Longo J, et al. Barriers to hyperglycemia control in hospitalized patients: a descriptive epidemiologic study. Endocr Pract. 2008;14(7):813-819.
11. Derr RL, Sivanandy MS, Bronich-Hall L, et al. Insulin-related knowledge among health care professionals in internal medicine. Diabetes Spectrum. 2007;20:177-185. 12. Tavakol M, Dennick R. Making sense of Cronbach’s alpha. Int J Med Educ. 2011;2:53-55. 13. Schafer RG, Bohannon B, Franz MJ, et al. Diabetes nutrition recommendations for health care institutions. Diabetes Care. 2004; 27(1):S55-S57. 14. Cook CB, Elias B, Kongable GL, et al. Diabetes and hyperglycemia quality improvement efforts in hospital in the United States: a current status, practice variation and barriers to implementation. Endocr Pract. 2010;16(2):219-230. 15. Garber AJ, Moghissi ES, Bransome ED Jr, et al. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract. 2004;10(suppl 2):4-9. 16. ACE/ADA Task Force on Inpatient Diabetes. American College of Endocrinology and American Diabetes Association consensus statement on inpatient diabetes and glycemic control: a call to action. Diabetes Care. 2006;29:1955-1962. 17. Cook CB, Jameson KS, Hartsell ZC, et al. Beliefs about hospital diabetes and perceived barriers to glucose management among inpatient midlevel practioners. Diabetes Educ. 2008;34(1):75-83. 18. Hirsch IB. Sliding scale insulin – time to stop sliding. JAMA. 2009;301(2):213-214. 19. Umpirrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 Trial). Diabetes Care. 2011;30(9):2181-2186.
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