Interprofessional, student-led intervention to improve insulin prescribing to patients in an Acute Surgical Receiving Unit

Abstract

Our aim was to test the feasibility of interprofessional, workplace-based learning about improvement through a 4-week placement for one medical and two pharmacy final year students in an Acute Surgical Receiving Unit (ASRU). The target was insulin because this is a common, high-risk medicine in this ASRU and the intervention was medicines reconciliation. Baseline data were collected from 10 patients and used to construct a cause and effect diagram and a process map through feedback and discussions with staff. Hypoglycaemia occurred in four patients but hyperglycaemia occurred in eight patients, of whom six were placed on intravenous insulin infusion (IVII). We estimated that £2454 could be saved by preventing one patient from going on IVII. The students designed and tested a sticker to improve medicines reconciliation for insulin patients. An online form was created to capture clinician feedback on the layout and usability of the sticker. The intervention was associated with improvements in the reliability of medicines reconciliation. The students’ work contributed to a larger project to reduce the risk of hypoglycaemia in the ASRU. This proved beneficial in enabling the students to engage with the clinical team. Nonetheless, it was challenging for students from two Universities to get a shared understanding of improvement methods and work effectively with the clinical team. The students said that they learnt more about quality improvement in a working healthcare environment than they would ever learn in a classroom and they valued the opportunity to work with students from other healthcare backgrounds in practice. Despite the additional staff time required to support students from two Universities, both have supported continuation of this work.

Interventions to improve insulin prescribing practice for people with diabetes in hospital: a systematic review

“…A smaller quality improvement project undertaken by Tully et al . focused on the medicines reconciliation process of insulin on admission to hospital . Using continuous improvement methodology, the design and introduction of a sticker to prompt accurate and complete prescribing of insulin on admission resulted in an increase in insulin medicines reconciliation from 64% to 91%.…”

“…All were uncontrolled before-after studies. Four studies were multisite [19,28,30,32], seven involved teaching or tertiary hospitals [26][27][28][29][30][31]33] and three studies involved district general hospitals [18,19,25].…”

“…There was a lack of consistency with respect to the methodology and outcome measures used in the studies. Seven studies measured the reduction in insulin prescribing errors [18,19,[25][26][27][28]32], three measured the accuracy, clarity and completeness of prescriptions [29,31,33], and one study measured opportunity for error as a result of unclear prescribing [30]. The types of intervention varied, as well as the implementation strategies, and measures of improvement between studies (see Table S4).…”

“…The types of intervention varied, as well as the implementation strategies, and measures of improvement between studies (see Table S4). Although three studies [19] x Courtenay 2007 [17] x x Donihi 2006 [26] x x Dooley 2011 [28] x Donsa 2016 [27] x x Doyle 2014 [54] x x x x Ena 2009 [41] x x Gomez-Huelgas 2014 [55] x x Guerra 2010 [43] x x x Hamilton 2013 [18] x Harbin 2015 [36] x x Helmle 2017 [37] x x x x x x x Horton 2015 [44] x Kowiatek 2001 [29] x x x x Lehnbom 2009 [35] x x Mamillapalli 2012 [38] x Maynard 2009 [45] x x x McIver 2009 [30] x x x Mulla 2015 [39] x x x Newsom 2018 [15] x x x x Noschese 2008m [46] x x Rushmer 2008 [31] x x x Schnipper 2009 [47] x x x Schnipper 2010 [48] x Taylor 2012 [32] x Thompson 2009 [49] x x x Trujillo 2008 [50] x x Tully 2018 [33] x x x Vaidya 2012 [56] x Valgardson 2015 [52] x x Wesorick 2010 [34] x x Wexler 2010 [52] x Wong 2016 [40] x x Yeung 2018 [53] x x ª 2019 Diabetes UK used the UK's National Inpatient Diabetes Audit (NaDIA) methodology and data collection tool, the follow-up period, interventions, implementation and the data reported were varied, hence it was difficult to pool data or make meaningful comparisons [18,19,32]. The introduction of simple, small focused interventions led to an improvement in the completeness and accuracy of insulin prescribing, particularly when they involved 'hard stops' (such as pre-printi...…”

“…Prescription accuracy did not increase significantly as a result (84% to 87%); however, by simply dedicating space for insulin device to be documented on the chart, prescriptions improved in their 'completeness' from 11% to 100%. A smaller quality improvement project undertaken by Tully et al focused on the medicines reconciliation process of insulin on admission to hospital [33]. Using continuous improvement methodology, the design and introduction of a sticker to prompt accurate and complete prescribing of insulin on admission resulted in an increase in insulin medicines reconciliation from 64% to 91%.…”