2019 Research Forum

Department of Clinical Pharmacy

Applicant: Frantze Agtarap, PharmD R1 Principal Investigator & Faculty Sponsor: Jeff Jolliff, PharmD, BCPS, BCACP, AAHIVP, CDE

Table 2. Compliance to Insulin Infusion Protocols after staff education

Evaluation of an Insulin Infusion Protocol After Staff Education

Frantze Agtarap PharmD, Alice Peng PharmD, Jeff Jolliff PharmD

INTRODUCTION Diabeticketoacidosis (DKA)andhyperosmolar hyperglycemicstate(HHS), describedcollectivelyashyperglycemic crisis, are the two most serious acute metabolic complications of diabetes. Intravenous insulin infusion is the standard of care for the treatment of patients with hyperglycemic crises. American Diabetes Association (ADA) recommends the utilization of insulin infusion protocols, which have been shown to improve time to resolution and decrease hospital length of stay. However, previous studies have shown that compliance to insulin infusion protocols is a common issue across hospitals, such as Kern Medical. In previous reviews, compliance to the two insulin infusion protocols utilized at Kern Medical have been suboptimal due to providers ordering the incorrect protocol and demand of nursing resources. An educational campaign on the appropriate use of the protocols was provided to healthcare providers and nurses; however, the long term impact of staff education has not been evaluated. PURPOSE To describe the impact of a pharmacist-led educational campaign on insulin infusion protocol adherence as well as safety and efficacy outcomes related to insulin infusions. METHOD A retrospective chart review was conducted on all patients admitted to Kern Medical for the treatment of DKA and/or HHS from zero to twenty-four months after staff education was provided. Inclusion criteria were all adult patients with a clinical diagnosis for DKA and/or HHS and an electronic order of an insulin infusion protocol. Patients were excluded if there was a lack of documentation, were pregnant, required surgery during admission, used for organ preservation after death, or if the duration of the insulin infusion was <3 hours. The results on compliance and performance metrics of the insulin infusion protocols will compare the pre-education cohort and post-education cohort at 0-6 months, 6-12 months, and 12-24 months after staff education. RESULTS Table 1. Compliance to Insulin Infusion Protocols before and after staff education

Table 3. Safety and Efficacy of Insulin Infusion Protocols before and after staff education

Table 4. Safety and Efficacy of Insulin Infusion Protocols before and 0 to 6 months after staff education

DISCUSSION: Overall, educational intervention significantly improved appropriate insulin infusion protocol prescribing by physicians and decreased the number of late blood glucose checks by nurses. However, it failed to improve overall blood glucose monitoring and overall frequency of hypoglycemic events. Given the low frequency of hypoglycemic events, this evaluation was not powered to detect a difference in hypoglycemia. Furthermore, the effect of staff education on appropriate protocol ordering by physicians, timing of BG (blood glucose) checks, and correct infusion rate adjustments significantly decreased over time, suggesting staff education should be provided on a recurring basis (i.e. annually).

CONCLUSIONS: Staff education had an overall positive impact by significantly improving the selection of the appropriate insulin protocol and decreasing the amount of late BG checks, but results highlight the need for education on a recurring basis.

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