Insulin Administration and Meal Delivery Coordination for ...

Insulin Administration and Meal Delivery Coordination forHospitalized Patients

Patrick M. Houck,* Naga Nalini Tirumalasetty, MD,� Renee Y. Meadows, MD�

*Tulane University, New Orleans, LA�Department of Endocrinology and

�Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, LA

ABSTRACTBackground: Through efforts to continuously improve thequality of care provided to hospitalized patients with diabetesby evaluation of adherence to standards and performancemetrics, we identified an opportunity for improvement.Methods: A plan-do-study-act cycle was initiated with the goalof enhancing patient satisfaction with the timing of bloodglucose monitoring, insulin administration, and meal delivery inthe hospital.Results: Despite an educational intervention with the nursingstaff, patient satisfaction with mealtime insulin administrationdecreased from 83% to 78%.Conclusion: Education of frontline staff was not adequate toachieve our quality improvement goal.

INTRODUCTIONA strong and growing body of evidence links high

patient satisfaction and enhanced patient/family ex-perience of inpatient hospital care to improved healthoutcomes.1 Improved patient experience leads tobetter management of chronic illnesses such asdiabetes. The Joint Commission expects organiza-tions to develop a comprehensive approach to

performance improvement, to evaluate patients’ per-ceptions of quality of care, and to use comparativedata to review interventions. To maintain the OchsnerMedical Center–New Orleans (OMC) disease-specificcertification by The Joint Commission in InpatientDiabetes Care, a multidisciplinary team focuses onperformance improvement related to the care ofpatients with diabetes. Patient satisfaction is one ofthe major performance metrics for the diabetesprogram. The diabetes program at OMC monitorspatient satisfaction with patient experience surveys.

OMC is a 473-bed, tertiary acute care hospital withmultiple bedded units taking care of patients withdiabetes. A national vendor sends patient satisfactionsurveys to hospital patients, but these surveys are notspecific to patients with diabetes. Therefore, theycannot adequately provide actionable items forimprovement specifically related to diabetes care.Moreover, the satisfaction surveys from the nationalvendor are sent via mail to patients after dischargefrom the hospital, requiring former patients to recalltheir treatment after the fact and to take the initiative toreturn the survey in the mail.

Consequently, a multidisciplinary team at OMCdeveloped an inpatient diabetes patient satisfactionquestionnaire to more specifically assess the careprovided to patients with diabetes before they leavethe hospital (Figure 1). This survey tool is used toidentify the success of inpatient diabetes care, as wellas to focus on areas to improve quality of care andadherence to best-practice standards. It is a means ofself-assessment and performance review, two impor-tant factors identified by The Joint Commission.

METHODSThe OMC patient satisfaction survey tool included

6 yes or no questions with space available toelaborate. The surveyors were dietary personnel, astudent volunteer, and the diabetes program clinicalcoordinator. Patients were screened based on dietarylists taken from the hospital’s electronic health recordand were included in the survey population if theywere placed on a diabetic diet, carbohydrate restric-

Address correspondence to

Renee Y. Meadows, MD

Department of Hospital Medicine

Ochsner Clinic Foundation

1514 Jefferson Hwy.

New Orleans, LA 70121

Tel: (504) 842-7518

Fax: (504) 842-2644

Email: [email protected]

Keywords: Blood glucose, hospitalization, insulin–administration

and dosage, quality improvement

The authors have no financial or proprietary interest in the subject

matter of this article.

Volume 13, Number 3, Fall 2013 327

The Ochsner Journal 13:327–333, 2013

� Academic Division of Ochsner Clinic Foundation

Figure 1. Inpatient Diabetes Patient Satisfaction Questionnaire.

Inpatient Insulin Administration and Meal Delivery

328 The Ochsner Journal

tion, and/or daily caloric intake of 1,800, 2,000, or2,200 kCal. Patients from 7 to 10 units wererepresented in the surveys monthly. Selected patientswere visited in their rooms, and the surveyor readeach question word for word. Only patients whoresponded yes to having diabetes were asked tocomplete the survey. If the patient were unsure of hisor her diabetes status, the survey was discontinued.Up to 10 patients from each inpatient unit weresurveyed each month. Multiple units were surveyed,but the intervention was conducted on 1 unit only.Data collected were entered into a spreadsheetconfigured so yes and no responses received scores;additionally, the spreadsheet provided a satisfactionscore per patient. Each month the patient satisfactionresults, per unit, were averaged to provide an overallpercentage of satisfaction of diabetes care both perunit and overall. The scores for each question wereaveraged to indicate focus areas for improvement.The target for patient satisfaction addressed by eachquestion is >90%.

The Institute for Healthcare Improvement recom-mends use of plan-do-study-act (PDSA) cycles as aframework for process improvement in its Model for

Improvement.2 The PDSA concept and applicationwere first introduced by Walter A. Shewhart and W.Edwards Deming, who were pioneers in qualitymanagement and whose work influenced businessleaders, corporations, and governments around theworld.3 Initially used by Bell Laboratories and thepost–World War II Japanese manufacturing industryfor total quality management, PDSA is considered tobe the mainstay of improvement science in health-care. Starting with small changes and limited scope,the PDSA cycle may be used for rapid tests of changethat build progressively with each cycle (Figure 2).

Survey data collected at OMC in the fourth quarterof 2012 pointed to the administration of mealtimeinsulin in relation to the delivery and consumption ofmeals as an opportunity for improvement. In responseto this finding, a PDSA rapid-change cycle wasinitiated by an endocrinology fellow and the diabetesprogram coordinator (Figure 3). The aim was toimprove patient satisfaction with regard to appropriatetiming of blood glucose monitoring and mealtimeinsulin administration by 5% to 10% within 2 months’time. The intervention was enacted on a medicalsurgical unit chosen for the type of patients it treats

Figure 2. Plan-do-study-act cycle.

Houck, PM


and its abundance of new nursing staff. The interven-tion involved unit-specific education for the bedsidenurses—sessions for both the day and night shifts—during scheduled monthly staff meetings. The ses-sions were led by an endocrinology fellow and thediabetes program clinical coordinator. The content ofthe presentations included the differences betweentype 1 and type 2 diabetes, stress hyperglycemia, andthe pharmacokinetics of rapid- and long-acting insulinused to manage hyperglycemia in hospitalizedpatients. The intervention highlighted the importanceof appropriate timing of blood glucose monitoring andinsulin administration in relation to mealtimes, mim-icking as closely as possible the normal insulinresponse by the pancreas linked to improved clinicaloutcomes. These sessions were well received bynursing staff.

RESULTSBaseline preintervention data for the test unit were

obtained from questionnaire responses provided by30 patients during October, November, and Decem-ber 2012. Patient satisfaction with respect to mealtimeinsulin administration (question 2) was scored at 83%during this final quarter of 2012. Patient satisfaction

for the same question and test unit was assessedafter the intervention was implemented in January andfound to be 78% for the 2 test months of February andMarch 2013. Because these data were based onconvenience samples, the number of respondentsvaried between the preintervention and the post-intervention surveys. Despite the intervention, the testunit’s patient satisfaction score for mealtime insulinadministration decreased by 5 percentage points,from 83% to 78%. However, the significance of thischange is unclear because of the 6-percentage-pointdecrease in overall satisfaction with diabetes careduring the same time period for the test unit (Tableand Figure 4).

DISCUSSIONThe first cycle intervention proved ineffective, with

results falling far short of the 5%-10% improvementgoal. Both the survey and the intervention hadlimitations. The survey was affected by several biases,including recall bias (eg, patient forgetting) andresponse bias. In several instances, patients an-swered in front of family members and/or nursesand possibly wanted to supply the ‘‘correct’’ re-sponse. Furthermore, the survey population was not

Figure 3. Plan-do-study-act cycle for the insulin administration and meal delivery project.



randomized. Although all patients who met theaforementioned criteria were included in the surveypopulation, the first 10 respondents were sampledbased on convenience and availability. The remark-ably higher standard deviation for question 2 re-sponses obtained per month (20.8) when comparedto that for the other survey questions (12.1) mayindicate that question 2 is more difficult for respon-dents to understand, thus creating variability ininterpretation for an affirmative response.

Education alone is generally not the best inter-vention for quality improvement or medication safety.Nevertheless, the unit-specific education session withbedside nurses served to reduce variation in nurses’knowledge so that other system issues could beaddressed in later stages of this rapid-change project.This particular approach of enacting, evaluating, andrevising or adjusting a small-scale intervention is inline with the characteristic nature of PDSA methodol-ogy. These findings indicate that a different and/oradditional intervention is needed. This first cycle reliedcompletely on the interaction of the patient and nurseand the effectiveness of their communication. Thenext cycle should include a third factor.

Ideas for the third factor are being considered,including the distribution of educational pamphlets topatients when they are admitted to the hospital, theplacement of posters in patients’ rooms to remindboth nurses and patients of the importance of

matching the timing of insulin administration to foodintake, and inclusion of dietary personnel in theprocess change.

The coordination of glucose testing, nutritiondelivery, and insulin administration is integral to thesafe management of hyperglycemia and diabetes inthe hospital. Historically, national guidelines for thetreatment of diabetes4 have called for consistent mealplans, which are preferred by many hospitals becauseof the enhanced ease of matching the prandial insulindose to the amount of carbohydrate consumed thatthey permit.5 However, current nutrition recommen-dations for hospitals, as opposed to the historicalapproach of standardization, advise meal plan indi-vidualization based on glycemic goals, physiologicalfactors, and medications used for treatment.4

Individualization of meal plans coupled withsynchronization of insulin administration, glucosemonitoring, and meal delivery presents significantchallenges. One observational cohort study foundthat for most patient meals (84%), patients did notreceive rapid-acting insulin within 10 minutes beforeor after the meal began, and glucose monitoringwas performed within 30 minutes before the mealonly 43% of the time.6 Many methods have beenapplied to improve the timing of insulin administra-tion in relation to meal delivery for hospitalizedpatients, including nurse page alerts of meal traysen route to units, equal distribution of diabetic

Figure 4. Monthly patient satisfaction scores before and after intervention.

Houck, PM


patients among nursing assignments, meal timesposted in patient rooms, standardized food deliveryschedules, no scheduling of inpatient proceduresduring mealtimes, signs on the doors of patientsscheduled to receive insulin, engagement of dietarypersonnel and patients, and nursing educationprograms.7-9 While nurses are essential to theseprocesses, they may not fully understand theimportance to inpatient hyperglycemia managementor be supported by optimal processes that ensurecoordination of meals and insulin administration.

As hospitals move toward greater patient-cen-tered care, patient-controlled diets are increasing inpopularity. Patient-controlled diets empower inpa-tients to make menu selections and receive individ-ualized nutrition education. The effect on glucosecontrol for hospitalized patients is unclear. Medicalnutritional therapy (MNT), individualized dietaryassessment and instruction incorporating diet ther-apy counseling for a nutrition-related problem thatis above basic nutrition counseling, has been amainstay for inpatient glycemic control. For patientswith diabetes, MNT usually includes a consistentcarbohydrate meal plan.

Typically, nurses do not deliver meals and may beunaware of a patient’s receipt of a meal tray. Patient-controlled diet plans not only require appropriate foodchoices but also engagement of the patient to alert thenurse for insulin administration. Dietary staff, nurses,and patients all require training. Processes involvingalert systems will be needed. Patient education shouldstart now by educating patients to notify their nursewhen meal trays arrive, ensuring the meal will not beconsumed until after blood glucose is monitored andprandial and correction dose insulin is administered.The literature regarding insulin therapy and MNT hasyet to fully address the issue of patient-controlled diets

for hospitalized patients, raising implications for pa-tient-centered meal delivery in hospitals.

CONCLUSIONSSelf-assessment of diabetes care revealed an area

for improvement regarding appropriate glycemicmanagement of patients with diabetes, specificallypoor patient satisfaction because of ill-timed bloodglucose monitoring and insulin administration relativeto meal tray delivery. It is therefore critical to educateboth the patient and the patient’s family on theimportance of informing the nurse when the mealtray has arrived and of waiting to have blood glucoselevels checked and insulin administered beforeeating. Possible solutions could vary from signs orposters in the patient’s room to a process integratedinto the electronic health record that alerts the nurseto a patient’s request for a meal. Education of frontlinestaff alone was not an adequate intervention for ourquality improvement initiative to succeed.

REFERENCES1. Balik B, Conway J, Zipperer L, Watson J. Achieving an Exceptional

Patient and Family Experience of Inpatient Hospital Care. IHIInnovation Series white paper. Cambridge, Massachusetts:Institute for Healthcare Improvement; 2011.

2. Langley GJ, Moen R, Nolan KM, Nolan TW, Norman CL, ProvostLP. The Improvement Guide: A Practical Approach to Enhancing

Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass Publishers; 2009.

3. Deming WE. The New Economics for Industry, Government, and

Education. Cambridge, MA: The MIT Press; 2000.4. American Diabetes Association. Standards of medical care in

diabetes—2013. Diabetes Care. 2013 Jan;36(Suppl 1):S11-S66.5. Curll M, Dinardo M, Noschese M, Korytkowski MT. Menu selection,

glycaemic control and satisfaction with standard and patient-controlled consistent carbohydrate meal plans in hospitalisedpatients with diabetes. Qual Saf Health Care. 2010 Aug;19(4):355-359.

Table. Monthly Patient Satisfaction Scores Before and After the Intervention

UnitQuestionNumber

Responses Patients Responding Yes

Change

N Before(Oct, Nov,Dec 2012) SD

N After(Feb, Mar

2013)

% Before(Oct, Nov,Dec 2012)

% After(Feb,

Mar 2013)

Test Unit 1 30 18 97 94 �32 30 20.8 18 83 78 �53 30 18 73 72 �14 30 18 97 89 �85 30 18 93 89 �46 30 18 100 83 �17All 30 12.1 18 91 85 �6

All Hospital Units All 5.5 87 91 þ4

SD, standard deviation.



6. Freeland B, Penprase BB, Anthony M. Nursing practice patterns:timing of insulin administration and glucose monitoring in thehospital. Diabetes Educ. 2011 May-Jun;37(3):357-362. Epub2011 Apr 5.

7. Pham JT, Schreiber P. Improving hyperglycemia management inthe inpatient orthopaedic population with a special focus onmealtime insulin administration. University of California SanFrancisco School of Nursing. http://nurseweb.ucsf.edu/conf/cripc/ebpabstract/pham-abst.pdf. Accessed April 10, 2013.

8. Yamamoto JJ, Malatestinic B, Lehman A, Juneja R. Facilitatingprocess changes in meal delivery and radiological testing toimprove inpatient insulin timing using six sigma method. Qual

Manag Health Care. 2010 Jul-Sep;19(3):189-200.9. Donihi AC, Abriola C, Hall R, Korytkowski MT. Getting the timing

right in the hospital: Synching insulin administration with meal trayarrival. American Diabetes Association 70th Scientific Sessions2010. http://professional.diabetes.org/Abstracts_Display.aspx?TYP¼1&CID¼79965. Accessed April 10, 2013.

This article meets the Accreditation Council for Graduate Medical Education and the American Board ofMedical Specialties Maintenance of Certification competencies for Patient Care and Practice-BasedLearning and Improvement.

Houck, PM


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