Study Abstract of AAAHC Institute QI Award Winner

The AAAHC Institute for Quality Improvement, a not-for-profit subsidiary of the Accreditation Association for Ambulatory Health Care, recently announced the winners of the 2011 Bernard A. Kershner Innovations in Quality Improvement Awards.

Two awards are given annually — one for surgical/procedural care and one for primary care. This year's winner in the surgical/procedural care category is Elgin (Ill.) Gastroenterology Endoscopy Center (EGEC).

Here is the abstract of the award-winning study from EGEC. It is being published with the explicit permission of the AAAHC Institute for Quality Improvement.

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Winning QI Activity: Blood Sugar Study

Winning organization: Elgin Gastroenterology Endoscopy Center (EGEC)

Purpose:

• There is an increasing incidence of diabetes in the United States and more diabetic patients are undergoing sedated procedures in the ambulatory setting. Abrupt changes in blood sugar levels can affect sedated patients more profoundly because normal responses to the fluctuations can be impaired.
• EGEC had two questions to answer:
  • Do significant fluctuations in blood sugar occur in diabetics undergoing sedated endoscopic procedures?
  • Do the type of intravenous solution used (with dextrose or no) during the procedure contributed to any fluctuations in blood sugars of diabetic patients?
• The purpose of this study was to answer these questions and, based on the answers, standardize IV solutions to protect diabetic patients from significant fluctuations in blood sugar during their procedures at EGEC.

Performance Goal:

• The first goal was to determine whether significant fluctuations in blood sugar occurred in diabetics undergoing sedated endoscopic procedures.
• The second goal was to assess whether the type (with dextrose or no) of intravenous solution used during the procedure contributed to any fluctuations.
• The third goal was to standardize the IV solutions used in endoscopy, if appropriate, and decrease fluctuations in associated blood sugar levels for diabetic patients.

Description of Data Collection:

• The data were collected over a two month period.
• The data was derived from finger stick blood sugars nursing staff obtained before and after procedures on diabetic patients.

• These interventions were chosen because EGEC did not want to provide additional sugar (dextrose) for patients who already had elevated blood sugar levels and increase these patients’ chances of hyperglycemia.
• The type of IV fluid was documented. The total volume of IV fluid administered as well as the amount of dextrose received (if any) was also recorded.
• EGEC took this approach to allow appropriate data collection in order to meet the performance goal and still maintain patient safety.

Evidence of Data Collection and Data Analyses:

• The data were broken into two groups depending on which type of IV fluid was infused (D5/0.9NS vs. 0.9NS).
• The numerical change in the blood sugar after completion of the procedure was assessed (mg/dl).
• 109 patients over a two month period
• The results of the two groups were as follows:

Comparison with Goal:

• The first goal was to determine whether significant fluctuations in blood sugar occurred in diabetics undergoing sedated endoscopic procedures. This goal was met:
  • There were spikes as high as 411 mg/dl in this group. This was quite concerning as this group of diabetics had relatively normal blood sugars (75-150) at the start of the procedure.
  • Significant fluctuations in blood sugar levels occurred in the diabetic group infused with D5/0.9NS in spite of receiving relatively small amounts of dextrose. The average amount of sugar administered was equivalent to a can of soda pop.
  • Diabetic patients who started the procedure with slightly elevated blood sugar levels and received 0.9NS ended the procedure with slightly low blood sugar levels.
• The second goal was to assess whether the type of intravenous solution used during the procedure contributed to any fluctuations. This goal was met: the group receiving 0.9NS had almost no change in their blood sugars before and after the procedure, while there were significant fluctuations in blood sugar for diabetic patients receiving D5/0.9NS.
• The third goal was to standardize the IV solution, if appropriate, and associated blood sugar levels. This goal had yet to be met.

Corrective Action:

• As a result of these findings, the IV solution was changed to 0.9NS and no diabetics were given dextrose during any procedure.
• Dextrose was not infused during the re-measurement period because of the significant increase in blood sugar noted during the initial measurement phase.

Re-Measurement:

• Blood sugars before and after each procedure were again measured.
• Fluctuations were again assessed.
• 62 patients were seen over a two month period.
• The results were as follows:

• The third goal was to standardize the IV solution, if appropriate, and associated blood sugar levels. This goal was met: It was decided that EGEC would use either 0.9NS or Lactated Ringers as the primary IV solution during endoscopic procedures. Neither contains sugar and both are cost-effective. Blood sugars will continue to be monitored as part of normal ongoing patient safety measures.

New Intervention-Re-Measurement: Not applicable.

Communication of Findings:

• The results were communicated to nursing staff by the nursing manager.
• The physicians were informed at the Medical Advisory Committee meeting.
• The Board of Directors was updated at the Board of Directors meeting.

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