The Western Zone (WZ) Diabetes and Long-Term Care Quality ...€¦ · Western Zone Diabetes and Long-Term Care Quality Initiative Diabetes Care Program of Nova Scotia – May 2018

DiabetesCareProgramofNovaScotia

TheWesternZone(WZ)DiabetesandLong-TermCareQualityInitiative–FinalReportMay2018

Western Zone Diabetes and Long-Term Care Quality Initiative Diabetes Care Program of Nova Scotia – May 2018

Preparedby:PeggyDunbar,ProgramManagerDiabetesCareProgramofNovaScotia(DCPNS)AndCrystalMacNeil,ProjectCoordinatorDCPNS/WesternZoneContactInformation:DiabetesCareProgramofNovaScotia1276SouthParkStreet,BethuneBuilding,Room548Halifax,NSB3H2Y9Telephone: (902)473-3219Fax: (902)473-3911E-mail: [email protected]: http://diabetescare.nshealth.ca


TABLEOFCONTENTS

EXECUTIVESUMMARY.............................................................................................................1

SummaryFindings.......................................................................................................................1

BACKGROUND............................................................................................................................3

PROCESSESANDTIMELINE....................................................................................................5

Engagement................................................................................................................................6

Communication...........................................................................................................................7

EDUCATIONSESSIONS/SUMMARYFEEDBACK.................................................................9

CHARTAUDITS(PREANDPOSTEDUCATIONALINTERVENTION)..............................11

PostChartAudits......................................................................................................................12

CURRENTPRACTICESURVEY(PREANDPOSTEDUCATIONALINTERVENTION)....14

SurveyParticipantCharacteristics............................................................................................16

SurveyParticipantConfidence..................................................................................................17

CurrentPractice/Knowledge....................................................................................................18

ApplicationtoPractice(CaseStudy)Questions........................................................................19

STAKEHOLDERFEEDBACK.....................................................................................................20

Co-LeadModelandCentralCoordination................................................................................20

Communication.........................................................................................................................21

EducationSessions....................................................................................................................21

OverallInitiative........................................................................................................................22

PuttingtheGuidelinesintoPractice.........................................................................................22

Province-WideConsiderations..................................................................................................23

Otherconsiderations................................................................................................................23

DEBRIEFSESSIONS..................................................................................................................24

SUMMARY.................................................................................................................................25


APPENDICES

FormerSouthShoreHealthQualityImprovementProject,2014-2015:FrailElderlywithDiabetes…CanWeImprovetheApproachtoCareintheAcuteCareSettingforthoseAwaitingLong-TermCare?.....................................................................................................27

DiabetesGuidelinesforFrailElderlyResidentsinorAwaitingLong-TermCare:PHASE1&2-2016/2017.......................................................................................................29

RoleDescriptions:DPNSProject:UpstreamIntegrationofLTCDiabetesGuidelines-WZProject..............................................................................................................................31

PromotionalFlyerSample......................................................................................................33

WesternZoneDiabetesQualityInitiativeSeptember2017Bulletin......................................35

WesternZoneDiabetesLong-TermCareQualityInitiative:EducationSessionEvaluation..37

SamplePresentationSlides....................................................................................................39

ChartAuditDataElements.....................................................................................................43

Pre-EducationSurvey.............................................................................................................45

StakeholdersSurveys..............................................................................................................49 AdvisoryCommittee.........................................................................................................49 ProjectCoordinator..........................................................................................................53 ProjectCo-Leads...............................................................................................................59


1

EXECUTIVESUMMARY

TheWesternZone(WZ)DiabetesandLong-TermCareQualityInitiativefocusedonthediabetesmanagementofthefrailelderlywithdiabeteswithinTransitionalCare(TC),AlternativeLevelCare(ALC),andVeterans(Vets)UnitsintwoareasintheWZ—YarmouthandMiddleton.ThisInitiativebegantotakeshapeinthefallof2016,buildingonasimilarprojectthatranfrom2014tolate2015intheformerSouthShoreHealthAuthority(SSH),WZ(seeAppendix1,page27).Beforeconsideringprovincialrollout,itwassuggestedadditionalsitesbeselectedintheWZtopilotandevaluateanewCo-leadmodel,buildonearlieridentifiedstrengths,andincreaseourunderstandingofpotentialchallengesandmitigationstrategies.AnAdvisoryCommitteehelpedtoshepherdthisworkthroughtheWZ.Thisprojectwasabletouse/adaptthemanyprocesses,materials,andinformationlearnedfromtheearlierprojectintheformerSSHandbuildonidentifiedstrengths.SuccessfulcompletionofanNSHAPrivacyImpactAssessmentandtheconcurrenthiringofapart-timeCentralCoordination/ProjectCoordinator,allowedtheprojecttotakefulladvantageofa6-monthperiod(MaytoNovember2017).AnursingandnutritionCo-leadmodelwasusedwithYarmouthandMiddleton,eachwithtwoCo-leads.SpearheadedbytheDiabetesCareProgramofNovaScotia(DCPNS),theinitiativeusedtheDCPNSDiabetesGuidelinesforFrailElderlyResidentsinorAwaitingLong-TermCare,v2016,asthefocusofaneducationalinterventionwithemphasisplacedonappropriatecareaimedatpatientsafetyandqualityoflife.ToguidefutureworkandtoassesstheeffectivenessoftheInitiative,anevaluationframeworkincludedpre-andpost-educationsessionprovidersurveysandchartaudits,educationsessionevaluations,andstakeholderfeedback.

WithThanks

TheinitiativeteamwouldliketotakethisopportunitytorecognizeandthankthevariousUnitstaffsfortheirsupportduringthisprojectandtheirgenuineinterestinthisimportantwork.

Thecommentsandsuggestionsofferedduringtheeducationsessions,ingeneraldiscussion,andinthesurveysandevaluationtoolsweregreatlyappreciated.

SummaryFindingsOverallresultsfromthisprojectweregenerallysimilartothatoftheearlierSSHprojectandsuccessfullydemonstratedthevalueofusingsimilarprocessesandmaterialsfornotonlyefficiency,butalsocomparability.Theeducationinterventionwaseffectiveinincreasingawareness,knowledge,andconfidenceandpositivepracticechangeasevidentinthechartaudits.Thirty-oneeducationsessionsweredeliveredandevaluatedinJune/earlyJulyanddirectlyreached84individualsatthetwosites(29inYarmouthand55inMiddleton).Atotalof10pre-and15post-chartauditswereconductedandpre-/post-educationsessionprovidersurveys,75and42,respectively,wereanalyzedforchangeinknowledgeandpractice.

2


Thevariouscomponentsoftheeducationsessionswereratedverypositively(usinga5-pointLikertScalewhere1waspoorand5wasexcellent);overallrating,4.7/5;contributedtonewknowledge,4.6/5;learningwasapplicabletopractice,4.5/5;likelytousethelearninginpractice,4.5/5.Whenaskedaboutareasofmajorlearning,participantsnoted:

• Increasedabilitytorecognizesigns/symptomsofhypoglycemiaandhyperglycemiaintheelderly

• BetterunderstandingofhowtoproperlyinterpretbloodglucosereadingsandA1Cresultsforthefrailelderly

• Increasedawarenessofappropriatefrequencyforcapillarybloodglucosemonitoring

Thepost-chartaudits,15intotal,showedsomeimprovementinthedocumentationofbloodglucosetargets(wherenonehadbeendocumentedinthepre-auditedcharts);medicationreduction/modificationwhenA1C<8%;staffrecognitionofhypoglycemiaanddocumentationofappropriatetreatment;effortstocontactphysicianswhenbloodglucose<7mmol/Land>20mmol/L(inkeepingwiththeDCPNSguidelines);andwithappropriatePhysicianresponse(medicationreduction/adjustment)whenthesecallsweremade.However,intheseareasofimprovement,positivechangewasnotconsistent.Thepost-providersurveycompletedbythosethatattendedtheeducationsessionsshowedimprovementinanumberofareasrelatedtoconfidenceandinrecognizingappropriatebloodglucoseandA1Cvalues.RecognitionofacceptableA1C(8-10%)increasedfrom52%to74%;theacceptablefrequencyofA1Ctesting(1-2x/year)increasedfrom26%to57%withanunsureresponsedroppingfrom43%to13%.Confidenceintheoverallmanagementofdiabetesincreasedfrom84%to96%;determiningtheappropriatefrequencyofbedsidecapillarytesting,from62%to91%;recognizingtheinappropriatenessofcallingthephysicianwithoccasionalbloodglucoseof10-15mmol/L,from56%to91%.StakeholderfeedbackidentifiedtheCo-leadModelandCentralCoordinationpositionaskeystrengthsinthisInitiative.Manyadditionalbenefitswereidentifiedthroughuseofthesepositionsandwiththeprocessesusedingeneral,includingcommunicationefforts(newsletters,directaccesstoUnitstaffs,etc.),accessibilityandflexibilityofkeyinitiativestaff,chartaudits,etc.Whilegreatprogresshasbeenmade,andwecanbuildontheidentifiedstrengths,additionaleffortsarerequiredtosustainpracticechange.Theseinclude:

• Developmentofadmissionorders/pre-printedorders• Earlyengagementofphysicians• Useofthechartauditsasateachingtool/discussiondocument• StaffremindersthroughNursingManagers/ChargeNurses• Positiveexperiences/feedbackfromstaffwhoparticipatedinthisinitiative.

Inanefforttokeepthefocusontheneedsofthisimportantpopulation-themedicallydischargedandfrailelderlywithdiabetes-andthemomentumofthisinitiative,additionalsiteswillbeselectedandsupportingtoolsdevelopedtoaidintheimplementationoftheguidelines.


3

BACKGROUND

ThisInitiativewasaimedatimprovingdiabetesmanagementofthefrailelderlywhohavebeenmedicallydischargedfromacutecareandareinorawaitingLTCplacementthroughuseofaqualityprocess.ThisprocessfocusedonimprovedknowledgetoimpactpracticechangethatwouldbeeasilyadaptabletootherpartsofNovaScotia.DiabetesCareProgramofNovaScotia(DCPNS)developedguidelinesfordiabetesmanagementinthefrailelderlytosupportbothpatientsafetyandimprovedqualityoflife.Theseguidelineswereinitiallyreleasedin2010toallLong-TermCareFacilities,withpositiveresultsreportedforstaffandpatients.Careofthissamepopulationintheacutecaresettingisoftenmoreaggressivelymanagedthroughtheapplicationoftighterglycemictargets.This2017qualityinitiativewasaimedathealthcareproviderswhocareforfrailelderlypatientsinTransitionalCare(TC),AlternativeLevelCare(ALC),andVeterans(Vets)UnitsintwoareasintheWesternZone(WZ)-YarmouthandMiddleton-tohelpincreasetheirunderstandingandapplicationofthenewguidelines(updatedin2016).SpearheadedbytheDCPNS,theinitiativeusedtheDCPNSDiabetesGuidelinesforFrailElderlyResidentsinorAwaitingLong-TermCare,v2016(Phases1and2),asthefocusofaneducationalinterventionwithemphasisplacedonappropriatecareaimedatpatientsafetyandqualityoflife.Ineffortstoreducetheriskofhypoglycemiaandpersistenthyperglycemia,appropriatebloodglucosetargetswerediscussed,alongwithassociatedchangesinthefrequencyofbedsidecapillaryglucosetestingandmonitoringofoverallglycemiccontrol(glycatedhemoglobin—A1C).Pre-andpost-educationsessionprovidersurveysandchartaudits,educationsessionevaluations,andstakeholderfeedbackwereusedtoassesseffectivenessoftheinitiativeandtoguidefuturework.ThisWZDiabetesQualityInitiativebegantotakeshapeinthefallof2016.DiscussionswereheldwithTimGuest,NSHAVPIntegratedHealthServiceProgramofCare,afterasimilarprojectthatranfrom2014tolate2015(seeAppendix1)hadbeensuccessfullycompletedintheformerSouthShoreHealthAuthority(SSH),WZ.Thisprojecthadbeenprofiledduringthe2015NSHAQualitySummitandtheInternationalDiabetesFederationmeetingsinVancouver,BC.Beforeconsideringprovincialrollout,itwassuggestedthatadditionalsitesintheWZbefoundtotryandthenevaluateanewCo-leadmodel,buildontheidentifiedstrengths,andincreaseourunderstandingofpotentialchallengesandhowbesttoaddress/mitigate.Withanintentionalfocusonengagement,opportunitiestolearnabouttheprojectthroughpresentationsanddiscussionsresultedinstrongalliancesandsupport.Keycontacts-MichelleMcLearn,WZDirectorofNutritionandFoodServices,andBethSnyder,WZDirectorofInterProfessionalPracticeandLearning-providedtheinterestandmomentumtomovetheprojectforward.AstrategicpresentationduringtheWZNutritionalCareMeetinginOctober2016resultedinindividualdietitians/sitesself-selecting,withenthusiasm,tocarrythisworkforward.NutritionServicesalsoprovidedsupportinrecommendingCrystalMacNeil,whowouldassumetheCentralCoordination/ProjectCoordinatorpositionfortheDCPNSandinhostingthispositionandprovidinglogisticalsupportrelatedtoofficespace,datasecurity,filesharing,etc.

4


AnAdvisoryCommitteewasformedfollowingmeetingswithBethSnyder,assheofferedtotakealeadershiproleinshepherdingthisworkintheWZ.ThefirstAdvisoryCommitteemeetingwasheldinJanuary2017.AdditionalcontactsweremadewiththeWZDirectorsofSeniors,Hospice,andPalliativeCare;PrimaryHealthCare;andPharmacyServicesaswellastheChiefsofInternalMedicineandFamilyPractice.SeeAdvisoryCommitteemembership,page7.Thisprojecttookoffquicklyandindoingso,wasabletouse/adaptthemanyprocesses,materials,andinformationlearnedfromtheearlierprojectintheformerSSH.SuccessfulcompletionofanNSHAPrivacyImpactAssessmentandtheconcurrenthiringofapart-time(0.3FTE)CentralCoordination/ProjectCoordinator,allowedtheprojecttotakefulladvantageofa6-monthperiod(MaytoNovember2017).AnursingandnutritionCo-leadmodelwasusedwitheacharea-YarmouthandMiddleton-havingtwoco-leads.Localphysicianchampions,nursingmanagers,andUnitteamleadssupportedtheseindividuals.TheProjectCoordinatorassistedwithcentralcoordination,providingsupportwithpresentationlogistics/promotions;materialpreparation;surveycollection/compilation;chartaudits;datacapture,analysis,andreporting;andcommunications.


5

PROCESSESANDTIMELINE

ThisisaninitiativethatwasabletomovequicklyoncetheNSHAPrivacyImpactAssessment(PIA)wascompletedandapprovedandtheCentralCoordination/ProjectCoordinatorpositionhired.ThePIAensuredthepurpose/intentoftheinitiative,theproposedtimeline,thedataelements,andtheprocessestosafe-guardthedataaswellasariskmitigationstrategywerewellthoughtoutandinplacebeforesign-offwaspossible.OncethePIAwasapproved,effortsfocusedonsecuringthesiteCo-leads,withcleardelineationofrolesandresponsibilitiesbetweenthekeyplayers—Co-leads,ProjectCoordinator,Unit/TeamLeads,etc.(seeAppendix3forroledescriptions).TheWZDirectorofFoodandNutritionServices,MichelleMcLearn,recommendedacandidateforthepositionofProjectCoordinatortotheDCPNSandofferedon-sitelogisticalsupportsforthisperson.Thisincludedofficespace,securefilecabinets,andadministrativesupporttosecurealaptop,establishsharedfolderspacewiththeDCPNS,ensuretimecapture,etc.Theprocesstimelinebelowprovidesasuccinctoverviewoftheinitiativeskeycomponents—engagement,communication,educationsessions,chartaudits(pre/post),provider/participantsurveys(pre/post),processreview,andfinalreportpreparation.Addedtothistimeline,duringthewrap-upmeetingheldinDecember2017,isfeedbacktotheUnits/Unitstaffintheformofsite-specificDebriefpresentations.ThesepresentationswereofferedinJanuaryof2018andincludedasummaryofthefindingsfromthechartaudits,providersurveys,andstakeholderfeedbackaswellasproposednextsteps.Thiswasanopportunitytothankthestafffortheirassistanceandinterestandtosharethemanysuccessesachievedbytheproject.Itwasalsoanopportunitytoreinforcetheneedforcontinuedbestpracticeandtonotewhereconsistencycouldbeimproved.Seepage24foradditionaldetailontheDebriefsessions.

UPSTREAM INTEGRATION OF LTC DIABETES GUIDELINES-WZ PROJECT

PROCESS TIMELINE—MARCH 2017 TO JANUARY 2018

March April May June July

• Privacy/QI Approval • Stakeholder engagement

• Educational Intervention (mid May to end of June)

• Pre Provider Survey • Pre Chart Audits

July August Sept. Oct. Nov.

• Compile Pre Provider Survey • Compile Pre Chart Audits • Prepare Draft Report • Prepare/plan Fall activities

• Post Provider Surveys • Post Intervention Chart Audits • QI Project Process review/feedback • Prepare Draft Report

• Unit Debriefs • Follow-up

Presentations • Final Report

January 2018

= Newsletter/Bulletin

6


EngagementOneofthemanysuccessesintheformerSouthShoreHealth(SSH)Projectwastheeffortfocusedonengagement.Thisengagementhelpedtoincreaseawarenessandunderstandingoftheprojectwithindifferentareasoftheorganization,gainsupportandbuy-in,createalliances,andprovideperspectivesandinsightsintoareasofstrengthandpotentialchallenges.Similartoothersuccessfulqualityimprovementendeavours,relationshipsandpartnershipsarekeyandthiswasthesameforthisinitiative.IntheWZDiabetesQualityInitiativeitwasidentifiedearlyonthatanAdvisoryCommitteewouldhelptoensureareasimpacted(ortobeimpactedinthefuture)wouldnotonlybeawareofbutengagedinthedecision-makingprocessesandthelearninggeneratedfromthiswork.Itwouldalsohelptoelevatethestatusoftheinitiativeandallowforreachacrossabiggergeographicarea.MeetingsbetweentheDCPNSandthePrimaryCareManagerintheformerSSHaboutthesuccessoftheSSHprojectledtoameetingwithTimGuest,NSHAVPIntegratedHealthServiceProgramofCareandNicoleLukeman,DirectorPolicyandPlanningAcuteMedicineServices.ThiscreatedtheopportunityforotherconversationsandmeetingswithindividualsthatwouldeventuallycometogethertosupportthisworkandtheformationofanAdvisoryCommittee.KeycontactswithMichelleMcLearn,WZDirectorofNutritionandFoodServicesandBethSnyder,WZDirectorofInterProfessionalPracticeandLearningprovidedtheinterestandmomentumtomovetheprojectforward.TheirassistancewasinstrumentalinidentifyingAdvisoryCommitteemembersaswellasappropriatesitesandpotentialsiteCo-leads.WhileotherareasintheWZwereidentifiedasinterestedandready,itwasdecidedwithonly0.3FTEofaProjectCoordinatortwoareaswouldbeselected(YarmouthandMiddleton)tokeeptheprojectmanageable.TheDCPNSprovidedtraining/informationexchangesessionsbetweenthenewlyhiredWZProjectCoordinator,andTinaWitherall,theformerSSHLead,toexplaintheapproachandthematerialsthathadbeendevelopedandsuccessfullyutilizedintheSSHProject.AdditionalsessionsledbytheDCPNSwithAdvisoryCommitteemembers,siteCo-leads,andotherinterestedstakeholdersprovidedacommonunderstandingoftheinitiativeandoutlinedthetimelinesandrequirementstodeliverandevaluatetheinitiativewithina6-8monthwindow.Asphysicianinvolvementwasrecognizedtobeessential,DCPNScontactwiththeWZChiefsofInternalandFamilyMedicinesecuredsupportfortheinitiative’sintentandpurpose.Anefforttosecurealocalphysicianchampioninthetwoareaswaspartiallysuccessfulbutimpededinoneareabytheprocesstimelines.Dr.LeslieRiberoexpressedherinterestandassumedtheroleoflocalphysicianchampionfortheMiddletonarea.IntheabsenceofasecuredfamilyphysicianchampionintheYarmoutharea,Dr.BrianMosesagreedtoactaslocalchampion.Wewereencouragedbythecommitmentprovidedbytheseareaphysiciansandtheinterestinthetopicarea.


7

TheAdvisoryGroupMembersareasfollow:

• BethSnyder,Director,InterprofessionalPractice&Learning-WZ• Fran Duggan, Director, Seniors, Hospice/Palliative Care, VAC, ALC, TCU, &

SpiritualCare&SMHHealthSystemsLeader• *NicoleLukeman,Director,PolicyandPlanningAcuteMedicineServices• *JulieSutherland-Jotcham,ClinicalNurseEducator,WZ• BrianMoses,MD,Chief,InternalMedicine,WZ• CrystalTodd,MD,Chief,FamilyMedicine,WZ• VanessaQuigley,InterimDirector,HealthServices/HealthSystemLeadVRH• TinaWitherall,ClinicalDietitian,QueensGeneralHospital,WZ• *MichelleMcLearn,Director,Nutrition&FoodServices,WZ• NancyMcLaughlin,Director,PharmacyServices,WZ• *CrystalMacNeil,ProjectCoordinator,(DCPNSCentralCoordination)• PeggyDunbar,ProgramManager,DCPNS

InJulyof2017asmallersub-group(membersindicatedby*above)wasformedtohelpensuretheinitiativecouldremainnimbleduringthesummermonths,astimelinesweretight.Thissub-groupwastomakedecisionsrelatedtothepostsurvey(whentoreleaseandhowtopromoteandensuregoodresponserates)andmoveforwardwithadraftdocumentforthepatientcharttoreinforcethenewglycemictargets,reducedbedsidemonitoring,appropriateMDnotification,etc.Thepre-chartauditshadhighlightedtheneedforthistypeofdocumentation.ItwasfeltthatthisformcouldbeusedtohelpinformAdmissionOrders/Pre-printedOrders.AdraftdocumentwaspreparedincludingasimplifiedhypoglycemiatreatmentalgorithmmodeledaftertheDCPNSTreatmentofMildorModerateHypoglycemiainPregnancy,butwasnotpiloted.KeycontentsoftheformwereadaptedandconsideredforinclusionaspartofadraftAdmissionOrderthatwasunderreview/revisionfortheMiddletonarea.ThisdraftwasplacedonholdasanNSHAcentralizedprocessforpre-printedorderswasindevelopmentandmembersofthesmallerworkinggroupwerefocusedoncompletingtheexistingworkandhadlittletimetoinvestigatefurther.

CommunicationEarlyinthelifeoftheproject,theProjectCoordinatorestablishedcontactwiththeUnitManagers/teamleadsandcreatedemaillistsofUnitstaff.Promotionalflyers(seeAppendix4)werecreatedtointroducetheinitiative,promoteupcomingeducationsessions,encouragesurveycompletionandadvertiseattendanceofdebriefsessions.Thesepromotionalflyersalongwithinitiativebulletinswerecirculatedviaemailtostaff,postedonunits’educationpinboards,placedinstaffcommunicationbindersandmailboxesofphysicianswhoprovidedservicetotheunitsinvolvedintheinitiative.TheWZDiabetesandLTCQualityInitiativeBulletinwasproducedfourtimesduringtheinitiative.Thebulletinswereintendedtokeepstakeholdersinformedoftheinitiativeanditsprogress.CopiesofthesebulletinscanbefoundontheDCPNSwebsite(diabetescare.nshealth.ca).

• TheMayissue(1stissue)providedanoverviewoftheinitiative,includingthebackground,projectobjectives,AdvisoryCommitteemembers,andcontactinformationforthesiteCo-leadsandtheProjectCoordinator.TheProjectTimeLineappearedineachissue.

8


• TheJulyissueprovidedinformationonwhathadbeenaccomplishedsincethestartoftheinitiative,includinganoverviewofthepre-educationchartaudits,currentpracticesurvey,andeducationsessions.AsmallsectionprovidedanoverviewofbloodglucosetargetsasfoundintheDCPNSGuidelinesfortheFrailElderlyResidentsinorAwaitingLong-TermCare(LTC),v2016.

• TheSeptemberissueprovidedasummaryoftheeducationsessionevaluations—keyfindingsincludingareasofmajorlearning,barrierstoputtingtheguidelinesintopractice,andrecommendationstofacilitateadoptionoftheguidelines.TheFollow-upProviderSurveywasalsopromotedaskingfortobecompletionbyearlyOctober.SeeAppendix5forSeptember2017Bulletin.

• TheJanuary2018issueprovidedclosuretotheinitiativewithasummaryofthefindingsfromthepost-educationchartaudit,pretopostprovidersurveys,andstakeholderfeedback.TheprojectteamextendedahugethankyoutotheUnits’staffsfortheirsupportandinvolvementinthisinitiative.

TheProjectCoordinatorwasinregularcontactwiththesiteCo-leadsandtheUnitstaffbyvisitingtheunitsoftenandreachingoutviaemail/phone.Somemeetingshadastructuredagendae.g.,reviewingdraftversionsofprojecttoolsforinput;meetingtoreviewfindingsfromthepre-educationchartauditsandsurveystohelpCo-leadsunderstandareastohighlightduringeducationsessionsandequippingthemwithcaseexamplestosharewithstaff;planningDebriefSessions.Othermeetingswereunstructuredcheck-insthatallowedtheProjectCoordinatortoassessuptakeoftheprojectbystaff,challengesteammemberswereexperiencingandtooffersupportintheseareas.Thesetouchpointsalsoallowedtheopportunitytokeeptheprojecttopofmindbymovingsurveystovisibleareas,answeringquestionsfromstaffandpromotingtheeducationsessions/surveycompletioninpersonandviaphonecallstotheunit.OpenlinesofcommunicationbetweentheProjectCoordinatorandDCPNSManagerwereheldthroughouttheentiretyoftheinitiative.Weeklycommunicationensuredbothpartieswereprivytonewdevelopments,complications,successesandrequiredadjustmentstotheinitiative.TheProjectCoordinatorandDCPNSManagerDraftreviewedtheprojecttools,communications,andpresentationstoensureclarityandeaseofunderstanding.Thiscollaborationallowedforseamlessintegrationoftheday-to-dayoperationswiththehigh-levelintentoftheinitiative.NSHANEWSwasusedasaplatformtopublicizetheinitiativetothebroaderaudienceoftheNovaScotiaHealthAuthority.TwosubmissionswerepublishedintheNSHANEWS.Theseoutlinedthegeneralpurposeandbackgroundoftheinitiative,explainedtheintervention(educationsessions)andthemajorevaluationtools(chartauditsandcurrentpracticesurveys).TheDCPNSalsohighlightedthisInitiativeinitsNovember2017NewsletterandtheDCPNSwebsitealsohoststheWZInitiativeBulletinsandbackgroundinformationontheinitiative(http://diabetescare.nshealth.ca/events-initiatives/special-projects-partnerships/western-zone-diabetes-quality-initiative-2017).Thefinalreportwillalsobehostedherealongwithcopiesofresourcematerialsthatmaybeofinteresttoothers.


9

EDUCATIONSESSIONS/SUMMARYFEEDBACK

DuringthemonthofJune,31educationsessionsontheDiabetesGuidelinesforFrailElderlyResidinginorAwaitingLong-TermCare(phases1and2)wereofferedintheTC,ALC,andVetsUnitsatSoldiers’MemorialHospital(SMH)andYarmouthRegionalHospital(YRH).Intotal,84stafffromvaryingprofessionsattendedthesesessions.Attendeeswereinvitedtocompleteanevaluationattheendofeachsession,andwereceived64evaluationsforaresponserateof76%!SeeAppendix5foracopyoftheEvaluationForm.

TABLE1:Responsesbyarea(YarmouthandMiddleton)

Site NumberofParticipants NumberofEvaluationsReturned

Responserate(%)

YRH 29 15 52%SMH 55 49 89%Total 84 64 76%

Thesessionsusedacase-basedapproachprovidedanintroductiontotheguidelinesandoverviewofthespecificcontent.Theoverviewincludedwhatweknowaboutindividualsadmittedtolongtermcare(age,averagelengthofstay,numberofmedications),rationaleforthedevelopmentoftheDCPNSguidelines,anintroductiontofrailty(acommonunderstanding),andthepurposefortheguidelinesincludingkeyconsiderationsoffrailty,lifeexpectancy,safety,andqualityoflife.Specificcontentrelatedto:

• Hypoglycemia—identification,signs/symptoms,causes,treatment,andprevention

• Relaxedtargetsforglycemiccontrol(acceptableranges,andwhentocontactthephysicianformedicationreductionorincrease)

• Frequencyofbedsidecapillaryglucosemonitoring(highlightingwhenshorttermhighfrequencymonitoringisrequiredandappropriatefrequencyofmonitoringinthewell-managedpatientdependentonmedicationtherapy)

• FrequencyofA1Cmonitoring(andwhatA1Ctellsus)

Participantsratedthesessionsverypositively.Usinga5-pointscale,where5wasexcellent;1waspoor:

• 100%(allparticipants)ratedthesessionsasverygood/excellent(overallrating4.7outof5)

• 97%ofparticipantsfeltverystronglythatthesessioncontributednewknowledgetotheirunderstandingofdiabetescareforfrailelderly(overallrating4.6outof5)

• 94%feltverystronglythatthelearningwasapplicabletotheirpractice(overallratingof4.5outof5)

• 94%statedtheywouldlikelyusethelearningfromthesessioninpractice(overallratingof4.5outof5)

10


Whenaskedaboutareasofmajorlearning,participantsnoted:

• Increasedabilitytorecognizesigns/symptomsofhypoglycemia&hyperglycemiaintheelderly

• BetterunderstandingofhowtoproperlyinterpretbloodglucosereadingsandA1Cresults

• Increasedawarenessofappropriatefrequencyforcapillarybloodglucosemonitoring

Many staff also reported that, as an outcome to their learning, they would be less restrictive withsnack/foodchoicesofferedtofrailelderlyclientswithdiabetes.

Although several barriers to putting the guidelines into practice were identified, many participantsstated theywould share their learning from the sessionwith colleagues and advocate for theDCPNSGuidelinestobeadoptedintopractice.Barriersidentified,includedamongothers:

• Resistanceofchangefromthecareteam• Lackofclient/familyeducationonrationaleforrelaxeddiabetestargets• Lackofaccesstophysicianfortimelychangestomedication

RecommendationsbyparticipantsforfacilitatingtheadoptionoftheDCPNSDiabetesGuidelinesforFrailElderlyResidinginorAwaitingLong-TermCareintopracticeincluded:

• Creatingpre-printedordersandpoliciesthatreflecttherecommendationsintheguidelines

• Moreeducationforphysicians,staff,clients,families,andevenhospitalvolunteers


11

CHARTAUDITS(PREANDPOSTEDUCATIONALINTERVENTION)

Tohelpevaluatepracticepriortoandafewmonthsaftertheeducationalsessionintervention,chartauditswereconducted.AllchartauditswerecompletedbytheProjectCoordinatortoensureconsistencyindatacollectionandinterpretation.Thepre-chartauditswerecompletedinMay2017andthepost-chartauditsinOctober–November2017(3-4monthsaftertheeducationsessionswerecompleted).Thishelpedtoensuresignificanttimehadpassedtoallowuptakeandintegrationoftheguidelinesintopractice,whilenotcompromisingtheoveralllengthoftheinitiative.Intotal10chartwerecompletedinMay(Pre)and15intheautumnof2017(Post).Allchartsthatmetthefollowingcriteriawereinvolvedintheaudit:

• AdmittedtoabedontheALC,VETSorTCunitsofYRHorSMH• Diagnosisofdiabetes(T1DMorT2DM)• Medicallydischarged(nolongerinhospitalforAcuteCarewithgoalofreturning

tohomeincommunity/independentliving)Anexcelspreadsheetwasusedtocollecttherequireddata,andthisguidedtheProjectCoordinatorcollectionoftherequiredelementsfromthecharts.ThistoolwasadaptedfromtheSSHLTCQualityInitiativeanddataelementscollectedincluded:typeofdiabetes;durationofdiabetes;diabetesmedicationanddosedirections;dietorder;bloodglucoseandA1Ctargetsandfrequencyofmonitoring;presenceoftime-limitedtestinguponadmission,followingdiabetesmedicationchangesandduringtimesofillness;BGreadings(outsideacceptablerange);episodesofhypoglycemia;notificationofphysicianwhenBGoutsideacceptablerange;etc.AlistofthedataelementscanbefoundinAppendix6.Thechartauditincludedanextensivereviewofthechartkeptatthenurses’station,alongwithreviewofpastmedicalrecordsforchartsthathadbeenthinned,theMedicationAdministrationRecord(MARS),bloodglucoserecordsheets,physiciancommunicationbinders,nursingcommunicationbooks,andPatientKardex.Issuesidentifiedinthepre-chartaudits:

• NodocumentationuponMedicalDischargeforchangeinBGandA1Ctargetsreflectingfrailtyconsiderations.NodocumentedtargetsforBGandA1C,ingeneral.

• AmbiguousordersforBGmonitoring,leadingtoinconsistenciesinfrequencyandduration.§ Noidentificationoftime-limitedtesting,leadingtoexcessivemonitoringfor

somepatients.• Hypoglycemia:

§ Noassessment/documentationofBGresultswhennursingnotesindicatepossiblesignsandsymptomsofhypoglycemia(falls,confusion,pale)

§ Vaguedocumentationoftheresponsetohypoglycemia(actiontaken)§ Overtreatmentofhypoglycemia§ DelayedBGrechecks,past15-minutes,followingtreatmentforhypoglycemia

12


• Insulincorrectiondoses:§ InplaceforBGvaluesconsideredintargetaspertheguidelines,resultingin

increasingtheriskofhypoglycemia.§ InplaceforexcessivelyhighBG.Thisresultedinamorereactiveapproachto

hyperglycemia,asopposedtoproactivecareifthephysicianhadbeennotifiedtoincreasemedicationtopreventfuturehyperglycemia.

PostChartAuditsDuringthepost-chartauditcollection,itwasnotedthatstaffweremuchmoreknowledgeableabouttheDCPNSDiabetesGuidelinesforFrailElderlyResidentsinorAwaitingLong-TermCare,v2016.StaffwasmoreengagedinaskingquestionsoftheCoordinator,duringtheactualaudit,aboutcases,andsomephysicianswouldrequestguidanceincare.Therewereanumberofareaswherechangeinpracticewasnoted:

• Documentationofbloodglucose(BG)orA1CTargets.Severalchartshadtargetsdocumentedwherenoneweredocumentedinthepre-chartaudit.

• Hypoglycemia.Improvementwasnotedinstaffs’abilitytorecognizesignsofhypoglycemiaanddocumentappropriatetreatmentofhypoglycemia,includingBGvalues.

• Physiciannotification.SeveralchartsindicatedthatthephysicianwasnotifiedwithBGvalues>20mmol/Lor<7mmol/L;andwhenthephysicianwasnotified,theresponsewasappropriate(medicationadjustment).

• Correctiondoses.Nodocumentationofcorrectiondosesforvaluesconsidered“intarget”usingthenewguidelines.

• Diabetesmedicationreduction:InseveralcaseswithA1C<8%,physiciansrespondedaspertheguidelinesandreducedtheappropriatemedication.

• Time-limitedBGtesting.Insomecases,time-limitedtestingwasseeninnewadmissioncasesaswellasfollowingdiabetesmedicationadjustments.

Whilethereweremanyareasofpositivechange,thesewereinconsistent;e.g.,thereweresomecaseswhereA1Csinthe6%rangedidnotresultinmedicationchange,wheretreatmentofhypoglycemiawaspoorlydocumented,andwherephysicianshadnotbeencontactedwhenbloodglucosevalueswerenotedtobeatundesirablelevelsaccordingtotheguidelines.Onsomeunits,dailybloodglucosemonitoringwasstillemployed,onotherunitstime-limitedtestingwasnotthepolicy,butreducedregulartestingwas(e.g.,onceaweektest,alternatingtimeeachweekorQIDtestingonedayamonth).Areasofgreatestconcerninthepostchartauditsincluded:

• Incorrectorincompleteresponsetohypoglycemia• Medicationadjustmentsthatdidnottargetthecauseofdysglycemia,thusfailing

topreventfuturedysglycemia• LackofmonitoringofBGandA1Cinsomenewadmissioncases


13

Note: Shortterm,highfrequencyBGmonitoringisrecommendedonadmissiontoassessimpactofchangeinenvironment,diet,stresslevels,andmedicationcompliance;timesofillness;andpostadiabetesmedicationchange.

ITwasstronglyfeltthatPre-PrintedOrdersforthechartwouldbeagreatasset.ManystakeholdersfeltthePre-PrintedOrderswouldprovidephysicianswithanefficientmeanstoimplementandcommunicatecaremanagementthatalignswiththeguidelines.Pre-PrintedOrderswouldactasareferenceastobestpracticesofcareandreduceinconsistenciesofcare.Apolicyoutlininghowtorecognize,treatanddocumenthypoglycemiawasalsonotedasapotentiallyusefultooltohelpreduceerrorsintheseareas.

14


CURRENTPRACTICESURVEY(PREANDPOSTEDUCATIONALINTERVENTION)

Toevaluatechangesinknowledgeandpractice,CurrentPracticeSurveysweredistributedpriortoandfollowingtheeducationalsessionintervention.CurrentPracticeSurveysweredistributedtothestaffoftheunitsinvolvedintheinitiative.Allstaffmemberswereinvitedtocompletethesurveysregardlessofdiscipline,yearsofexperience,orrecenteducationinthetopicofdiabetesmanagementinthefrailelderly.Thepre-interventionsurveyswerecirculatedandcollectedinMay2017(educationsessionswereheldinthemonthofJune2017),andthepost-interventionsurveyswerecirculatedandcollectedinSeptember–October2017(3-4monthsaftertheeducationsessionswerecompleted).Thishelpedtoensuresignificanttimehadpassedtoallowuptakeandintegrationoftheguidelinesintopractice,whilenotcompromisingtheoveralllengthoftheinitiative.ThesurveyswereadaptedfromtheSSHLTCQualityInitiative.Boththepreandpostsurveyswerefourpagesinlengthandwerecomposedofavarietyoftrueandfalse,multiplechoiceandshortansweropen-endedquestions(10intotal).Therewereseveralareasoffocusedquestionsonthesurveys:

• SurveyPopulationCharacteristics:Theseincludeddiscipline,site/unitofemployment,yearsofexperience,andrecentpasteducationondiabetesmanagementforfrailelderly.

• ConfidenceQuestions:Participantswereaskedtoratetheirconfidencelevelwithvariousaspectsofdiabetesmanagementinthefrailelderly.

• CurrentPractice/KnowledgeQuestions:Participantswereaskedtosharetheirknowledge/currentpracticeofBloodGlucose(BG)andA1Ctargetsinthefrailelderly;frequencyofA1CandcapillaryBGtesting;knownrisksofhypoglycemia;andBGvaluesthatwarrantmedicationadjustment(notificationofphysician).

• ApplicationtoPractice(CaseStudy)Questions:SeveralcasestudiesaskedparticipantstodetermineappropriateBGtargetsandfrequencyofA1Cmonitoringdependingoncasecharacteristics.

Toreviewthepre-surveyinfull,pleaserefertoAppendix7.

Surveycompletionwaspromotedintheweeksprecedingsurveyavailabilityusingflyersthatwerecirculatedbyemailtostaff,postedonunitpinboards,placedincommunicationbindersanddeliveredtophysicianmailboxes.Surveysweredirectlydistributedtoallstaffviaemail.CopiesofblanksurveyswerealsoplacedattheNursingStationsoftheunitsinvolvedintheinitiative.Physicalcopiesofthesurveywereplacedinphysicianmailboxes.Staffswereencouragedtocompletethesurveysbytheirunitmanagers,teamleadsandtheCo-leadsoftheprojectwhoreinforcedcompletionthesurveyswhenvisitingtheunits.TheProjectCoordinatoralsovisitedandtelephonedtheunits,especiallyduringtheeveningshift,topromptsurveycompletion.Participantscouldreturnthecompletedsurveyin-persontotheProjectCo-leadsviaemailtotheProjectCoordinator,orbyplacingitinthemarkedenvelopesleftoneachunit.


15

Intotal,75pre-surveyswerecompleted(39–YRH,36–SMH);and42post-surveys,werecompleted(22–YRH,20–SMH).KnowingthatpostsurveycompletionhadbeenlimitedintheformerSSHproject,andwithaccreditationlooming,effortshadbeenfocusedonensuringgoodpostcompletionrates.Theseincludedthepromotionalflyers,advertisementofthepost-surveyinInitiativebulletins,encouragedparticipationbytheinitiative’steamandUnitleaders,andanextensionoftheoriginalcompletiondatebyoneweektoOctober13,2017.Thelowerthanintendedcompletionratemightreflectthatparticipantsfoundthepre-surveychallengingandthisdeterredthemfromdoingthepost-surveyagain. SurveyRespondents–SelectionforAnalysisTABLE2:SurveyRespondentCharacteristics PRESURVEY

RESPONDENTSPOSTSURVEYRESPONDENTS

N=75

AllN=42

AttendedEducationEventN=23

N % N % N %Location

• Yarmouth

39

52%

22

52%

10

43%• Middleton 36 48% 20 48% 13 57%

DISCIPLINE: • RN 10 13% 3 7% 3 13%• LPN 33 44% 18 43% 17 74%• CCA 18 24% 11 26% 2 9%• MD 7 9% 9 21% 0 0%• Alliedhealth

Professional7

9%

1

2%

1

4%

YEARSINPRACTICE • <2 9 12% 5 12% 3 13%• 2-4.9 8 11% 4 10% 1 4%• 5-14.9 23 31% 12 29% 5 22%• 15ormore 35 47% 21 50% 14 61%

ATTENDEDRECENTDIABETESEDUCATION

• Yes% 18 24% 23 55% 23 100%

16


Inordertodiscerntheimpactoftheinitiative’sinterventionontheresults,theinformationthatfollowsfocusesonasubgroupthatattendedtheeducationalsessions.Intotal,23/42post-surveyparticipantsreportedthattheyhadattendedaWesternZoneDiabetesLTCQualityInitiativeEducationSession.Thefollowinganalysiscomparesthissubgroup(23)tothepre-educationsurveyresults(n=75).NOTE: Insomecases,whentheentirepostgroupwasanalyzed(42)therewasamoresignificant

difference(improvement)intheresults.Wefeelthismayreflectthelargergroupofphysiciansinthepost-surveygroupaswellasthesharedlearningexperiencesbetweeneducationsessionattendeesandnon-attendees.

Physicianswerenotincludedinthepostsub-groupforanalysis,astheyhadnotattendedaneducationsession.Wealsosuspectindirectimpactonawarenessandknowledgefromourintervention(theeducationsession),asthetoolssharedintheeducationsessionswerereadilyavailabletoothersontheUnitswhodidnotattend.Forexample,someparticipantswhoattendedtheeducationsessionindicatedthattheyintendedtosharewhattheyhadlearnedwithcolleagueswhodidnotattend.Severalpost-surveyparticipantswhohadnotattendedaneducationsessionsupportedthis.TheyindicatedthattheyhadrecentlyreviewedtheDCPNSDiabetesGuidelinesforFrailElderlyResidentsinorAwaitingLong-TermCare,v2016,independentlyorwithcolleagues.

SurveyParticipantCharacteristicsAwidearrayofdisciplinesparticipatedinthesurveysincluding:RegisteredNurses(RNs),LicensedPracticalNurse(LPNs),ContinuingCareAssistants(CCAs),Physicians,andAlliedHealthProfessionals-includingDietitians,OccupationalTherapists,PhysiotherapyAssistants,andPharmacists.ThelargestparticipationratescamefromLPNsandCCAs,astheseprofessionslargelystafftheUnits.TherewasgreaterAlliedHealthProfessionalparticipationinYRHcomparedtoSMH.ThiscouldbeexplainedbythefactthatRegionalHospitalsemploysignificantlymoreAlliedHealthProfessions.


17

SurveyParticipantConfidenceTherewasachangenotedintheparticipants’self-assessmentoftheirconfidencelevelinregardstodiabetesmanagementinthefrailelderly.Inallareas,Confidence(ratingassomewhatorveryconfident)wasimprovedwitheducation:

• Overallmanagementofdiabetesincreasedfrom84%to96%• Determiningtheappropriatefrequencyofbedsidecapillarytestingincreased

from62%to91%• SettingBGtargetsincreasedfrom64%to92%• Managinghyperglycemiarosefrom78%to96%• Managementofhypoglycemiarosefrom84%to96%

18


CurrentPractice/Knowledge

Markedimprovementofknowledgewasnotedinmostareasofdiabetesmanagementinthefrailelderly;forexample:

• AbilitytorecognizeanappropriateA1Ctarget(8-10%)increasedby22%.

• Respondentsweresurerofthemselvesinthisareawith19%fewerselecting“NotSure”inthepostsurvey.

Note: AnA1Cof8-10%isequaltoanaveragebloodglucoseofbetween10-13mmol/L

• AbilitytoidentifyappropriatefrequencyofA1Cmonitoring(1-2timesperyear)increasedby31%;57%ofeducatedparticipantsansweredthiscorrectly.

• Abilitytoidentifyappropriatepractice(noneedtocallphysician)whenBGrunningbetween10.1-15mmol/Lformedicationchange,increasedby35%;91%ofeducatedparticipantsansweredthiscorrectly.

Note: Thisisconsideredanacceptable

rangeormostfrailelderlyindividualsrange(ifnoreversiblesymptoms;i.e.,polyuria,polydipsia)arepresent


19

• AbilitytoidentifyapossibleacceptableBGrange(15-20mmol/L)ifinfrequentandnotpersistent),increasedby40%.Virtuallyalleducatedparticipants,96%,knewthistobetrue.

Note:Thisrangemaybeacceptable,ifinfrequentandnotpersistent.Ifpersistent,notifyphysiciantoassesspossiblemedicationchange.

• Abilitytoidentifyanappropriatepractice(callthephysicianforamedicationreduction)whenBGrunning4-7mmol/L,increasedby22%.However,26%ofeducatedparticipantsrespondedincorrectlystatingtherewasnoneedtocontactphysicianand13%statedtheywerenotsure.Duetosubstandardresponse,thistopicwasrevisitedintheDebriefSessionsthatwereheldwithunitstaff.

Note: ThisisconsideredanunacceptableBGrangeincreasingtheindividual’sriskforhypoglycemiaanditsrelatedsequelae.

ApplicationtoPractice(CaseStudy)QuestionsAbilitytocorrectlyapplynewknowledgetocaseexamplesshowedareasofimprovement.ParticipantscomfortwithLTCguidelinetargetsof10-15mmol/Linspecificsituations,increased41%andunderstoodaninappropriatetargetof4-7mmol/L;weresurerofthemselveswithfewernotsure/noresponses.

20


STAKEHOLDERFEEDBACK

StakeholdersurveyswerecompletedlateNovember/earlyDecember2017bytheSiteCo-leads(4),theCentralCoordination/ProjectCoordinator(1),andmembersoftheAdvisoryCommittee(6of10).ThesesurveysweredistributedbyandreturneddirectlytotheManageroftheDCPNS.TheDCPNSManageralsoprovidedhigh-levelreflections.Thesurveysfocusedpredominatelyontheprocesses.StakeholderswereaskedtoprovidefeedbackontheCo-leadmodel;thepositionofProjectCoordinator;communication,educationsessionsandmaterials;andtheoverallframeworkfortheinitiative(includingtheprocesstimelineandevaluationmetrics).Respondentswerealsoaskedtoprovideadditionalinsightsintowhatwasrequiredtoputtheguidelinesintopractice,guidancewhenconsideringprovince-widerollout,andsummarycommentsaboutwhatworkedwell.Theyalsoprovidedaratingfortheplanning,delivery,andevaluationoftheoverallinitiative.CopiesofthesurveysarelocatedinAppendix10.Allrespondentsfelttheywerewellinformedabouttheinitiativeandwellsupportedintheirroles.Thiswasachievedthroughone-on-onediscussionsthatwereheldwithandbetweenAdvisoryCommitteemembers;face-to-face/virtualmeetingsthatprovidedanoverviewoftheinitiative,proposedtimeline,rolesandresponsibilitiesoftheteammembers,andkeymessagesfromtheguidelines;emails;newsletters;andon-sitecontact,whereapplicable,withtheProjectCoordinator.

Co-LeadModelandCentralCoordinationThenurseanddietitianCo-leadmodelwasanidentifiedstrength,aswastheroleofCentralCoordination/ProjectCoordinator.RespondentsfelttheCo-leadmodel:

• Supportedbuy-infromNursingandNutrition,andmodeledInterProfessionalcollaboration.

• Recognizedtheexpertiseofthetwoprofessionsandbroughtdifferent,yetcomplementary,viewstothetable.

• Allowedforthesharingofworkloadandthedemandsoftheeducationsessions.

Whilethismodelwasintendedtobuildandgrowexpertise/capacityatthelocallevel(champions),theCo-leadsdidnotseemuchchangeinhowstaffregardedtheminrelationtodiabetesandfrailty;however,theywereoccasionallyapproachediftherewasaparticularquestion/problemduringthelifeoftheinitiative.Centralcoordination(bothprovidedbyDCPNSandtheProjectCoordinator)supportedtheprocesstime-linebykeepingthevariouspartsoftheinitiativeonscheduleandtruetotheintendedprocesses.TheProjectCoordinatorcompletingtasksthatwouldnothavebeenpossiblebytheCo-leads.

• Havingadedicatedpersonensurestheworkmovesforwardandiscompleted,insteadofittryingtobecompletedoffthesideofsomeone’sdesk.Thisspecificworkincludedchartaudits,photocopying,preparingeducationpackets,reviewingparticipantevaluations,creatingposters,correspondingwithunitstaff,draftingnewsletters,enteringdata,analyzingdata,contributingtothereport,andpresentingtotheAdvisoryCommittee.


21

• Consistencyinapproachwasalsorecognizedasastrengthincompletionandinterpretationofthechartaudits.Havingonepersoninvolvedinallaspectsoftheinitiativeallowedforthebigpicture/purposetostaytopofmindandallowedforconnectionstobemadebetweenallcomponentsoftheproject.

• Thispositionalsohelpedtogiveafacetotheproject.StaffbecamefamiliarwiththeProjectCoordinator,askedquestions,andrecognizedherasaresourcenotjustfortheinitiative,butalsofordiabetesspecifically.

• Thispositionwasfelttobepivotaltothesuccessoftheinitiative.

Itwasrecognizedandstatedmanytimes,thatCrystalMacNeil,intheroleofProjectCoordinator,wastherightpersonforthispositionandthattheprojectwouldnothavehappenedwithoutherinthisrole.EverythingdonebyCrystalwasverywelldone.TheProjectCoordinator,withherCertifiedDiabetesEducator(CDE)designation,didfindthestaffreachedouttoherastheinitiativeprogressedaskingherquestionsabouttheguidelines,spendingtimewithherassheconductedthepostchartaudits,talkingaboutspecificcases,etc.CommunicationCommunicationbetweentheProjectCoordinatorandtheCo-leadsandtheCoordinatortotheUnit/areastaffs,wasrated4.75/5bytheCo-leadsand5/5bytheCoordinatorandtheAdvisoryCommitteemembers.Ratingswereconductedusinga5-pointLikertscale,where1waspoorand5wasexcellent.TheoverallcommunicationthroughtheWZDiabetesandLTCQualityInitiativeBulletinwasratedat4.25/5,asweretheNSHANewsUpdates.AreasforimprovementincludedAdvisoryCommitteemembercommunicationtotheirareasofresponsibility.TheCoordinatorandtheAdvisorymembersratedthis3and3.75/5,respectively.EducationSessionsTheCo-leadsfeltthattheyhadadequatetrainingandknowledgeofthematerialstheyweretoteach.OneCo-leadindicatedadditionaltrainingmighthavebeenbeneficial.Whenaskedaboutthereceptivityofthestafftotheeducationsessions,theCo-leadsappliedaratingof4.25/5.Effectivenessinincreasingawarenessandunderstandingoftheguidelineswasratedat4.0/5andpreparednessofthestafftoimplementtheguidelineswasratedat3.5/5.Suggestedimprovementstotheeducationsessionsincluded:

• Developmentofon-linelearningmoduleswithmandatorycompletionbystaffwhoworkonunitswithapredominatelyfrailseniorpopulation.

• Fewerslide,toallowforagreaterfocusonhowtointerpret/implementguidelinesandusethesupportinghandouts.

• Focustheeducationonthe5areasofgreatestneed,withlesstimedevotedtothebackgroundandrationale:

22


1.BGandA1Ctargets2.Whentocallthedoctor3.HowoftentomonitorBGandwhentoincreasethefrequencyoftesting4.HowoftentomonitorA1C5.Howtoidentify,treat,anddocumenthypoglycemia

• Keepthesessionsrelaxedandinformal,allowingforinput,discussionandtimetopracticeapplying theknowledge topatient caseexamples,as theyareeffectiveforlearning.

• Better space and timing for the sessions (part of staffmeeting) and design forsmallergroups.

OverallInitiativeWhenaskedtoprovideanoverallratingfortheinitiativeframeworkandprocessesintheareasofplanning,deliveryandevaluation,Co-leadsandAdvisoryCommitteemembersprovidedthefollowing,respectively:

• Planning(DCPNSrole,AdvisoryCommitteemembership/role,engagementefforts,co-leadmodel,etc.): 4.5,4.25

• Delivery(centralcoordinationsupports,communications,chartaudits,providersurveys,educationsessions,etc.): 4.5,4.25

• Evaluation(preandpostchartaudits;preandpostprovidersurveys,educationsessionevaluations,co-leadsurvey,etc.): 4.0,4.00

PuttingtheGuidelinesintoPracticeWhenaskedwhatwasrequiredtoputtheguidelinesintopractice,theCo-leads,theCoordinator,andtheAdvisoryCommitteememberscitedtheneedfor:

• Pre-printedordersets/admissionorders.Aformthatcanbeappliedtothepatient’schartoncemedicallydischargedfromacutecarewouldbeveryhelpful,similartowhatisappliedtocardiacpatients.Thiswouldallowforreinforcementoftheguidelinesandbeanefficientmeansforphysicianstoimplementtheseguidelinesandtoprofileindividualizationasrequired.

Otherconsiderationsinclude:

• Standardsofpractice• Continuedmonitoringofcurrentpractices,withreminderstostaff• ReinforcementbyManager/ChargeNurse/CNE• Havingpositivefeedbackfromthepilotsites’teammemberstosharewithother

units.Itwasfeltthiswouldhelpwithspreadandsustainability• Continued reminders to staff and follow-up from the Project Coordinator to

ensureanyquestions/concernsareaddressed• Sharepositive feedback frompilot teammembers (writtenmessages,video),as

thiswasfelttobeverypowerful


23

Province-WideConsiderationsAsthisinitiativewasintendedtohelpinformprovince-wideadoption/adaptation,theCo-leads,theProjectCoordinator,theAdvisoryCommitteemembers,andtheDCPNSManagersuggestedthefollowing:

• Usethesameprocessandstandardtools/materials(fidelity).Initsentirety,thisinitiativeworkedverywellallowingforconsistentimplementationandcomparisonacrosssites.

• ImplementaCo-leadmodel(buildsonandrecognizeslocalcapacity).• ImplementCentralCoordinationsupportasthisensuresprocessandtimelinesare

met,supportsCo-leads,connects“thedots”,andfacilitatessharedlearningacrosssites.

• Sharewhathasbeenlearnedfromthelasttwoprojects,includingprocessandcontextualconsiderations.

• UpdatethePIAtoreflectprocesschangesinlightofnewareas/localcontext.• Planforactivephysicianengagementandbuy-in/support.Consideranactive,

localphysicianchampion,withanexpertiseintheDiabetesandLTCguidelines,tocomplementtheCo-leadteam.

• Meetwiththeareaphysiciansveryearlytoprovideconsistenteducationontheguidelines,includingrationaleandbackground,andtoreviewthechartaudittoolsothattheyknowwhatisbeinglookedforandwhy.

• Bringevenmoreawarenesstotheinitiativeviacommunications,posters,andreminders.

• DevelopProvince-wideforms/orderstosupporttheapplicationoftheguidelinesandtoroundouttheeducationsessions.

• Workwithteams/programsthatarealreadyprovincialinnature,andduplicatethisapproachinotherzones,forexample,NutritionandFoodServicesandInterprofessionalPracticeandLearning.MeetwiththeseSeniorDirectors/Directorstogainsupportandcreatethenaturallinkagestosites/areasthatare“readyandeager.”

• Learnandimproveaswego—beingflexibleindifferentareaswithdifferentresources.

• Usethechartauditstosupplementtheeducationsessions.Theyposeagreatteaching/learningopportunitywithcase-by-caselearning.

• AddinDebriefsessionsforthestaffoftheunitsinvolvedintheinitiative—whatdidwefind(positive);whatwouldweliketosee.

Otherconsiderations• Considerdoingawaywiththepreandpostprovidersurveysastheyarebothtime

consumingandforsome,imposing.Iftheemphasisgoingforwardistobeonimplementingpracticechange,thechartauditandothertoolsmaybemosteffective.

• Reducethelengthoftheeducationsessions,andsupplementwithon-linelearningmodulesthatprovideanswerstocommonquestions,etc.

24


DEBRIEFSESSIONS

InsharingthefinalresultsoftheinitiativewiththeAdvisoryCommitteeMembersinDecember2017,itwasdecidedthatitwouldbevaluableandmeaningfultoreturntotheunitsthatparticipatedintheWZDiabetesQualityInitiativetoholddebriefsessions.Theobjectivesofthedebriefsessionswereto:

• Thanktheunitsfortheirparticipationintheinitiative,theircommitmenttobestpractice,andfortakingonthispilotprojecttohelpguideaprovincialapproachtoimplementingtheLTCDiabetesGuidelinesforFrailElderlyPatientswithinsimilarsettings.Acertificateofthankswaspresentedtoeachoftheunitsduringthedebriefsessionstocommemoratetheirrole.Thesuccessofthisinitiativecouldnothavebeenachievedwithouttheirtimecommitmentandopennessthroughouttheproject.

• Shareresultsandfindingswiththefrontlinestaff.Itwasfeltthatthedatacollectedandcollatedfromthechartaudits,practicesurveysandeducationsessionsshouldbesharedwiththestaffthatprovidedthisdata.Thedebriefsessionsaffordedtheopportunitytobothcelebratepositivechangesandalsohighlightsomeareaswheretherecouldbeimprovedconsistency.Theyalsoofferedanopportunityforre-educationonspecificareasofpracticeincluding:propertreatmentanddocumentationofhypoglycemia,appropriatecontactingofphysiciansfordysglycemia(toohighortoolow),andareviewoftime-limited,highfrequencyBGtesting(whenitisrequired).

• Encourageopenconversationaboutthebarrierstoguidelineimplementationandthesuggestionsstaffhadmadethroughouttheprojecttoimproveimplementationanduptake.ThedebriefsessionsprovidedtheopportunitytoassurestafftheywerebeingheardandtoreinforcethecommitmentfromtheDCPNStoaddressthepointsraised.Forexample,staffidentifiedthatfamiliesandpatientsmaynotbeawareofthebestpracticesfordiabetesmanagementinthefrailelderlyandasaresulttheymayperceivethelackofbloodglucosemonitoringormedicationadjustmentforhigherBGtargetsasinadequatecare.Staffwasreassuredthatabrochurewouldbedevelopedtosupportconversationswiththepatientsand/ortheirfamilies.Itwillhelptointroducetheconceptsofpatientsafetyandqualityoflife,andtherolerelaxedglycemictargetscanplayinthese.Otherareastobeaddressedinclude:educationalopportunitiesforphysicians,developmentofahypoglycemiaalgorithm/tooltoguidestaffonhowtoproperlytreatanddocumenthypoglycemia,andthecreationofpre-printedorderstohelpfacilitatetheadoptionoftheLTCDiabetesGuidelinesintopractice.

• Invitestafftobecomeinvolvedandtopromotetheinitiative.Staffwasaskedtoconsiderdoingashort,recordedinterview,orprovidingaquotethatwouldhelpexplain/promotethisinitiativetootherfrontlinestaffthroughoutNovaScotia.

Intotal10debriefsessions(2perunit)wereheldthroughoutJanuary2018.Physicians,nursingstaff,alliedhealthprofessionals,andUnitmanagementwereinvitedtoattendthesessions.TheCentralCoordinatorandtheCo-leadsfacilitatedthesessions.TheywereheldattheNursingStationsoftheUnitsinvolvedintheinitiativetoallowallondutystafftoattend.Intotal35staffattendedthe20-miinutesessions.Manypositiveandconstructiveconversationsoccurredduringthesesessions;e.g.,startingtotalkaboutandplanforaContinualMedicalEducation(CME)eventforphysiciansintheYarmoutharea.ThiswouldhelpensureastrongandconsistentunderstandingoftheDCPNSDiabetesGuidelinesforFrailElderlyResidentsinorAwaitingLong-TermCare,andwhattheWZQualityInitiativewasabletoaccomplish.


25

SUMMARY

Thedocumentedapproachtothisqualityimprovementwork(includingtheextensiveAppendices)isintendedtoguidefutureworkandtohelpprovideanswerstoquestionsrelatedtoallaspectsofthisInitiative—howitwasstartedandwhyandwhatwasinvolvedineverystepalongtheway.

Asevidentthroughoutthisreportuseofthewell-definedprocesses,aswellasthemeasuresusedtoevaluateit,haveallowedustocontinuetolearnthroughadynamicandevolutionaryprocess.

WherethisinitiativefollowedontheheelsofthesuccessfulformerSSHproject,wehavebeenabletoclearlyidentifyandbuildonthemanystrengths,aswellasprovideclearguidanceonareasrequiringfuturefocus.Smallworkinggroups/teamswillworkonthepatient/familybrochure,preprintedordersetorsupportingdocumentationform,refinementoftheeducationsessionandpossibleLMSmodule.

Movingtoadditionalsitesshouldbeournextgoal,toagainimplementandevaluatefurtherenhancements.

Inclosing,wewanttosharethese1stvoicereflections.Wethinkthesesayitall.

ImpactTestimonialsThefollowingarequotesfromHealthCareProviderswhostafftheunitsdirectlyengagedintheWesternZoneDiabetesandLong-TermCareQualityInitiative.

Staffweretoldthatthequotecouldpertaintotheprocess,structureortimelineoftheinitiative;thecontentoftheintervention(educationanddebriefsessionsregardingtheDCPNSDiabetesGuidelinesforFrailElderlyResidentsinorAwaitingLong-TermCare,v2016);howtheyfeelthisinitiativehasaffectedtheirclients,workdayorunit.Essentially,staffswereinvitedtocommentonanyfacetoftheinitiative.

• VeteransUnit–Yarmouth(LPN)“Ithasreducedanxietyoflows[hypoglycemia]byhavingmorerelaxedsugar[bloodglucose]targets.”“Itallowsclientstohaveabetterqualityoflifebecausethestaffdonotfeeltheneedtorestrictdietasmuch”.

• VeteransUnit–Yarmouth(RN)“TheDebriefSessionswereagreatreminderforeveryone”

• AlternativeLevelofCare–Yarmouth(TeamLead)“Thenicethingaboutthenewguidelinesisitgivesmorefreedomtoourfrailelderly.Theyarenotsorestrictive.NoteverythingrevolvesaroundthemhavingDiabetes–it’saboutenjoyinglife”“EducationSessionswereinformative.Informationwasacceptableandapplicable”

• AlternativeLevelofCare–Yarmouth(RN)“Whenwesuggestguidelinestophysiciansthey’renowmoreopentoit”

26


• VeteransUnit–Middleton(RN)“Ithoughtitwasagoodupdateforusandthedoctors.Sometimesdoctorsgetstuckinoldways”

• Yarmouth(MD)“Evidencebasedmedicineistoday'scatchphrase.Theprojectgaveusthechancetoviewwhatwasbeingdone,toaddaneducationalperspectiveandthentomeasurethechangeinpractice.”


27

APPENDIX1

FormerSouthShoreHealthQualityImprovementProject,2014-2015FrailElderlyWithDiabetes…CanWeImproveTheApproachtoCare

intheAcuteCareSettingforThoseAwaitingLong-TermCare?

Background

Careoftheelderlywithdiabetes(DM);specifically,thefrailelderly,posesmanychallengesforhealthcareproviders(HCP)practicingintheacutecaresetting.Agreaterfocusonrelaxedglycemictargetsandaresultingreductioninbedsidemonitoringhelpstosupportbothpatientsafetyandimprovedqualityoflife.

In2010,theDiabetesCareProgramofNovaScotia(DCPNS)releaseddiabetesguidelinesfortheelderlypopulationresidinginLong-TermCare(LTC)Facilities.Theseguidelinesaddressedglycemictargets(toreduceover-management),hypoglycemiaprevention/management,andthefrequencyofbedsidecapillaryandA1Cmonitoring.In2012,surveyfindingsfromthesesamefacilitiessupportedpositivebenefitsattributedtotheguidelinesforbothresidentsandstaff.Staffreportedlessinvasivediabetescareandimprovedqualityoflifeforresidents.Theyalsoreportedlessstress,moreconsistentnursingcare,abetterunderstandingofandincreasedconfidenceindiabetesmanagement,andimprovedtimemanagementforstaff.

TakingintoconsiderationthepositivefeedbackintheLTCpopulation(above),in2014aqualityimprovementprojectwasinitiatedbytheDCPNSwithTinaWitherall,PDtMAEdasProjectLeadintheformerSSH.ThisprojectaimedtoimprovethecareandapproachprovidedtoelderlydiabetespatientsmedicallydischargedfromhospitalbutwaitingLTCplacementwithintheformerSSHDistrictHealthAuthority(DHA)acutecarefacilities.

Workingina0.5FTEpositionwiththeDCPNSandhavingotherprojectresponsibilities,thispositionindependentlyplannedanddeliveredtheeducationsessions,developedtherequiredresourcesandtools,conductedthechartaudits,engagedwithkeystakeholders,preparedcommunications,andconductedtheanalysisandinterpretationofthefindings.

Methods

ThisDHA-wideprojectincludedstakeholderengagement,routinecommunication(newsletters),andaHCPeducationalintervention(20-minutesessionsdeliveredtonursingandotherHCP)asmeanstointroduceanddiscusstherationaleforandspecificguidelinesfoundwithintheProvincialDiabetesGuidelinesforElderlyResidentsinLong-TermCare(LTC)Facilities,v2010.Preandpostmeasuresofknowledge(providersurveyincludingcaseexamples)andpracticechange(chartaudit)wereutilizedtoevaluatetheeffectivenessoftheintervention.

BetweenNovember2014andJanuary2015,atotalof21presentationswereprovidedwithinvariousinpatientunitsatthreefacilities.Atotalof112staffattended,includingavarietyofHCPs(RNs,LPNs,RDs,MD,FPNs,etc.

28


Results

Incomparisontothepre/postsurvey,providersincreasedtheirconfidenceinmanagementofthispopulation,reportedreductioninbedsidemonitoring,andimprovedunderstandingoftherationaleandintentforchangewithapplicationofmoreliberalizedglycemictargets.Chartauditsreflectedamovetowardmoreliberalizedglycemictargetsinphysicianorders,reducedcallstophysiciansforinsulin/medicationadjustmentduetoelevatedbloodglucosevalues,andmoreappropriatetreatmentofhypoglycemia.

Providersofferedadditionalsuggestionsonwhatwouldberequiredtochangepracticewitharequestforrevisionofstandingorders/policy/procedures,continuededucationandreminders(postersfornursingunits),targetedphysicianengagement,andtheinclusionofadditionalkeyprofessionalteammembers,includingpharmacists.

Conclusions

Thisapproachsupportedbyastrongfocusonpartnerships,stakeholderengagement,ongoingcommunication,standardizedevaluationtools(providersurveys[preandpost]andchartauditinstrumentation),anda“tight”yetflexibleeducationalintervention,havebeenabletodemonstrateanincreaseinknowledgeandacceptanceoftheLTCguidelinesaswellasearlychangesinthemanagementofdiabetesinthefrailelderlythatsupportimprovedsafetyandqualityoflife.Additionalworktofurtheradvancepracticechangewillincludepolicyandstandingordersdevelopment,specificphysicianengagement,andprovince-widedissemination.

NextSteps

BuildonthesuccessesofthisprojectinadditionalsiteswithintheWesternZonewithafocusonTransitionalCareUnits/AlternateLevelofCareBedstoimprovethecareprovidedtothefrailelderlywithdiagnoseddiabetes.

• Engagekeypartners(intheareasofNutrition,Nursing,Medicine,andPharmacy)tosupportthisprojectwork.

• Sharetheprojectanditsfindingsandthroughthisprocessidentifyinterestednextsites(readyandwilling).

• Useavailabletoolsandresources(surveyinstruments,chartauditform,educationalintervention/materials)tocollectbaselinedata,measurechange,andtoensurefidelityindeliveryoftheeducationalcontent.

• Guide,encourage,andevaluateadditionalimplementationmodelstobesharedinfuturesitesacrosstheprovince.

• Inparallel,examinestandingordersandrelatedpolicy/proceduresrequiredtosupporttheprovincialimplementationofthiswork.


29

APPENDIX2

DiabetesGuidelinesforFrailElderlyResidentsinorAwaitingLong-TermCarePHASE1-2016

DIABETES GUIDELINESfor Frail Elderly Residents in or Awaiting Long-Term Care (LTC)

POCKET REFERENCE

l Notify physician to decrease diabetes treatment.

RECOMMENDATIONS

Less than 7 mmol/L

TARGETS FOR GLYCEMIC CONTROL

RATIONALE

The goals of managing diabetes in frail3 elderly residents admitted to, or awaiting placement to, a LTC facility are different than for people in younger age groups. There is no evidence of benefit from tight glycemic control (i.e., fasting plasma glucose 4 to 7 mmol/L) for the LTC population.

t Hypoglycemia can lead to poor balance and risk of falls.

t Severe hypoglycemia can lead to seizures and death.

t Sustained hyperglycemia (over several days and not just a periodic spike) can lead to polyuria and nocturia. Trips to the bathroom late at night increase the risk of falls.

t Sustained hyperglycemia may also contribute to dehydration that can lead to coma or death.

The goal for elderly residents with diabetes is to avoid the acute complications of poor glycemic control, including hypoglycemia and prolonged, severe hyperglycemia.

REFERENCES1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes

Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2013;32(suppl 1):S1-S201.

2. Abdelhafiz A, Rodriguez-Manas L, Morley J, Sinclair A. Hypoglycemia in Older People - A Less Well Recognized Risk Factor for Frailty. Aging Dis. 2015 Mar; 6(2):156-167.

3. Moorhouse P, Rockwood, K. Frailty and its qualitative evaluation. JR Coll PhysiciansEdin6. 2012; 42:333-340.

l This range is acceptable if the resident has no reversible symptoms such as polyuria or nocturia.

l If the resident has reversible symptoms, notify the dietitian to assess food intake. Notify physician to assess the diabetes treatment. Increased treatment may not improve symptoms if due to other causes.

l This range may be acceptable. There is risk for hypoglycemia with Glyburide, Gliclazide, and Glimepiride or insulin therapy. If the resident has hypoglycemia (more than once a month), notify the physician to decrease treatment.

l Notify physician to increase diabetes treatment.

l Notify the physician.

Greater than 20.0 mmol/L

Greater than 33.0 mmol/L with stupor or coma

10.0 - 14.9 mmol/L

7.0 - 9.9 mmol/L

TreatmentIf Random Blood Glucose (BG):

15.0 - 20.0 mmol/L l This range may be acceptable. Occasional values in this range (not persistent) do not require medication adjustment.

l With persistent values, notify physician to assess possible medication change.

Diabetes Care Program of Nova Scotia 1276 South Park Street Bethune Building, Suite 548 Halifax, NS B3H 2Y9Tel: (902) 473-3219 Fax: (902) 473-3911 E-mail: [email protected] Website: http://diabetescare.nshealth.ca Revised November 2016

When the health care team discusses an individual’s overall health status and prognosis with either the patient or the family, a review of glycemic targets and the importance of avoiding hypoglycemia would be beneficial. If glycemic targets are different from the diabetes guidelines,

this should be clearly documented and include the rationale.

HYPOGLYCEMIA (Low Blood Glucose)

HYPOGLYCEMIA (Low Blood Glucose)Aging is a risk factor for hypoglycemia. The goal of treatment should be to prevent hypoglycemia.1

Hypoglycemia is defined as: 1

A blood glucose (BG) level less than 4.0 mmol/L with symptoms (trembling, sweating, palpitations, nausea, hunger, confusion, drowsiness, weakness, difficulty speaking, and headache).

RATIONALEHypoglycemia in the elderly person with diabetes can be a serious and underestimated clinical problem that has significant morbidity and mortality.t� �0MEFS�QFSTPOT�XJUI�EJBCFUFT�NBZ�IBWF�GFXFS�TZNQUPNT�PG�IZQPHMZDFNJB�PS�

decreased awareness of hypoglycemia. 2

t� �)ZQPHMZDFNJB�JO�UIF�FMEFSMZ�DBO�CF�NPSF�TFWFSF�BOE�QSPMPOHFE �BOE�JU�DBO�precipitate a cardiovascular event.

t� �)ZQPHMZDFNJB�JT�DBVTFE�CZ�JOBEFRVBUF�DBSCPIZESBUF�$)0�JOUBLF�BU�NFBMT �increased physical activity, or excess oral antihyperglycemic agents/insulin.

t� �(MVDPTF�PS�EFYUSPTF�UBCMFUT�PS�TVHBS�EJTTPMWFE�JO�XBUFS�TFF�5BCMF��BSF�UIF�preferred choice for treatment because these are absorbed more quickly than orange juice or glucose gels. Although glucose and dextrose tablets are the preferred treatment choice, these tablets may be difficult to chew or swallow.

t� �(MVDPTF�HFMT�BSF�HFOFSBMMZ�OPU�SFDPNNFOEFE�CFDBVTF�UIFZ�NVTU�CF�swallowed to be effective and are slowly absorbed.

The elderly are frequently on multiple medications and may have kidney or liver impairment that may lead to changes in breakdown of medications. Therefore, it is important to prevent, recognize, and treat hypoglycemic episodes secondary to the use of diabetes medications.

PRACTICE TIPSIt is important to have a hypoglycemia treatment kit readily available. It should include sources of CHO for treatment (see Table 2).Do not use any examples in Table 2 if the person is unable to safely ingest or is unconscious.

RECOMMENDATIONS*Prevent, recognize, and treat a low blood glucose level promptly to raise the blood glucose to a safe level (greater than or equal to 4 mmol/L).t� 15 g glucose will increase blood glucose by ~ 2.1 mmol/L within

20 minutes.1

*Recommendations for treatment of hypoglycemia in elderly residents in LTC facilities are adapted from the Canadian Diabetes Association 2013 Clinical Practice Guidelines.1

BG less than 4.0 mmol/Ll Resident is able to ingest

HYPOGLYCEMIA - Assessment HYPOGLYCEMIA - Treatment

Give:l Oral ingestion of 15 g CHO. See Table 2 for examples. l Wait 15 minutes and retest. If BG is less than or equal to 3.9 mmol/L, re-treat

with 15 g CHO, wait 15 minutes and retest. l Continue to treat/test until BG is greater than or equal to 4.0 mmol/L.l If a meal is more than 30 minutes away, a snack containing CHO and protein

should be provided (e.g., 1 slice bread and 1 oz. [30 g] cheese or meat).

Give:l 1 mg glucagon (intramuscularly) if ordered by a physician. (There should be a prn/standing order for glucagon on the chart.) l Notify the physician.

Give:l 1 mg glucagon (intramuscularly) if ordered by a physician. (There should be a prn order for glucagon on the chart.) l Notify the physician.

FOLLOWING A HYPOGLYCEMIC EVENT:

l Assess factors that may have contributed to the hypoglycemia, such as inadequate CHO intake at meals, increased physical activity, or too much oral antihyperglycemic agent/insulin, and adjust treatment accordingly.

l Reduce diabetes intervention accordingly if pattern of repeated hypoglycemia (greater than once a month).

Tabl

e 1

l Resident is unable to ingest

l Resident is unconscious

Tabl

e 2

After treatment (BG greater than or equal to 4.0 mmol/L) and symptoms remain, look for other causes of symptoms.

Examples of 15 g CHO for treatment of hypoglycemia

l 3 teaspoons (15 ml) or 3 packets of table sugar dissolved in waterl 3/4 cup (175 ml) juice or regular soft drinkl 1 packet (15 ml) honey or jaml 6 Life Savers (1 = 2.5 g CHO)l 15 g glucose in the form of glucose tabletsl 15 g glucose in the form of glucose gel (slowly absorbed)

30


Diabetes Care Program of Nova Scotia - Draft May 5, 2016

PHASE 2: Long-Term Care Guidelines Guidelines for Monitoring A1C for the Frail Elderly with Known Diabetes in or Awaiting Long-Term Care (LTC) A1C Monitoring

Rationale

A1C Interpretation* Treatment types • Lifestyle only ……. • Non-insulin agents • Insulin ……………

On Admission ………………..Possibly ………………….Yes ………………….Yes

• To determine need to adjust DM treatment

(!,", discontinue* DM med) *If medication significantly changes, consider retesting A1C in 3 months.

< 8%: " or discontinue DM medications 8-10%: acceptable if resident asymptomatic ≥ 11%: consider ! DM medication/treatment, if aligned with goals of care An A1c of: - 8% is equal to an average glucose of ~ 10 mM - 10% is equal to an average glucose of ~ 13.4 mM

Lifestyle only

Routine-Ongoing (frequency) No more than 1 x per year

Non-insulin agents and/or basal insulin only

1-2 x per year

Basal insulin and meal time insulin

1-2 x per year

Non-insulin agents = oral agents and injectable incretin-based therapies DM = Diabetes mM = mmol/L basal = background insulin (N/NPH), usually taken 1-2 times per day bolus = insulin taken to cover specific meals/snacks

Diabetes Care Program of Nova Scotia - Draft May 5, 2016

Guidelines for Capillary Blood Glucose for the Frail Elderly with Known Diabetes in or Awaiting Long-Term Care (LTC) Blood Glucose (BG) Monitoring

Rationale

BG Interpretation Treatment types • Lifestyle only ……. • Non-insulin agents • Insulin …………

*No known diabetes, no testing required

On Admission

………………. Possibly ………………….Yes ………………….Yes 2 times per day for 1-2 weeks— alternate testing times, e.g., Day 1: ac bkft and evening meal; Day 2: ac noon meal and HS;

then repeat

• To establish baseline • To determine need to adjust DM treatment as

per recommended glycemic targets due to: o Changing environment (from home to LTC) o Change in oral intake and possible change

in DM treatment regimen • A1C takes 2-3 months to demonstrate change

Recommendations BG 1: < 7 mM: " DM treatment 7.0-9.9 mM: This range may be acceptable There is risk for hypoglycemia with glyburide, gliclazide,

and glimepiride or insulin therapy. If hypoglycemic (more than 1x per month), " DM

treatment 10.0-14.9 mM: This range is acceptable if no reversible symptoms (i.e.,

polyuria or nocturia) 15.0 -20.0 mM: This range may be acceptable. Occasional values in this

range (not persistent) do not require medication adjustment.

> 20.0 mM: Notify MD/NP to increase diabetes treatment

Lifestyle only

Routine-Ongoing (frequency)

• Test when:

o Major change in health status More frequent BG monitoring may be needed:

o During acute illness o Major change in health status o Significant change in oral intake o Suspicion of marked dysglycemia (high or

low blood glucose) o During adjustment in diabetes treatment o After initiating or changing oral steroid

treatment

If BG is consistently < 7 mM, stop or " DM treatment o If on low dose insulin once/day, consider stopping insulin * o If on multiple injections, reduce appropriate insulin based on the

timing of the low BG

If BG is consistently > 15 mM: o If on no medication, start DM treatment as indicated

– metformin + or – sulfonylurea o If on oral therapy, ! oral therapy to maximum dose o If on max oral therapy, start basal insulin 10u HS o If on basal insulin only, ! insulin by 2 units every 3-4 days until BG

mostly 10-15 mM

Not required

Non-insulin agents and/or Basal Insulin only

If stable, regular testing not required If unstable, use clinical judgment

Basal insulin and meal time (bolus) insulin

If stable, 1 x/ day (alternate times) Note, most people on meal time insulin can be switched to Basal insulin only (1-2 x/day)

1. Diabetes Care Program of Nova Scotia. Diabetes Guidelines for Frail Elderly Residents in or Awaiting Long-Term Care (LTC). November 2016. Key: Non-insulin agents = oral agents and injectable incretin-based therapies DM = Diabetes; mM = mmol/L MD = Physician NP = Nurse practitioner ac = before bkft = breakfast HS = at bedtime basal = background insulin (N/NPH), usually taken 1-2 times per day bolus = insulin taken to cover specific meals/snacks

Note: If no action is taken with routine BG test results, consider stopping or reducing this practice. SMBG testing is only necessary if it results in a treatment change. *In the situation where a resident has true type 1 DM, their basal insulin should never be discontinued. See FAQ for distinguishing type 1 from type 2 DM.

APPENDIX2(continued)

DiabetesGuidelinesforFrailElderlyResidentsinorAwaitingLong-TermCarePHASE2-2017


31

APPENDIX3

RoleDescriptionsDCPNSProject:UpstreamIntegrationOfLTCDiabetesGuidelines-WZProject

CENTRAL COORDINATION (PROJECT COORDINATOR)

NURSING/NUTRITION CO-LEADS

UNIT-SPECIFICTEAMLEADS

Communications • Routine communication/correspondence with DCPNS/Peggy

• Advisory Group member/attendance (updates as needed)

• Regular contact with co-leads re: time lines, logistics, support materials (reminders)

• Develop e-distribution lists (by site, for all stakeholders) o E-mail distribution of surveys o Reminders to Team Lead o Promotional posters/emails

to all staff applicable units • Newsletters/bulletins (draft and

tweak)

• Promote and answer questions /queries re: the project intent, purpose, processes

• Work closely with the Unit Team Leads

• Organize an MD session (on a meeting agenda), and others as needed

• Routinely communicate with Crystal to provide progress update (concerns, challenges, meeting time lines, etc.) for newsletter and other

• Share newsletters and other project information among team

• Promote and answer general questions/queries re the project intent, purpose, and processes

• Encourage completion of surveys (pre and post)

• Share newsletters and other project information among team

Chart Audits (Pre and Post Educational Intervention)

• Conduct chart audits (pre and post)

• Compile, analyze and interpret chart audits

• Share with site co-leads to inform educational intervention (add as speaker notes to presentation)

• Review chart audit results/feedback for inclusion of messages into Educational Events. Include relevant information to support changes in practice, or to encourage continued best/promising practice

• Introduce Project Coordinator and discuss the purpose behind the chart audit, if needed

• Facilitate ease of chart audit (DM patients, audit location)

Provider Pre and Post Surveys

• Print hard copies for distribution • E-mail distribution of surveys to

unit personnel and others (to be determined)

• Collect from co-leads and collate, compile surveys (high level interpretation)

• Distribute pre and post surveys (offer frequent reminders)

• Collect surveys from units and give to Crystal

• Work with the Team Leads to increase completion rates

• Select a place for completed surveys to be left.

• Remind staff to complete surveys and put completed surveys here, and retain for co-lead to pick up.

Educational Intervention

• Advertise/Promote site-specific education sessions

• Provide handout packets for attendees (prepared by DCPNS)

• Compile event feedback forms

• Planning with Team Lead for delivery (best dates, times to meet needs of all staff)

• Deliver education sessions • Take attendance (use

attendance sheet), keep a copy (for reference purposes to encourage attendance), and give a copy to Crystal

• Distribute session evaluation forms, collect, and give to Project Coordinator

• Assist with determining best dates, times, locations for staff education

• Encourage attendance of events (for all applicable staff). Review attendance sheet, if needed.

Other

NOTE: DCPNS will provide oversight and central support in the funding of the Project Coordinator, preparing of documents, providing of educational materials, etc.

32



33

APPENDIX4

PromotionalFlyerSample

COMING SOON To Soldiers' Memorial Hospital ALC TCU & VETS UNITS

Western Zone - Diabetes Quality Initiative

How to play a role: 1. Complete a Current Practice Survey (available mid-May).

§ This will help us understand current practices & approaches used in the management of diabetes in frail elderly residents

§ Surveys will be available on the TCU, ALC & Vets Units or you may request an elecronic survey by contacting one of the co-leads.

2. Attend an Upcoming Education Session (June) § Watch for dates and times for education sessions to be offered on the

TCU, ALC and Vets Units. § Encourage colleagues and staff to attend as well

What is the Diabetes Quality Initiative? § An initiative of the Diabetes Care Program of Nova Scotia (DCPNS) and the

Western Zone (WZ).

§ Guided by an Advisory Committee and Local Physician Champions as well as site-specific co-leads in the areas of nursing and nutrition.

§ Focused on the diabetes management of frail elderly residing in the ALC, TCU and Vets Units along with other sites in the Yarmouth area of the WZ.

§ Will provide focused education on the DCPNS Diabetes Guidelines for Frail Elderly Residents in or Awaiting Long-Term care with emphasis on appropriate, safe care.

Project Contacts Middleton Project co-leads: o Jennifer McNeil: 902-825-6160, Ext 1762228 o Julie Sutherland-Jotcham: 902-825-6160 Ext. 1762229

Physician Champions: o Dr. Crystal Todd

Central Coordination/Project Coordinator o Crystal MacNeil PDt CDE

[email protected]

34



35

WZ Diabetes & LTC Quality Initiative Bulletin September 2017

1 Western Zone (WZ) Diabetes Quality Initiative Guidelines for Frail Elderly Patients in TC/ALC and Vets Units !

Sept. 2017 Volume 3, Issue 1 LTC Project Update

Things are moving along very nicely! Over the summer months, we worked on analyzing the surveys and planned for moving the project into its final phase.

• Participant evaluations from the education sessions held in June have been reviewed and compiled.

• Further analysis was completed on the May Pre-Education Survey, based on direction given by the Advisory Committee.

• Findings from the chart audits have been compiled and themes identified. • We are working to see what additional tools are required to help promote and

support practice change. Supports include guidance for chart documentation, review/revision of admission orders, a brochure for families, etc.

INSIDE THIS ISSUE:

SPECIAL POINTS OF INTEREST:

• Participant’s Evaluations of the Education Sessions have been reviewed

• Pre – education Practice Survey & chart audits data have been complied & analyzed.

• Post-Education Surveys and chart audits will soon begin to assess change in knowledge & practice.

1

Education Session Evaluations During the month of June, 31 education sessions on the Diabetes Guidelines for Frail Elderly Residing or Awaiting Long-Term Care (phases 1 and 2) were offered in the TC, ALC, and Vets Units at Soldiers’ Memorial Hospital (SMH) and Yarmouth Regional Hospital (YRH). In total, 84 staff from varying professions attended these sessions. Attendees were invited to complete an evaluation at the end of each session, and we received 64 evaluations for a response rate of 76%! Participants rated the sessions very positively. Using a 5-point scale, where 5 was excellent and 1 was poor: • 100% (all participants) rated the sessions as very good/excellent (overall rating

4.7 out of 5) • 97% of participants felt very strongly that the session contributed new knowledge

to their understanding of diabetes care for frail elderly (overall rating 4.6 out of 5) • 94% felt very strongly that the learning was applicable to their practice (overall

rating of 4.5 out of 5) • 94% stated they would likely use the learning from the session in practice (overall

rating of 4.5 out of 5) When asked about areas of major learning, participants noted: • Increased ability to recognize signs/symptoms of hypoglycemia & hyperglycemia

in the elderly. • Better understanding of how to properly interpret blood glucose readings and

A1C results. • Increased awareness of appropriate frequency for capillary blood glucose

monitoring. Many staff also reported that, as an outcome to their learning, they would be less restrictive with snack/food choices offered to frail elderly clients with diabetes. Although several barriers to putting the guidelines into practice were identified, many participants stated they would share their learning from the session with colleagues and advocate for the DCPNS Guidelines to be adopted into practice.

1

• WZ LTC Project Update

1

• Education Sessions – Evaluations

1-2

• Follow-Up Survey

2

• Time Line • Contact

Information

2 2

W

Diabetes Care Program of Nova Scotia

2

APPENDIX5

SampleBulletin

36


WZ Diabetes & LTC Quality Initiative Bulletin September 2017

2

FOLLOW-UP SURVEY

• Compile Pre Provider Survey/Chart Audits • Prepare Draft Report • Prepare/Plan Fall Activities

• Post Provider Surveys • Post Intervention Chart Audits • QI Project Process Review/Feedback • Prepare Draft Report

• Final Report

= Newsletter/Bulletin

It is about safety and quality of life.

2

PROJECT TIME LINE

Site co-leads: • Yarmouth: o Lisa Gaudet: 902-742-3542,

Ext. 1192 o Linda Wilson: 902-742-3542,

Ext. 1576 • Soldiers: o Jennifer McNeil: 902-825-6160,

Ext. 1762228 o Julie Sutherland-Jotcham:

902-825-6160, Ext. 1762229 • Central Coordination/Project

Coordinator o Crystal MacNeil PDt CDE

902-742-3542, Ext. 1246 [email protected]

Evaluations continued Barriers identified, included among others:

• Resistance of change from the care team. • Lack of client/family education on rationale for relaxed diabetes targets.

Recommendations by participants for facilitating the adoption of the DCPNS Diabetes Guidelines for Frail Elderly into practice included:

• Creating standing orders and policies that reflect the recommendations in the guidelines.

• More education for physicians, staff, clients, families, and even hospital volunteers.

We have started to promote the Follow-Up Survey! • The Surveys will be available Sept. 25 to Oct. 6, 2017. • Care staffs on our target units are encouraged to complete the survey

(Physicians, RNs, LPNs, CCAs and Allied Health Professionals). • Please complete the survey whether or not you completed the Pre-Education

survey or participated in the education sessions. • The Follow-Up Survey will help us determine change in knowledge, either

directly from attending an education session or indirectly (perhaps peer learning that occurred from colleagues who did attend a session).

• Surveys will be available on the VETS, TC & ALC units. An electronic survey can be requested by contacting the project’s team.

• Please help us to Promote the Follow-Up Survey!

• Privacy/QI Approval • Stakeholder engagement

• Pre Provider Survey • Pre Chart Audits

• Educational Intervention (end May to end of June)

March April May June July

July August Sept. Oct. Nov.

APPENDIX5(continued)


37

PleaseTurnPageOver–EvaluationContinuesonNextPage

WZDiabetes&LongTermCareQualityInitiative May/June2017

Western Zone

Diabetes Long-Term Care Quality Initiative Education Session Evaluation

Date: _________________

Please take a few minutes to complete this evaluation. Thank you for taking the time to fill out this evaluation; we truly value your input.

Please rate the session on a scale of 1 to 5, where 1 is poor and 5 is excellent.

Overall Evaluation on a scale of 1 to 5, where 1 is not at all and 5 is a great deal

How do you plan to use the content of this information session in your daily practice? Please provide 2 to 3 specifics.

Poor 1

2

3

4

Excellent 5

Overall presentation

Organization

Contribution to new knowledge

Applicability to practice

Not at all 1

2

3

4

Great Deal 5

To what extent did the presentations meet the objectives?

To what extent did the presentations meet your expectations?

How likely are you to use this information in your practice?

WZDiabetes&LongTermCareQualityInitiative May/June2017

What barriers, if any, do you expect when sharing/applying the content of this session to your daily practice or work setting?

Do you have any recommendations on how to adopt these guidelines for diabetes management and care in the elderly within our health district? (e.g., policy development, education, standing orders.)

Overall, I would rate the session as:

Fair Good Very Good Excellent

Discipline

RN LPN Pharmacist CAA

Dietitian Physician Other

Location

SMH ALC Unit SMH TC Unit SMH Vets Unit

Yarmouth ALC Unit Yarmouth Vets Unit Other:

Years in Practice

Under 2 2-4.9 5-14.9 15 or more

Additional comments:

Thank you!

APPENDIX6

WesternZoneDiabetesLong-TermCareQualityInitiative:EducationSessionEvaluation

38



39

2018%05%03(

1(

UPSTREAM INTEGRATION OF LTC DIABETES GUIDELINES WZ PROJECT

Diabetes Quality Improvement Initiative

Presented By: Jennifer McNeil and Julie Sutherland-Jotcham

CASE 1: Age: 86 Gender: M Medical History: 10- year history of type 2 DM & severe stage dementia & CHF DM Meds: Metformin 1000mg bid & Gliclazide 10mg bid A1C: 11.0% BG: 10-15mmol/L; sometimes > 20 mmol /L Other: Hx of resistance/agitation(aggression, striking

out) with BG checks

CASE 2: Age: 96 Gender: F Reason for admission: Hip fracture Medical History: Type 2 DM, HTN, hearing problem, GERD, AF DM Meds: Insulin, 12u NPH q hs

A1C: 6.7% (most recent, 6 months ago)

Glucose Monitoring: BID (7h00 & 22h00)

Blood Glucose Results:

Days Insulin 7h00 22h00

Day 1-3 NPH: 12u *3.9-6.9 6.6-9.0

Day 4-6 Day 6: ! 6u 4.2-4.4 8.5-10.8

Day 7-10 Day 10: d/c Insulin 4.1-5.2 6.2-8.8

Day 11-13 Day 13: d/c glucose checks

6.7-11.0 7.3-8.1

*Treated for hypo, as < 4.0 mmol/L

LEARNING OBJECTIVES To share with you: "  Rationale/background for the NS guidelines (brief), with a focus on

frailty ◆  Glycemic management guidelines in the context of frailty and

limited life expectancy ■  Hypoglycemia ■  Relaxed Glycemic Targets ■  Capillary Bedside BG and A1C Monitoring

◆  Impact of this approach to glycemic management on LTC residents, families, and professional staff

Average age : 77.8 to 82.3 years

Average length of stay (LoS): 2.5 years (1.9 to 3.3 yrs)

74% on more than 9 medications; was 54% in 2002/3

Source: NS DHW, SEAscape Database, June 2011

AT ADMISSION TO LONG TERM CARE:

GUIDELINES DEVELOPMENT (cont’d) BACKGROUND:

■  Lack of evidence-based DM guidelines for the frail elderly population ■  Resulted in over treatment and under treatment of frail elderly in NS

◆  CDA 2008 Clinical Practice Guidelines (CPGs) ■  Goals should be “Less stringent” in elderly with multi-morbidity, limited life…

◆  Review of the evidence—UKPDS, ADVANCE. ACCORD, VADT ◆  DCPNS Released NS Guidelines, 2010 ◆  We since have CDA 2013 CPGs

■  These now acknowledge the need for relaxed glycemic targets in the presence of limited life expectancy, higher level of functional dependency, but do not specifically address these within the context of severe/moderate frailty

◆  DCPNS Revised NS Guidelines, 2016

GUIDELINES DEVELOPMENT (cont’d)

WHAT IS FRAILTY? ◆  Accumulation of multiple chronic illnesses with

associated vulnerabilities such as dementia, functional decline, and geriatric syndrome including falls, impaired mobility, and polypharmacy.

◆  Care needs to be organized in the context of frailty,

where many things are wrong at once.

GUIDELINES DEVELOPMENT (cont’d)

PURPOSE ◆  To standardize DM management of frail elderly patients through the

development of appropriate, safe, reasonable guidelines.

Considering: #  Frailty Severity/Co-morbidities #  Limited Life Expectancy #  Safety (over/under treatment) #  Quality of Life

APPENDIX7

SamplePresentationSlides

40


2018%05%03(

2(

Revised Guidelines February 2016

DIABETES GUIDELINESfor Frail Elderly Residents in or Awaiting Long-Term Care (LTC)

POCKET REFERENCE

O Notify physician to decrease diabetes treatment.

RECOMMENDATIONS

Less than 7 mmol/L

TARGETS FOR GLYCEMIC CONTROL

RATIONALE

The goals of managing diabetes in frail3 elderly residents admitted to, or awaiting placement to, a LTC facility are different than for people in younger age groups. There is no evidence of benefit from tight glycemic control (i.e., fasting plasma glucose 4 to 7 mmol/L) for the LTC population.

t Hypoglycemia can lead to poor balance and risk of falls.

t Severe hypoglycemia can lead to seizures and death.

t Sustained hyperglycemia (over several days and not just a periodic spike) can lead to polyuria and nocturia. Trips to the bathroom late at night increase the risk of falls.

t Sustained hyperglycemia may also contribute to dehydration that can lead to coma or death.

The goal for elderly residents with diabetes is to avoid the acute complications of poor glycemic control, including hypoglycemia and prolonged, severe hyperglycemia.

REFERENCES1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes

Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2013;32(suppl 1):S1-S201.

2. Abdelhafiz A, Rodriguez-Manas L, Morley J, Sinclair A. Hypoglycemia in Older People - A Less Well Recognized Risk Factor for Frailty. Aging Dis. 2015 Mar; 6(2):156-167.

3. Moorhouse P, Rockwood, K. Frailty and its qualitative evaluation. JR Coll PhysiciansEdin6. 2012; 42:333-340.

O This range is acceptable if the resident has no reversible symptoms such as polyuria or nocturia.

O If the resident has reversible symptoms, notify the dietitian to assess food intake. Notify physician to assess the diabetes treatment. Increased treatment may not improve symptoms if due to other causes.

O This range may be acceptable. There is risk for hypoglycemia with Glyburide, Gliclazide, and Glimepiride or insulin therapy. If the resident has hypoglycemia (more than once a month), notify the physician to decrease treatment.

O Notify physician to increase diabetes treatment.

O Notify the physician.

Greater than 20.0 mmol/L

Greater than 33.0 mmol/L with stupor or coma

10.0 - 14.9 mmol/L

7.0 - 9.9 mmol/L

TreatmentIf Random Blood Glucose (BG):

15.0 - 20.0 mmol/L O This range may be acceptable. Occasional values in this range (not persistent) do not require medication adjustment.

O With persistent values, notify physician to assess possible medication change.

Diabetes Care Program of Nova Scotia 1276 South Park Street Bethune Building, Suite 548 Halifax, NS B3H 2Y9Tel: (902) 473-3219 Fax: (902) 473-3911 E-mail: [email protected] Website: http://diabetescare.nshealth.ca Revised November 2016

When the health care team discusses an individual’s overall health status and prognosis with either the patient or the family, a review of glycemic targets and the importance of avoiding hypoglycemia would be beneficial. If glycemic targets are different from the diabetes guidelines,

this should be clearly documented and include the rationale.














20 minutes.1


BG less than 4.0 mmol/LO Resident is able to ingest


Give:O Oral ingestion of 15 g CHO. See Table 2 for examples. O Wait 15 minutes and retest. If BG is less than or equal to 3.9 mmol/L, re-treat

with 15 g CHO, wait 15 minutes and retest. O Continue to treat/test until BG is greater than or equal to 4.0 mmol/L.O If a meal is more than 30 minutes away, a snack containing CHO and protein


Give:O 1 mg glucagon (intramuscularly) if ordered by a physician. (There should be a prn/standing order for glucagon on the chart.) O Notify the physician.

Give:O 1 mg glucagon (intramuscularly) if ordered by a physician. (There should be a prn order for glucagon on the chart.) O Notify the physician.


O Assess factors that may have contributed to the hypoglycemia, such as inadequate CHO intake at meals, increased physical activity, or too much oral antihyperglycemic agent/insulin, and adjust treatment accordingly.

O Reduce diabetes intervention accordingly if pattern of repeated hypoglycemia (greater than once a month).

Tabl

e 1

O Resident is unable to ingest

O Resident is unconscious

Tabl

e 2



O 3 teaspoons (15 ml) or 3 packets of table sugar dissolved in waterO 3/4 cup (175 ml) juice or regular soft drinkO 1 packet (15 ml) honey or jamO 6 Life Savers (1 = 2.5 g CHO)O 15 g glucose in the form of glucose tabletsO 15 g glucose in the form of glucose gel (slowly absorbed)

HYPOGLYCEMIA

KEY MESSAGE: "  Prevent, recognize, and treat hypoglycemia promptly to

raise BG > 4.0 mmol/L. "  Subsequently, keep BG > 7.0 mmol/L

HYPOGLYCEMIA RATIONALE: ◆  Hypoglycemia in the elderly person with DM can be serious (falls,

adverse effects) and underestimated. ■  Fewer symptoms ■  Can be hidden by lack of symptoms ■  Dementia can limit ability to communicate symptoms

◆  Polypharmacy is common with the elderly who also may have kidney or liver impairment--may lead to changes in breakdown of medications.

�  Quality of life may be adversely affected by trying to achieve tight BG control (frequent testing, food restrictions…)

�  The cost and human resources needed to measure and maintain tight control is significant

HYPOGLYCEMIA TREATMENT














20 minutes.1


BG less than 4.0 mmol/LO Resident is able to ingest


Give:O Oral ingestion of 15 g CHO. See Table 2 for examples. O Wait 15 minutes and retest. If BG is less than or equal to 3.9 mmol/L, re-treat

with 15 g CHO, wait 15 minutes and retest. O Continue to treat/test until BG is greater than or equal to 4.0 mmol/L.O If a meal is more than 30 minutes away, a snack containing CHO and protein


Give:O 1 mg glucagon (intramuscularly) if ordered by a physician. (There should be a prn/standing order for glucagon on the chart.) O Notify the physician.

Give:O 1 mg glucagon (intramuscularly) if ordered by a physician. (There should be a prn order for glucagon on the chart.) O Notify the physician.


O Assess factors that may have contributed to the hypoglycemia, such as inadequate CHO intake at meals, increased physical activity, or too much oral antihyperglycemic agent/insulin, and adjust treatment accordingly.

O Reduce diabetes intervention accordingly if pattern of repeated hypoglycemia (greater than once a month).

Tabl

e 1

O Resident is unable to ingest

O Resident is unconscious

Tabl

e 2



O 3 teaspoons (15 ml) or 3 packets of table sugar dissolved in waterO 3/4 cup (175 ml) juice or regular soft drinkO 1 packet (15 ml) honey or jamO 6 Life Savers (1 = 2.5 g CHO)O 15 g glucose in the form of glucose tabletsO 15 g glucose in the form of glucose gel (slowly absorbed)

FOLLOWING A HYPOGLYCEMIC EVENT "  After treatment, if symptoms remain, look for other causes of

symptoms. "  Assess: CHO intake at meals, increased physical activity, or too

much OAA/insulin, and adjust treatment accordingly. "  Reduce diabetes intervention accordingly if pattern of repeated

hypoglycemia (> 1x per month).

TARGETS FOR GLYCEMIC CONTROL RATIONALE: �  There is no evidence of benefit from tight control (i.e. FBG 4 to 7

mmol/L) for the frail elderly LTC population. �  It takes 5 years to demonstrate a reduction in risk for micro vascular

complications and 10+ years for macrovascular complications. �  Quality of Life can be impacted by trying to achieve stringent control �  Tight control increases the risk for adverse events (hypoglycemia,

falls, etc.)

GOAL: Avoid the acute complications of poor glycemic control including hypoglycemia and prolonged, severe hyperglycemia.

TARGETS FOR GLYCEMIC CONTROL (cont’d)

�  On admission, review BG targets and the importance of avoiding hypoglycemia

�  If glycemic targets for the patient are different from the LTC diabetes guidelines, this should be clearly documented, including the “why”.

�  Remember, the goals of managing DM in elderly are different than for people in younger age groups.

So how did these guidelines impact providers and patients?

APPENDIX7(continued)SamplePresentationSlides


41

2018%05%03(

3(

EARLY IMPACT ON RESIDENTS/FAMILY AND STAFF

Most facilities (66%) reported that episodes of BG over 20 mmol/L did not decrease or increase.

16%

18%

50%

50%

58%

0% 10% 20% 30% 40% 50% 60% 70%

Calls to 911

Falls Related to Hypoglycemia

Episodes of Hypoglycemia

Calls to MD/NP

Bedside BG Testing

Facilities that Implemented Guidelines (n=38) % of Respondents that Reported a Decrease:

EARLY IMPACT ON RESIDENT/FAMILY AND STAFF (cont’d)

RESIDENT/FAMILY: POSITIVE IMPACT •  Less invasive diabetes care •  Improved quality of life—food, flexibility, less worry, less

negative talk about diabetes STAFF: POSITIVE IMPACT

•  Decreased stress •  Standardized and consistent nursing care

“better understanding and increased confidence” •  Improvement in time management-fewer calls, more time on

other things that improve quality of life

PHASE 2: A1C AND CAPILLARY BG MONITORING FOR LTC FRAIL ELDERLY RESIDENTS WITH KNOWN DIABETES

GUIDELINES FOR CAPILLARY BLOOD GLUCOSE TESTING FOR FRAIL ELDERLY

Treatment Type

On Admission Capillary Testing Frequency

Routine, On-going Capillary Testing Frequency

Insulin Yes If stable, 2 x/ day (alternate times)

Note, most people on meal time insulin can be switched to Basal insulin only (1-2 x/day)

Non-Insulin Agents &/or Basal Insulin

Yes If stable, regular testing not required If unstable, use clinical judgment

Lifestyle Only Possibly + or - Not required

Test 2 times per day, alternative times, for 1-2 weeks: e.g.,

Day 1: ac bkft and evening meal; Day 2: ac noon meal and HS; then repeat

Test when: o  Major change in health status

More frequent BG monitoring may be needed: o  During acute illness o  Major change in health status o  Significant change in oral intake o  Suspicion of marked dysglycemia (high or low blood glucose) o  During adjustment in diabetes treatment o  After initiating or changing oral steroid treatment

WHEN SHOULD WE TEST MORE? BLOOD GLUCOSE INTERPRETATION Blood Glucose Action Additional Comments

< 7 mmol/L Not Acceptable Stop or ! DM treatment

Notify Physician

7 to 9.99 mmol/L May be Acceptable If hypo > 1x/month, Not Acceptable

There is risk of hypo with certain meds, including insulin Stop or ! DM treatment

10 to14.9 mmol/L Acceptable If no reversible symptoms.

15 to 20 mmol/L May be Acceptable, if not persistent (occasional value)

If persistent, Notify Physician

> 20 mmol/L Not Acceptable Add or " DM treatment

Notify Physician

> 33 mmol/L with stupor or coma Notify Physician

GUIDELINES FOR MONITORING A1C FOR FRAIL ELDERLY

Treatment Type On Admission A1C Testing Frequency

Routine, On-going A1C Testing Frequency

Basal and Meal time bolus) Insulin

Yes 1-2 x per year

Non-insulin Agents &/or Basal Insulin only

Yes 1-2 x per year

Lifestyle only Possibly No more than 1 x per year To determine need to adjust DM treatment (",!, discontinue* DM med)

*If medication significantly changes, consider retesting A1C in 3 months.

A1C Interpretation: < 8%: ! or discontinue DM medications 8-10%: acceptable if resident asymptomatic ≥ 11%: consider " DM medication/treatment, if aligned with goals

of care An A1c of: - 8% is equal to an average glucose of ~ 10 mmol/L - 10% is equal to an average glucose of ~ 13.4 mmol/L

WHAT DOES AN A1C TELL US ABOUT BLOOD GLUCOSE VALUES?

CASE 1:

Age: 86 Gender: M Medical History: 10- year history of type 2 DM & severe stage dementia & CHF DM Meds: Metformin 1000mg bid & Gliclazide 10mg bid A1C: 11.0% BG: 10-15mmol/L; sometimes > 20 mmol /L Other: Hx of resistance/agitation(aggression, striking

out) with BG checks What is the next step?


42


2018%05%03(

4(

Answer: #  This gentleman has an A1C just above 11%, which would require a

discussion about the pros and cons of insulin therapy.

#  NPH insulin could be started at HS using a low dose (6-10 units). #  Watchful waiting with monitoring of symptoms would be alternate

approach.

CASE 2:

Age: 96 Gender: F Reason for admission: Hip fracture

Medical History: Type 2 DM, HTN, hearing problem, GERD, AF

DM Meds: Insulin, 12u NPH q hs

A1C: 6.7% (most recent, 6 months ago)

Glucose Monitoring: BID (7h00 & 22h00)

Blood Glucose Results:

Days Insulin 7h00 22h00

Day 1-3 NPH: 12u *3.9-6.9 6.6-9.0

Day 4-6 Day 6: ! 6u 4.2-4.4 8.5-10.8

Day 7-10 Day 10: d/c Insulin 4.1-5.2 6.2-8.8

Day 11-13 Day 13: d/c Glucose Checks

6.7-11.0 7.3-8.1

*Treated for hypo, as < 4.0 mmol/L

What Do We Notice Here?

�  A1C too low �  Control is too stringent, requires more relaxed control

�  Hypoglycemia may have contributed to her fall �  She may not experience hypo symptoms as others do

�  Quality of life is important �  No need for insulin �  Reduction in monitoring (discontinuation)

WHAT DO WE NOTICE HERE?

IN SUMMARY �  Frailty is complex, and must be considered �  Hypoglycemia should be avoided at all costs

�  There is a for more relaxed glycemic targets to avoid overtreatment (based on individual symptoms and tolerance)

�  With relaxed BG values, there is less need for capillary testing

�  With insulin, the preference for basal insulin, and less meal time insulin to prevent hypoglycemia

�  Nutritional management is not needed

�  For true type 1 diabetes, basal insulin should never be discontinued

ACKNOWLEDGEMENTS, WITH SPECIAL THANKS! Tina Witherall, Former DCPNS Consultant & Lead SSH Diabetes Quality Initiative (2014-2016) Members of the DCPNS Long-Term Care Committee

And, The Palliative and Therapeutic Harmonization (PATH) Program, former Capital Health, NS

THANK YOU FOR YOUR TIME

QUESTIONS?



43

APPENDIX8

ChartAuditDataElements

MEASURE PURPOSEFORCOLLECTIONTYPEOFPERSONALINFORMATION

ID Code Assigned Project Code To be used in place of unique identifier. To verify collected information, if required.

Site Yarmouth or Middleton To be able to present findings by each of the two selected sites, Yarmouth and Middleton.

Medical Unit i.e., Vets, TCU, ALC Unit To be able to present findings by specific unit/per site.

Date of Admission dd/mm/yy

A descriptor of the study population. To provide range and estimate of average length of stay (LoS).

Current Resident of LTC Facility Y/N

A descriptor of the study population. To assist with assessment of management practices prior to admission.

Type of Diabetes (DM) Type 1 or Type 2

A descriptor of DM. To determine use of appropriate management guidelines; insulin guidelines are different for type 1 diabetes.

Type of DM Treatment

Insulin (In), oral antihyperglycemic agents (OAA), insulin and oral agent (InOAA), diet only

A descriptor of DM management. To be able to determine uptake of guidelines and changes overtime.

If on Insulin or OAA, Type Name and frequency/day

A measure of DM management practices. To be able to determine uptake of guidelines and changes overtime.

If on Insulin or OAA, Dosage Frequency/day, dose/time


Duration of DM Years

A descriptor of the study population. To provide range and estimate of average duration (aggregate).

Date of Medical Discharge dd/mm/yy A descriptor of the study population. To provide estimate of average LoS.

Diet Order Y/N, specify if yes


Age Years A descriptor of the study population. To determine range of ages/mean/median age.

MEASURE PURPOSEFORCOLLECTION DIABETES AND GLYCEMIC CARE Blood Glucose (BG) Targets Set Y/N, and values A measure of DM management practices.

To be able to determine uptake of guidelines and changes overtime.

A1C Target Set (Y, N, and Value) Y/N, and value A measure of DM management practices. To be able to determine uptake of guidelines and changes overtime.

Insulin Standing Orders—Used per Policy

Y/N, if yes adapted or individualized, or cancelled


44


APPENDIX8(continued)ChartAuditDataElements

MEASURE PURPOSEFORCOLLECTION DIABETES AND GLYCEMIC CARE

Time-limited testing indicated Y/N, specifics


Recent decrease in diabetes medications to meet liberalized targets Y/N


Glucometer readings < 4 mmol/L Number in the past 2-week period


Glucometer readings > 20 mmol/L Number in the past 2-week period


Frequency of bedside BG monitoring Number in the past 2-week period


A1C completed within 3 months of acute care admission/medical discharge Y/N


Frequency of A1C testing Number in the past year


Date of last A1C (most recent) dd/mm/yy A descriptor of DM management.

A1C Value Actual value A descriptor of DM management.

Episodes of hypoglycemia (# in past 4- week period) Number in past 4 weeks


Appropriate treatment of hypoglycemia Y/N


Adverse reaction to hypo event within 4 hours of event (chest pain, angina, MI, fall, seizure) Y/N, if yes specify type


Calls to MD/NP for insulin orders Y/N To be able to determine uptake of guidelines and changes overtime.

Frequency of calls for DM medication orders (total # of calls in past 4 weeks)

Number of calls in past 4 weeks


Delay in Medical D/C due to DM medication management Y/N A descriptor of the study population.

Actual Point of Care BG testing results

Number in the past 2-week period; Min-Max range, and usual:

- AC B; AC L; AC S; HS - Random



45

Western Zone Diabetes LTC Quality Initiative Project May/June 2017

Western Zone Diabetes Quality Initiative

Guidelines for Frail Elderly Patients in TC/ALC and Vets Units The goal of the Western Zone Diabetes Quality Initiative is to enhance the uptake of the Diabetes Care Program of Nova Scotia (DCPNS) Phase 1 and 2 Diabetes Guidelines for Frail Elderly Residents in or Awaiting Long-Term Care (LTC) in Transitional Care/Alternate Level of Care/Veterans Units. As part of this initiative, we would like to assess current practices. We will also re-assess these practices once we have completed our education and focused intervention. Please take a few minutes to complete this survey. There are no right or wrong answers (you do not need to prepare); we just want to determine current practice. As you complete the survey, please remember that ALL questions pertain to the care of the medically discharged, FRAIL elderly patient in hospital awaiting LTC or those residing in Vets Units. We are focusing on the FRAIL ELDERLY PATIENTS only and not the general population with diabetes.

Please return the completed survey by Friday, May 26, 2017, to the designated box / envelope located on your Unit. For help locating a drop off box / envelope or if you have any questions or comments about this survey, please contact:

• Yarmouth: Lisa Gaudet: 902-742-3542, 1192 Linda Wilson: 902-742-3542, 1576 • Soldiers: Jennifer McNeil: 902-825-6160, 1762228 Julie Sutherland-Jotcham: 902-825-6160, 1762229

Thank you for taking the time to fill out this survey; we truly value your input.

It should take approximately 15-20 minutes to complete.

PART 1: DEMOGRAPHICS

Discipline

RN LPN CCA Pharmacist

Dietitian Physician Other

Location

SMH ALC Unit SMH TC Unit SMH Vets Unit

Yarmouth ALC Unit Yarmouth Vets Unit Other:

Years in Practice

Under 2 2-4.9 5-14.9 15 or more

1. Have you received recent education (last 2-3 years) about the care/management of the FRAIL elderly living with

diabetes?

No Yes (If yes what, where, and when)

APPENDIX9

Pre-EducationSurvey

46


P a g e |2


2. How confident are you about the MANAGEMENT OF DIABETES IN THE FRAIL ELDERLY? (Please check the most appropriate answer.)

PART 2: CURRENT PRACTICE Thinking about your current patient population (medically discharged, frail elderly patient with diabetes in hospital awaiting LTC care or residents of the Vets Unit)…

3. What are the current goals for blood glucose?

Not Sure

4. How often are bedside capillary glucose levels measured in the person well managed on insulin therapy (e.g.,

twice a day, twice a week, not testing)?

Not Sure 5. When are bedside capillary glucose levels measured (e.g., at breakfast only, before meals, varied times before

meals)?

Not Sure 6. How often is an A1C blood test completed?

Not Sure

Very Confident

Somewhat Confident

Not Sure Not very Confident

Not at all Confident

Overall management of diabetes

Management of hypoglycemia

Management of hyperglycemia

Setting blood glucose goals

Determining the frequency of bedside capillary testing of blood glucose

APPENDIX9(continued)Pre-EducationSurvey


47

P a g e |3


7. Consider the following statements. Please check (√) if the statement is true, false or not sure in spaces provided.

8. At what glucose levels are the physicians usually contacted to assess for a medication change?

Blood glucose is between……. Medication Increase

Medication Decrease

No Change Needed Not Sure

4-7 mmol/L

7.1-10 mmol/L

10.1-15 mmol/L

15.1-20 mmol/L

>20.1 mmol/L

True False Not Sure

Hypoglycemia in the frail elderly person with diabetes can lead to poor balance, risk of falls, seizures and even death.

Elderly persons with diabetes have the same symptoms of hypoglycemia and hypoglycemia awareness as the general population.

There is good evidence to support the goal of a fasting blood glucose value between 4-7 mmol/L for the frail elderly.

An A1C level of 8-10% is acceptable for the frail elderly, if the person is asymptomatic.

In the frail elderly, hypoglycemia can be more severe, prolonged, and precipitate a cardiovascular event.

The most significant concern in management of diabetes for the frail elderly is to avoid hyperglycemia.

Blood glucose levels between 10-15 mmol/l are acceptable if the person has no polyuria or nocturia?

Blood glucose levels between 10-20 mmol/l are acceptable if infrequent/not persistent?


48


P a g e |4


9. In your opinion, should the goals for diabetes management be the same for those in\or awaiting LTC and Acute Care?

Diabetes management goals should be tighter in acute care Diabetes management goals should be tighter in long-term care Diabetes management goals should be the same Not Sure

10. Consider the following case examples and check (√): • The MOST appropriate blood glucose goal for that person • The recommended frequency for A1C testing for this same individual • If you are not sure, check (√) “Not Sure.”

Blood Glucose Frequency of A1C testing

4 - 7 mmol/L

7.1 - 9.9 mmol/L

10 – 14.99 mmol/L

15 – 20 mmol/L

Not Sure

Once a year

1-2 times a year

Not Sure

Mrs. M is 85 years old. She is lives alone, does all her own care and often volunteers in the community. She has type 2 diabetes and is on metformin for her diabetes. She is able to return home upon discharge.

Mr. G is 78 years old. He lives with family but is no longer able to return to his home and is awaiting LTC placement. He has heart disease, hypertension and mobility issues. He has type 2 diabetes and is managed with metformin.

Mr. Q is 68 years old and admitted from long-term care. He has had diabetes for 20 years and also has Parkinson’s disease and severe dementia. He is currently on glicazide and long acting insulin bid. His glucose levels are between 10-13 mmol/L.

Mrs. P is a 76-year old who is medically discharged from hospital awaiting LTC. She has a 10-year history of type 2 diabetes. She is on metformin, glyburide and bedtime insulin. Her glucose levels are between 5-7 mmol/L.

THANK YOU FOR YOUR TIME AND INPUT



49

WesternZoneDiabetesQualityInitiative

GuidelinesforFrailElderlyPatientsinTC/ALCandVetsUnits

DCPNSNovember15,2017

PleasesendresponsestoPeggyDunbar.

1

AdvisoryCommittee(AC)Evaluation

ToassistinevaluationofthisInitiative,wewouldvaluecompletionofthefollowingquestions.Yourthoughtsandsuggestionswillbegreatlyappreciated.CompletedsurveysshouldbereturnedbyNovember29,2017.

• Byfax:902-473-3911

• Byemail:[email protected](scannedandattached)Ifyouwouldprefertocompletethesurveybyphone,Iwouldbehappytoarrangethiswithyou.Name:

Date:

1. Didyoufeelyouwere:

• Wellinformedabouttheproject(background,purpose,intent,proposedco-leadmodel,roleasACmember)? Yes No

• Engagedintheplanningforimplementation? Yes No

Ifyes,whatwasmosthelpful?

Ifno,whatcouldhavebeenimproved?

THINKINGABOUTTHECO-LEADMODEL:2. Doyoufeelitwasvaluablehavingaco-leadmodelwithanurseanddietitianineachlocation? Yes No

Pleasegivereasonstoexpandonyourresponse.

THINKINGABOUTTHEEDUCATIONSESSIONS:3. DoyoufeelthiswasagoodwaytoreachthevarioushealthcareprovidersontheUnitsthatwere

partofthisinitiative? Yes No

Pleaseexpandonyourresponse?

APPENDIX10

StakeholderSurveys–AdvisoryCommittee

50






2

THINKINGABOUTYOURROLEASADVISORYCOMMITTEEMEMBER:4. Doyoufeelyourinvolvementwiththeinitiativewasimportanttotheprojectandeffective?Usinga

scaleof1-5,where1isnotatallimportant/effective,and5isveryimportant/effective.

1 2 3 4 5

Myinvolvementwasimportanttotheproject

Myrolewaseffective

Pleaseexpandonyourresponse:

THINKINGABOUTCRYSTALMACNEILANDHER“CENTRALCOORDINATIONROLE”:5. DoyoufeelitwasvaluablehavingapersonintheCentralCoordinationrole? Yes No


6. Canyouthinkofanywayinwhichthispositioncouldhavebettersupported/facilitatedtheproject? Yes No


THINKINGABOUTCOMMUNICATION:

7. Howeffectivedidyoufindthefollowinginsupportingcommunicationabouttheinitiative,(1ispoor,3isneutral,and5isexcellent)?

1 2 3 4 5

WesternZoneDM&LTCQualityInitiativeBulletins

NSHANewsUpdates

CentralCoordinator(on-siteactivities,accessibility,etc.)

Siteco-leads(nursingandnutrition)

ACmembers(sharingwiththeirdirectareasofresponsibility)

Other(pleasenote):

APPENDIX10(continued)StakeholderSurveys–AdvisoryCommittee


51





3

8. Howcouldcommunicationbefurtherimproved? Noimprovementrequired


THINKINGABOUTTHEOVERALLINITIATIVEFRAMEWORK/PROCESSES:9. Howimportant/effectiveweretheinitiativeframeworkandevaluationmetrics(where1isnotatall

important/effective,and5isveryimportant/effective)?

1 2 3 4 5

Overallframework/process?(engagement,AdvisoryCommittee,processtimeline,centralcoordination/supports,localco-leadmodel,routinecommunication,educationalsessions[standardizedmaterials])

Evaluationmetrics(chartauditsandprovidersurveys[preandposttheeducationalsessions];educationsessionevaluations;co-lead,AdvisoryCommitteemember,andCentralCoordinatorsurveys)?

OVERALL:

10.WhatarethenextstepsneededtoeffectivelyputtheDCPNSLTCGuidelinesintopracticeinourtargetareas(TransitionalCareUnits,AlternativeLevelofCarebeds,andVetsUnits)?

11.Ifweweretomovethisprovince-wide:

Whatguidancewouldyougive(specifictotheAdvisoryCouncil,co-leadmodel,centralcoordination,communication,etc.)?

Whatworkedwillwiththisinitiative?


52






4

Whatchangeswouldyousuggest?

12.HowwouldyouratethePlanning(DCPNSrole,AdvisoryCommitteemembership/role,engagement;Delivery(communications;chartaudits;providersurveys;educationsessions;andEvaluationofthisWZDiabetesQualityInitiative?

1 2 3 4 5

Planning(DCPNSrole,AdvisoryCommitteemembership/role,engagementefforts,co-leadmodel,etc.)

Delivery(centralcoordinationsupports;communications;chartaudits;providersurveys;educationsessions;etc.)

Evaluation(preandpostchartaudits;preandpostprovidersurveys,educationsessionevaluations,co-leadsurvey,etc.)

13. Pleaseaddadditionalcommentshere.Isthereanythingyouwouldliketosaythatwedidnotask

about?

Manythanks!!



53

WesternZone

DiabetesQualityInitiative




1

CentralCoordination/CoordinatorProjectEvaluation

ToassistinevaluationofthisInitiative,wewouldvaluecompletionofthefollowingquestions.Your

thoughtsandsuggestionswillbegreatlyappreciated.Completedsurveysshouldbereturnedby

November29,2017.• Byfax:902-473-3911

• Byemail:[email protected](scannedandattached)

Ifyouwouldprefertocompletethesurveybyphone,Iwouldbehappytoarrangethiswithyou.

Name:

Date:

1. Didyoufeelyouwere:

• wellinformedabouttheproject(background,purpose,intent,androles[yoursaswellasothers

includingtheco-leads])andorientedtotheposition? Yes No

• orientedtotheposition(tools,resources,approaches,etc.)? Yes No



THINKINGABOUTTHE“CENTRALCOORDINATIONROLE”:

2. DoyoufeelsupportedbytheDCPNSinthisrole? Yes No Pleaseexpandonyourresponse:

3. DoyoufeelitwasvaluablehavingapersonintheCentralCoordinationrole? Yes No


APPENDIX10(continued)StakeholderSurveys–ProjectCoordinator

54






2

4. Canyouthinkofanywayinwhichthispositioncouldhavebettersupported/facilitatedtheproject? Yes No


5. Whatsuggestionswouldyouhavetoimprovethisrole?

THINKINGABOUTTHEROLEOFTHECO-LEAD:6. Doyoufeelitwasvaluablehavingaco-leadmodelwithanurseanddietitian? Yes No


7. Whatsuggestionswouldyouhavetoimprovethisrole?

THINKINGABOUTTHEEDUCATIONSESSIONS:8. Doyoufeelthematerialsprovidedtosupportthesesessions(powerpoint,guidelinedocuments,

evaluationform,samplepromotionalposters,etc.)werehelpful? Yes No


9. Whatwouldyoudotoimprovetheeducationsessions?



55





3

THINKINGABOUTCOMMUNICATION:10. Pleasecommentonthecommunicationduringtheproject(where1ispoorand5excellent).

Communicationincludesin-persontouchpoints,emails,phonecontact,newsletters,posters,etc.

1 2 3 4 5

CoordinatortoCo-leads

CoordinatortoUnit/areastaffs(participants)

CoordinatortoDCPNSManager

CoordinatortoAdvisoryCouncil/smallerWorkingGroup

Other(pleasenote):

11. Howeffectivedidyoufindthefollowinginsupportingcommunicationabouttheinitiative,(1is

poor,3isneutral,and5isexcellent)?

1 2 3 4 5

WesternZoneDM&LTCQualityInitiativeBulletins

NSHANewsUpdates

CentralCoordinator(on-siteactivities,accessibility,etc.)

Siteco-leads(nursingandnutrition)

ACmembers(sharingwiththeirdirectareasofresponsibility)

ACmeetings

Other(pleasenote):

12. Howcouldcommunicationbefurtherimproved? Noimprovementrequired



56






4

THINKINGABOUTTHEOVERALLINITIATIVEFRAMEWORK/PROCESSES:13. Howimportant/effectiveweretheinitiativeframework,includingprocesstimeline,andevaluation

metrics(where1isnotatallimportant/effective,and5isveryimportant/effective)?

1 2 3 4 5

Howimportant/effectivewastheoverallframework/process(engagement,AdvisoryCommittee,centralcoordination/supports,localco-leadmodel,routinecommunication,processtimeline,educationalsessions[standardizedmaterials],andevaluationmetrics)?

Howimportant/effectiveweretheevaluationmetrics(chartauditsandprovidersurveys[pre-andpost-educationalsessions];educationsessionevaluations;co-lead,AdvisoryCommitteemember,andCentralCoordinatorsurveys)?

OVERALL:

14. WhatarethenextstepsneededtoeffectivelyputtheDCPNSLTCGuidelinesintopracticeinourtargetareas(TransitionalCareUnits,AlternativeLevelofCarebeds,andVetsUnits)?

15. Ifweweretomovethisprovince-wide,whatguidancewouldyougive(e.g.,specifictotheAdvisoryCouncil,co-leadmodel,centralcoordination,communication,etc.)?

WhatguidancewouldyougivesomeoneabouttostepintotheroleoftheCoordinator?

16. Whatworkedwellwiththisinitiative?

Whatchangeswouldyousuggest?



57





5

17. HowwouldyouratethePlanning(DCPNSrole,AdvisoryCommitteemembership/role,

engagement;Delivery(communications;chartaudits;providersurveys;educationsessions;andEvaluationofthisWesternZoneDiabetesQualityInitiative?

1 2 3 4 5




18. Pleaseaddadditionalcommentshere.Isthereanythingyouwouldliketosaythatwedidnotask

about?

Manythanks!!


58



59





1

Co-LeadsProjectEvaluation

ToassistinevaluationofthisInitiative,wewouldvaluecompletionofthefollowingquestions.Yourthoughtsandsuggestionswillbegreatlyappreciated.CompletedsurveysshouldbereturnedbyNovember27,2017.

• Byfax:902-473-3911

• Byemail:[email protected](scannedandattached)Ifyouwouldprefertocompletethesurveybyphone,Iwouldbehappytoarrangethiswithyou.Co-LeadName:

Date:

1. Didyoufeelyouwerewellinformedabouttheproject(background,purpose,intent,androles

[yoursaswellasothersincludingtheprojectcoordinator])? Yes NoIfyes,whatwasmosthelpful?


THINKINGABOUTYOURROLEASCO-LEAD:2. Didyoufeelyouweresupportedinyourroleasco-lead? Yes No



3. Doyoufeelitwasvaluablehavingaco-leadmodelwithaNurseandDietitian? Yes NoPleasegivereasonstoexpandonyourresponse?

4. Whatbarriers,ifany,didyoufaceincarryingoutyourroleinthisproject?

APPENDIX10(continued)StakeholderSurveys–ProjectCo-Leads

60






2

THINKINGABOUTTHEEDUCATIONSESSIONS:5. Didyoufeelyouhadadequatetrainingandknowledgeofthematerialsonwhichyouwere

providingtheeducation? Yes No


6. Usingascaleof1-5where1ispoor,3isneutral,and5isverygood,pleaseratethefollowingquestions:

1 2 3 4 5

HowreceptivewerethestaffstotheEducationSessions?

HoweffectivewerethesesessionsinincreasingawarenessandUnderstandingoftheguidelines?

Howpreparedarethestafftoimplementtheguidelines?

7. Whatwouldyoudotoimprovetheeducationsessions?

THINKINGABOUTYOURCURRENTROLE:

8. DoyoufindthestaffsonthevariousunitsthatwereinvolvedinthisinitiativearenowreferringtoyouforguidanceinDiabetesManagementoffrailelderly? Yes No


9. Doyoufindyouhavebecomearesourceperson?(DoesthestaffaskyouropiniononBGlevels,medschanges,BG/A1Cmonitoringfrequency?) Yes No


THINKINGABOUTCRYSTALANDHER“CENTRALCOORDINATIONROLE:”

10. DidyoufeelsupportedbyCrystalinthisrole? Yes No




61





3

11. Didyoufeelitwasvaluablehavingapersoninthisrole? Yes No


12. Canyouthinkofanywayinwhichthispositioncouldhavebettersupported/facilitatedtheproject?

Yes No Pleaseexpandonyourresponse:

THINKINGABOUTCOMMUNICATION:

13.Pleasecommentonthecommunicationduringtheproject(where1waspoor,and5excellent).Communicationincludesin-persontouchpoints,emails,phonecontact,newsletters,posters,etc.

1 2 3 4 5

CoordinatortoCo-leads

Coordinatortounit/areastaffs(participants)

14. Howeffectivedidyoufindthefollowinginsupportingcommunicationabouttheinitiative,(where

1waspoor,and5excellent)?

1 2 3 4 5

WZInitiativeNewsletters/Bulletins

NSHANewsUpdates

OVERALL:

15.WhatarethenextstepsneededtoeffectivelyputtheDCPNSLTCGuidelinesintopractice?

16.Ifweweretorepeatthisprojectinanotherareaoftheprovince:

Whatguidancewouldyougivesomeoneabouttostepintotheroleof“Co-Lead”?

Whatwouldyouchangeregardingtheprojectprocesses?


62






4

17.HowwouldyouratethePlanning(DCPNSrole,AdvisoryCommitteemembership/role,engagement;Delivery(communications;chartaudits;providersurveys;educationsessions;andEvaluationofthisWZDiabetesQualityInitiative?

1 2 3 4 5




18.Insummary,

Whatworkedwellwiththisinitiative?

Whatshouldbeimprovedwiththisinitiative?

19. Pleaseaddadditionalcommentshere.Isthereanythingyouwouldliketosaythatwedidnotaskabout?

Manythanks!!


Documents

The Western Zone (WZ) Diabetes and Long-Term Care Quality ...€¦ · Western Zone Diabetes and Long-Term Care Quality Initiative Diabetes Care Program of Nova Scotia – May 2018