Roman S H, Linekin P L, Stagnaro-Green A
Department of Medicine, Mount Sinai Medical Center, New York 10029, USA.
Jt Comm J Qual Improv. 1995 Dec;21(12):693-9. doi: 10.1016/s1070-3241(16)30197-3.
The goal of this study was to establish a continuous quality improvement (CQI) program for diabetes which would identify patterns in the problems of care encountered by hospitalized patients with diabetes and improve the in-hospital process of diabetes care delivery.
The laboratory information system in an acute and tertiary care 1,000-bed urban teaching hospital provided us on a daily basis with a list of patients on the medical service having blood glucose (BG) levels < 40mg/dl or > 450mg/dl and positive serum acetones. We performed concurrent implicit chart review when BG levels were hypoglycemic (< 40mg/dl) or hyperglycemic (> 450mg/dl on two occasions) or when diabetic ketoacidosis (DKA) was present (acetones were > 1+) using preset indicators for documentation and appropriate medical management. Data were expressed as the ratio of number of cases in compliance with the indicator over total number of cases identified. A test for trend in proportions was used to assess compliance with the indicators over time.
Documentation of nursing unit-based capillary blood glucose (CBGM) and insulin infusion monitoring improved significantly over time (p < 0.001 for both). The medical management of hypoglycemia, hyperglycemia and DKA improved (p = 0.1) over the three-year period. Identification of recurrent multidisciplinary process problems in the management of DKA, intravenous insulin infusion constitution and delivery, CBGM determination in the setting of anemia, and recognition of clinical settings conducive to the development of hypo- and hyperglycemia were identified and addressed with standardization in documentation, an insulin infusion protocol, administrative rules, and staff education.
Efforts to standardize specific clinical and documentation processes had a positive impact on the care of hospitalized patients with diabetes and resulted in an institutional effort to improve inpatient diabetes care with a CQI team.
本研究的目的是建立一个糖尿病持续质量改进（CQI）项目，该项目将识别住院糖尿病患者护理问题中的模式，并改善糖尿病护理的院内流程。
一家拥有1000张床位的城市急性和三级护理教学医院的实验室信息系统每天为我们提供一份内科服务患者名单，这些患者的血糖（BG）水平<40mg/dl或>450mg/dl且血清丙酮呈阳性。当BG水平为低血糖（<40mg/dl）或高血糖（两次>450mg/dl）或存在糖尿病酮症酸中毒（DKA）（丙酮>1+）时，我们使用预设的记录和适当医疗管理指标进行同步隐性病历审查。数据表示为符合指标的病例数与识别出的病例总数的比率。使用比例趋势检验来评估随时间对指标的依从性。
随着时间的推移，基于护理单元的毛细血管血糖（CBGM）记录和胰岛素输注监测有显著改善（两者p<0.001）。低血糖、高血糖和DKA的医疗管理在三年期间有所改善（p = 0.1）。识别出DKA管理、静脉胰岛素输注配制和给药、贫血情况下的CBGM测定以及识别有利于低血糖和高血糖发生的临床环境中反复出现的多学科流程问题，并通过记录标准化、胰岛素输注方案、行政规则和员工教育加以解决。
规范特定临床和记录流程的努力对住院糖尿病患者的护理产生了积极影响，并促使机构通过CQI团队努力改善住院糖尿病护理。
