Sticking Points - Reducing Excess Fingerstick Blood Glucose Testing In Hospitalized Patients With Well-Controlled Type 2 Diabetes Mellitus: A Quality Improvement Project

Samir Kamat BA1, Jared Dashevsky, M.E.1, Alyssa Gontzes, MS1, Madeline Floodstrand, MS1, Grenye O’Malley, MD,1,2 , Anne S. Linker, MD1,3

Icahn School of Medicine at Mount Sinai
Division of Endocrinology, Diabetes, and Bone Diseases, Icahn School of Medicine at Mount Sinai
Division of Hospital Medicine, Mount Sinai Hospital

1. Specific Aims of the Project

We piloted a multifaceted, student-led electronic medical record (EMR) and educational intervention to reduce fingerstick blood glucose (FSBG) testing in low-risk patients with type 2 diabetes mellitus (T2DM) cared for in the Hospital Medicine service at Mount Sinai Hospital (MSH). In patients at low risk for inadequate glycemic control, FSBG monitoring may add to the nursing workload, cause patient discomfort, and waste resources without improving the quality of care. MSH is an urban, academic, tertiary care center in New York City. With feedback from specialists in hospital medicine and endocrinology, we defined “Low-risk” as patients with the following characteristics: 1) not on home insulin, 2) 72-hour blood glucose less than 250 mg/dl, 3) total daily dose of insulin less than five units, 4) not on high-risk medications that can cause hyperglycemia, such as steroids.

2. Intervention and Results

The project consisted of an EMR and educational intervention starting in June 2021 and ending in December 2021. A new order for twice daily before meals (BID AC) for point-of-care FSBG monitoring was added to the standard Diabetic Agent order set, which is used to order all medications and labs related to diabetes care. The EMR change was implemented before the educational intervention. Educational sessions were delivered to all providers through monthly lectures and individual educational sessions. Topics covered included discussion of overuse of testing, the definition of “low-risk” patients for purposes of the project, and how to execute the BID AC FSBG order in the EMR.
Outcome measures included the number of FSBG order changes per month, the percentage of low-risk patients with T2DM receiving BID FSBG or who had the FSBG order discontinued, and the total number of fingersticks avoided. We defined an "order change" as a QID to BID order change or a canceled QID or BID order. Our post-intervention analysis found a significant 208% relative increase in the number of order changes per month, from 4.60 orders to 14.71 orders (p<0.01). The percentage of qualifying patients whose FSBG order changed increased 115% during the post-intervention period from 2.90% to 4.93%, avoiding 1,541 fingersticks and saving $14,000 in costs related to supplies and nursing time.

3. Significance of Results
            Our findings suggest the EMR and educational interventions are feasible, despite only affecting a small population thus far. The intervention can be scaled to make a more significant impact on the avoidance of excessive FSBG testing in low-risk patients with T2DM at our institution.
Avoiding excessive FSBG testing not only optimized patient care but also improved nursing workflows and reduced healthcare costs. Our preliminary nurse perception survey found that nurses spent on average 5 minutes administering one FSBG test, a process estimated to cost $9. Therefore, the 1,541 fingersticks avoided saved over five days of nurses’ time and $14,000. Nurses, theoretically, had more time to focus on caring for other patients or tasks. Though the project impacted workflows, there were missed opportunities and limitations despite our educational campaign. Our project occurred concurrently with two surges of Covid-19, during which most educational sessions occurred remotely. We believe this reduced the impact of our educational interventions, as it was more challenging to make providers aware of the available FSBG order modification, and this intervention became a lower priority for front-line providers. However, we saw an initial uptick in order changes when the EMR order set was updated before our educational intervention began. This suggests that the EMR order set intervention was critical to affecting change in the context of limited education given Covid-19 restrictions. In a setting without the challenges of Covid-19, we believe the efficacy of our intervention would have significantly improved, resulting in more FSBG tests avoided and time and cost savings.
Overall, these results suggest we improved the value of care delivered to patients by (1) avoiding patient discomfort through excessive FSBG testing and (2) minimizing low-value waste of resources.

4. Lessons Learned:

We gained a firsthand immersion in the quality improvement process throughout the entire process. We now recognize the number of key stakeholders and the iterative process required to implement even a small change. For example, we accomplished managing various components and stakeholders by delegating responsibility to individual team members, such as remote education, troubleshooting EMR issues, or tracking patient safety information. We also appreciate having champions and mentors who helped grease the wheels whenever we experienced setbacks. For example, having our physician mentors accompany us on our educational outreach helped provide legitimacy from the perspective of frontline staff. This project has given us a deep belief in our ability to enact change and improve patient safety through quality improvement efforts.

5. Plans for Future Work
            We hope to scale our project to have an even more profound impact across the Mount Sinai Health System. This may involve identifying other opportunities for continued education around the quality improvement effort, expanding the intervention to include non-medicine floors, and raising awareness of our findings to clinicians at different hospital sites.

Acknowledgments:
We are grateful to the Society of Hospital Medicine for providing grant funding, allowing us to pursue this pilot project. We are also thankful for the EMR staff, nurses, residents, and others who helped make this project possible.

Order Changes	Pre_Intervention	CI (95%)	Post_Intervention	CI (95%)	% Change
Total Number of Low-Risk Patients with Order Changes	23		71		208.70%
Number of Order Changes/Month (SD)	4.600(2.966)	[3.437,5.763]	14.71(3.729)	[13.67, 15.76]	219.88%

Outcome Measures	Pre_Intervention	Post_Intervention	% Change
Total fingersticks administered among pts who meet criteria	20,199	27,168
Percent of patients with Type 2 DM receiving FSBG twice per day instead of four times per day	0.80%	2.29%
Percent of patients with Type 2 DM receiving FSBG twice per day or no times per day instead of four times per day	2.29%	4.93%
Total Fingersticks Saved	412	1541	274.03%
Total costs saved	$3,708.78	$13,867.99	273.92%
Total Nursing Time Saved	1 days 10:20:25	5 days 08:24:26