Implementing an Evidence Based Practice Guideline to Standardize the Care of Adults with Type 2 Diabetes

Abstract

PURPOSE: The purpose of this quality improvement project was to explore the impact of implementing the Health TeamWorks practice guideline in standardizing the care for adults with type 2 diabetes. The goal was to improve patients’ glycosylated hemoglobin A1c (HbA1c) levels to less than 8% and Low Density Lipoprotein (LDL) levels to less than 100mg/dL. The Implementation Model, adapted by Titler (2010) and built on Rogers Diffusion of Innovation Theory (Rogers, 2003), guided this project. Interventions used to promote the use of guideline included the use of opinion leaders, education classes, audit and feedback of performance during providers’ meetings. METHODS: A ‘pre and post’ implementation evaluation of patients’ laboratory results was the design used to gather data. Patients with uncontrolled HbA1c levels were checked every three months and LDL levels once during the year of project. RESULTS: The convenience sample of 11 providers included six medical doctors and five nurse practitioners employed at Kalihi Pālama Health Center. They were primary care providers of record for 88 patients with diabetes whose laboratory results were tracked for this project. Descriptive and trend analyses revealed the 3-months, 6-months, 9-months and 12-months checks results of 74%, 32%, 52% and 43% of patients with improved HbA1c levels, respectively. Of the 88 patients, 19% met the target of HbA1c level of less than 8% at least once during the project year. Forty three patients had their LDL levels rechecked in 2015 and 33% of them met the target goal of less 100 mg/dL. DISCUSSION. The results revealed a decrease in HbA1c in the majority of patients; however, glycemic relapse was noted at the 6-months checkpoint. Despite the work of care coordinators, the patient ‘no show’ for appointments was a common occurrence due to a lack of insurance and financial resources. Providers identified facilitators and barriers to using the guideline. It was difficult to establish adherence of providers’ use of the guideline because of the multiple ‘patient factors’ identified that prevented consistent implementation and evaluation. However, working in a collaborative team made a difference in bridging the gaps in the care of diabetic patients.