Can an interprofessional education tool improve healthcare professional confidence, knowledge and quality of inpatient diabetes care: a pilot study?

Adequacy of knowledge of new medical graduates about diagnosis and management of children and adolescents with type 1 diabetes in a developing country

BACKGROUND

Knowledge of diabetes by the graduate physicians had been reported to be deficient in many aspects of diagnosis and management of type 1 diabetes (T1D). This will reflect on patient care and quality of health services especially in limited-resources countries. Our aim was to assess knowledge of basic management of T1D in new medical graduates in Jordan.

METHODS

A questionnaire was developed to collect information concerning demographics and knowledge and was distributed in paper form and online using google forms. The knowledge was assessed using 28 questions on different aspects of the disease.

RESULTS

A total of 358 new medicine graduates responded to the survey and female respondents were significantly higher than male respondents. Average number of lectures concerning diabetes during the medical school years was 3.92 ± 1.37. High knowledge scores were on pathophysiology of T1D, hypoglycemia, and certain aspects of diabetic ketoacidosis. Female gender, higher number of persons with T1D the participant had encountered during medical school, and good or excellent expected degree of self-knowledge of diabetes were associated with high knowledge score, p values = 0.01, 0.009, and < 0.001, respectively. Female gender and good or excellent expected degree of knowledge of diabetes predicted high knowledge score, p value = 0.008, and < 0.001, respectively.

CONCLUSION

Gaps in knowledge of new medical graduates in certain T1D subjects exist. This can be corrected by many strategies including changes in curricula, elective courses, more clinical exposure, and interprofessional education. These measures must be evaluated for their short and long-term benefits.

The impact of nursing staff education on diabetes inpatient glucose management: a pilot cluster randomised controlled trial

BACKGROUND

An increasing number of patients in hospital have diabetes, with most of them cared for by non-specialist staff. The effect of diabetes education for staff on patient outcomes, as well as the most effective method of staff education is unclear. Therefore, the aim of this study was to compare diabetes outcomes in medical wards where nursing staff were offered one face-to-face (F2F) session followed by access to online education (online), F2F education only, or standard care (control).

METHODS

We conducted a pilot cluster randomised controlled trial involving 16-weeks baseline/rollout followed by a 28-week post-intervention period across three medical wards (clusters) in a Sydney Teaching Hospital. The online ward provided an online competency-based diabetes education program and 1-h F2F teaching from a diabetes nurse educator (DNE), the F2F ward provided four separate 1-h teaching sessions by a DNE, with no additional sessions in the control ward. The primary outcome was length of stay (LOS); secondary outcomes included good diabetes days (GDD), hypoglycaemia and medication errors. Poisson and binary logistic regression were used to compare clusters.

RESULTS

Staff attendance/completion of ≥ 2 topics was greater with online than F2F education [39/48 (81%) vs 10/33 (30%); p < 0.001]. Among the 827/881 patients, there was no difference in LOS change between online [Median(IQR) 5(2-8) to 4(2-7) days], F2F [7(4-14) to 5(3-13) days] or control wards [5(3-9) to 5(3-7) days]. GDD improved only in the online ward 4.7(2.7-7.0) to 6.0(2.3-7.0) days; p = 0.038. Total patients with hypoglycaemia and appropriately treated hypoglycaemia increased in the online ward.

CONCLUSIONS

The inclusion of online education increased diabetes training uptake among nursing staff. GDD and appropriate hypoglycaemia management increased in the online education wards.

TRIAL REGISTRATION

Prospectively registered on the Australia New Zealand Clinical Trials Registry (ANZCTR) on 24/05/2017: ACTRN12617000762358 .

What participants learn, with, from and about each other during inter-professional education encounters: A qualitative analysis

BACKGROUND

Safe healthcare requires teamwork and collaboration. To meet the needs of healthcare organizations and professionals, inter-professional education, is no longer an optional educational trend but rather a mandate of accrediting health education agencies.

OBJECTIVE

In an effort to better understand the impact of inter- professional educational activities, this study sought to explore via qualitative methods what nursing and medical students learn with, from, and about one another during a week - long simulation-based inter-profession education course.

DESIGN

A convenience sample of post-course survey responses from students participating in a week-long, inter-professional, simulation-based patient safety course was used to longitudinally explore what participants learn with, from, and about each other.

SETTINGS

The setting for this study was a research university located in the southeast United States.

PARTICIPANTS

The participants included a total of 272 second semester accelerated option Bachelor of Nursing students and 599 medical students entering the 3rd year of their program that participated in an annual patient safety course. The study analyzed responses of students to questions in a post-course survey regarding educational outcomes while learning with students from a different profession.

RESULTS

In the responses from 871 students collected over four years, the following key themes emerged. Students: 1) articulated learning the importance of contributions of other professions to the healthcare team, 2) expressed an appreciation for areas where their colleagues' training was superior to their own; and 3) identified deficiencies in their own knowledge and skill sets.

CONCLUSION

The findings of this study provide a basis for developing more specific curricular content as part of inter-professional education endeavors to strengthen constructive views of healthcare professions, foster a more collaborative shared mental model, and to correct perceived misconceptions.

Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the prevention of foot ulceration in persons with diabetes and updates the 2015 IWGDF prevention guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We recommend to screen a person at very low risk for ulceration annually for loss of protective sensation and peripheral artery disease and persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate the at-risk patient about appropriate foot self-care and treat any pre-ulcerative sign on the foot. Instruct moderate-to-high risk patients to wear accommodative properly fitting therapeutic footwear, and consider instructing them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking to prevent plantar foot ulcer recurrence. In patients that fail non-surgical treatment for an active or imminent ulcer, consider surgical intervention; we suggest not to use a nerve decompression procedure. Provide integrated foot care for high-risk patients to prevent ulcer recurrence. Following these recommendations will help health care professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer-free days, and to reduce the patient and health care burden of diabetic foot disease.

Treatment of modifiable risk factors for foot ulceration in persons with diabetes: a systematic review

BACKGROUND

Prevention of diabetic foot ulcers is important. Preventative treatment mostly targets and aims to improve modifiable risk factors of foot ulceration. While effectiveness of interventions in ulcer prevention has been systematically reviewed, their effectiveness in improving modifiable risk factors is unknown.

METHODS

The available medical scientific literature in PubMed, Excerpta Medica Database, and the Cochrane database was searched for original research studies on six interventions to treat modifiable risk factors for diabetic foot ulceration (ie, education for patients; education for professionals; self-management; pre-ulcer treatment; orthotic interventions; and foot- and mobility-related exercises). We assessed interventions for eight outcomes (ie, patients' knowledge; treatment adherence; professionals' knowledge; pre-ulcers; mechanical stress; neuropathy symptoms; foot/ankle joint mobility; and foot function). Both controlled and noncontrolled studies were selected. Data from controlled studies were assessed for methodological quality by two independent reviewers and extracted and presented in evidence and risk of bias tables.

RESULTS

We included 72 publications (26 with a controlled study design and 46 noncontrolled). We found that structured education may improve foot self-care behaviour of patients, yearly foot examinations, and foot disease knowledge of health care professionals. Callus removal reduces peak plantar pressure. Custom-made therapeutic footwear can be effective in reducing plantar pressure and may reduce callus. Foot- and mobility-related exercises may improve neuropathy symptoms and foot and ankle joint range of motion, while they do not seem to reduce peak plantar pressure; evidence for their effect on foot strength is conflicting.

CONCLUSIONS

Structured education for patients and health care professionals, callus removal, custom-made therapeutic footwear, and foot- and mobility-related exercises may be beneficial for improving modifiable risk factors for foot ulceration. However, we generally found low quality of evidence for interventions targeting modifiable risk factors for ulceration in persons with diabetes, with frequently inconsistent or limited results available per intervention and outcome.

Pediatric diabetes inpatient care: can medical staff knowledge be improved?

Background The purpose of this study was to assess the benefit of a short workshop addressing knowledge and confidence of inpatient caregivers (physicians and nurses) treating pediatric type 1 diabetes mellitus (T1DM) patients. Methods Questionnaires to determine familiarity with T1DM management and confidence in care were distributed at three university-affiliated medical centers. A 5-h practical-skills workshop was conducted at one center. Same questionnaires were filled out immediately after the workshop and 3 months later. Evaluation of knowledge was based on 16 multiple-choice questions, and confidence based on 10 categorical questions. Results Nurses and physicians (total 135, 106 women, 85 nurses) completed the questionnaires. The median knowledge score was 53.33 (40-66) and 46.7 (26.7-66.7) for nurses and physicians, respectively (p = 0.76). The confidence scores were 1.44 (1.1-1.9) and 1.56 (1.2-1.8), respectively (p = 0.7). More experience among nurses (>10 years) was associated with higher confidence scores (p = 0.04). Twenty-one physicians and 52 nurses, 66 women, attended the workshop. The median knowledge grade improved from 60 (47-67) to 81 (69-81), p < 0.001, immediately after, and to 69 (63-81), p < 0.001, 3 months post-workshop. The median confidence score improved from 1.8 (1.6-2) to 2.4 (2.1-2.6), p < 0.001, and to 2.2 (2-2.6), p < 0.001, respectively. There was no association with profession or seniority. Conclusions Knowledge and confidence in care of medical staff treating inpatient T1DM pediatric patients are lacking. Both improved significantly after the workshop, independent of seniority or profession.

Assessment of Insulin-related Knowledge among Healthcare Professionals in a Large Teaching Hospital in the United Kingdom

Despite numerous strategies introduced to promote the safe use of insulin, insulin-related medication errors persist. Our aim was to examine the knowledge and self-reported confidence of a range of healthcare professionals regarding insulin use in a large teaching hospital in the North of England. A 16-item electronic questionnaire was prepared in light of locally reported insulin-related incidents and distributed electronically to all healthcare professionals at the hospital over a 4-week study period. A range of healthcare professionals, including nurses, pharmacists, pharmacy technicians, junior doctors and consultants, completed the questionnaires (n = 109). Pharmacists achieved the greatest percentage of mean correct answers overall (49%), followed by consultant doctors (38%) and pharmacy technicians (37%), junior doctors (34%) and nurses (32%). Healthcare professionals were mainly “slightly confident” in their knowledge and use of insulin. Confidence level positively correlated to performance, but number of years’ experience did not result in higher confidence or performance. This small-scale study allowed for a broad assessment of insulin-related topics that have been identified both nationally and locally as particularly problematic. Identifying knowledge gaps may help tailor strategies to help improve insulin knowledge and patient safety.

An integrative systematic review of interprofessional education on diabetes

Interprofessional education (IPE) aims at enhancing the ability of healthcare professionals from different disciplines to work together effectively, improving the quality of patient care. An interprofessional approach is essential in diabetes management, but there is only limited evidence of the effects of diabetes-specific IPE. The aim of this integrative review is to gather all relevant recent data on the outcomes of IPE on diabetes management. The search in the CINAHL, Medline and PsycINFO databases resulted in 1136 potential studies. An inductive content analysis was used to synthesize the key findings of the 14 studies found to fulfill the inclusion criteria of the systematic review. Two main categories and four subcategories of findings were identified. Firstly, the achieved outcomes included individual gain (e.g., learner´s confidence and motivation to treat patients with diabetes) and external benefits (e.g., benefits for the patient). Secondly, the experiences of IPE included both challenges (e.g., competing interests of different professions) and strengths (e.g., practical approach to diabetes management). In conclusion, the findings indicate that both learners and patients with diabetes benefit from IPE on diabetes management. Educators are encouraged to adopt practical IP approaches in diabetes education. However, it is necessary to estimate the resources available. More research is needed on the cost-effectiveness, long-term effects, and patient perspective of IPE on diabetes management.

Can a single interactive seminar durably improve knowledge and confidence of hospital diabetes management?

BACKGROUND

Safe and effective diabetes management in the hospital is challenging. Inadequate knowledge has been identified by trainees as a key barrier. In this study we assess both the short-term and long-term impact of an interactive seminar on medical student knowledge and comfort with hospital diabetes management.

METHODS

An interactive seminar covering hospital diabetes management and utilizing an audience response system was added to the third-year medical student curriculum. Students were given a multiple choice assessment immediately before and after the seminar to assess their comprehension of the material. Students were also asked to rate their confidence on this topic. Approximately 6 months later, students were given the same assessment to determine if the improvements in hospital diabetes knowledge and confidence were durable over time. Students from the preceding medical school class, who did not have a hospital diabetes seminar as a part of their curriculum, were used as a control.

RESULTS

Fifty-three students participated in the short-term assessment immediately before and after the seminar. The mean score (maximum 15) was 7.7 +/- 2.7 (51%) on the pre-test and 11.4 +/- 1.8 (76%) on the post-test (p < 0.01). 75 students who attended the seminar completed the same set of questions 6 months later with mean score of 9.2 ± 2.3 (61%). The control group of 100 students who did not attend seminar had a mean score of 8.8 ± 2.5 (58%). The difference in scores between the students 6-months after the seminar and the control group was not significantly different (p = 0.30).

CONCLUSIONS

Despite initial short-term gains, a single seminar on hospital diabetes management did not durably improve trainee knowledge or confidence. Addition of repeated and focused interactions during clinical rotations or other sustained methods of exposure need to be evaluated.

The Case for Diabetes Population Health Improvement: Evidence-Based Programming for Population Outcomes in Diabetes

PURPOSE OF REVIEW

The goal of this review is to describe diabetes within a population health improvement framework and to review the evidence for a diabetes population health continuum of intervention approaches, including diabetes prevention and chronic and acute diabetes management, to improve clinical and economic outcomes.

RECENT FINDINGS

Recent studies have shown that compared to usual care, lifestyle interventions in prediabetes lower diabetes risk at the population-level and that group-based programs have low incremental medial cost effectiveness ratio for health systems. Effective outpatient interventions that improve diabetes control and process outcomes are multi-level, targeting the patient, provider, and healthcare system simultaneously and integrate community health workers as a liaison between the patient and community-based healthcare resources. A multi-faceted approach to diabetes management is also effective in the inpatient setting. Interventions shown to promote safe and effective glycemic control and use of evidence-based glucose management practices include provider reminder and clinical decision support systems, automated computer order entry, provider education, and organizational change. Future studies should examine the cost-effectiveness of multi-faceted outpatient and inpatient diabetes management programs to determine the best financial models for incorporating them into diabetes population health strategies.

PERSPECTIVES ON LEARNING AND CLINICAL PRACTICE IMPROVEMENT FOR DIABETES IN THE HOSPITAL: A REVIEW OF EDUCATIONAL INTERVENTIONS FOR PROVIDERS

OBJECTIVE

The management of inpatient hyperglycemia and diabetes requires expertise among many health-care providers. There is limited evidence about how education for healthcare providers can result in optimization of clinical outcomes. The purpose of this critical review of the literature is to examine methods and outcomes related to educational interventions regarding the management of diabetes and dysglycemia in the hospital setting. This report provides recommendations to advance learning, curricular planning, and clinical practice.

METHODS

We conducted a literature search through PubMed Medical for terms related to concepts of glycemic management in the hospital and medical education and training. This search yielded 1,493 articles published between 2003 and 2016.

RESULTS

The selection process resulted in 16 original articles encompassing 1,123 learners from various disciplines. We categorized findings corresponding to learning outcomes and patient care outcomes.

CONCLUSION

Based on the analysis, we propose the following perspectives, leveraging learning and clinical practice that can advance the care of patients with diabetes and/or dysglycemia in the hospital. These include: (1) application of knowledge related to inpatient glycemic management can be improved with active, situated, and participatory interactions of learners in the workplace; (2) instruction about inpatient glycemic management needs to reach a larger population of learners; (3) management of dysglycemia in the hospital may benefit from the integration of clinical decision support strategies; and (4) education should be adopted as a formal component of hospitals' quality planning, aiming to integrate clinical practice guidelines and to optimize diabetes care in hospitals.

Impact of a multifaceted strategy to improve perioperative diabetes care

AIMS

To assess the impact of a multifaceted strategy to improve perioperative diabetes care throughout the hospital care pathway.

METHODS

We conducted a controlled before-and-after study in six hospitals. The purpose of the strategy was to target four predominant barriers that obstruct optimal care delivery. We provided feedback on baseline indicator performance, developed a multidisciplinary protocol and patient information, and provided professional education. After a 6-month intervention, we determined the performance changes against three outcome indicators and nine process indicators using data on 811 patients with diabetes who underwent major surgery. The progress of the interventions was monitored closely.

RESULTS

Two process indicators improved significantly in the intervention hospitals: the proportion of patients for whom glycaemic control had been evaluated preoperatively increased by 9% (P < 0.002) and the proportion of patients with blood glucose measurements within 1 h after surgery increased by 29% (P < 0.0001). Four other process indicators and all three outcome indicators improved more in the intervention hospitals than in the control hospitals, but the differences were not statistically significant. These included the proportion of patients with all glucose values at 6-10 mmol/l (+3%) and the proportion of patients with hyperglycaemia (-8%). The implementation of the multidisciplinary protocol was still ongoing after the 6-month intervention period.

CONCLUSIONS

The multifaceted improvement strategy had a limited impact on the quality of perioperative diabetes care. This study demonstrates the complexity of improving perioperative diabetes care throughout the multiprofessional hospital care pathway.

Evaluation of the Diabetes, Multidisciplinary, Experiential (DIAMANTE) Program for Retail Pharmacists: A Mixed-Method Study

INTRODUCTION

The Diabetes, Multidisciplinary, Experiential (DIAMANTE) program was established to enhance collaboration between retail pharmacists and the diabetes care team in the health institutions through interprofessional education. This article describes the program and reports on an evaluation of its impact on attitudes, knowledge, and confidence of the participants in managing diabetic patients.

METHODS

This study utilized a mixed-method design with focus group (FG), exit assessment, and survey. Ten participants were approached to complete the 2-week DIAMANTE program with hands-on training from a multidisciplinary diabetes team. In addition to an exit assessment and a pre-post online survey to assess attitudes of participants toward diabetes care, diabetes knowledge, and confidence in managing diabetic patients, FG was used to obtain the qualitative feedback of pharmacists. Feedback of the preceptors related to the program and pharmacist performance was also sought through an online survey. Survey data and FGs were analyzed using Wilcoxon signed-rank test and thematic analysis, respectively.

RESULTS

All participants completed the program successfully. The FGs revealed four themes: program design, participants' view on preceptors, participants' perceptions of program benefits, and program's outlook. Participants perceived the program content as comprehensive and relevant. With experiential learning, the pharmacists reported improved counseling skills and increased understanding of the roles of different healthcare members. Their knowledge and confidence in managing diabetic patients was improved (P = .008). All participants passed the exit assessment. In general, the preceptors were satisfied with the program design, assessment content, and participant performance.

DISCUSSION

The overall view of DIAMANTE appeared positive. The program also improved knowledge and confidence of the participants in managing diabetic patients.

Impact of the Diabetes Inpatient Care and Education (DICE) project and the DICE Care Pathway on patient outcomes and trainee doctor's knowledge and confidence

AIM

To evaluate the impact of the Diabetes Inpatient Care and Education project and a comprehensive diabetes care pathway, the Diabetes Inpatient Care and Education Care Pathway, on patient outcomes and on the knowledge and confidence of trainee doctors.

METHODS

The effect on patient outcomes was evaluated by comparing the National Diabetes Inpatient Audit data before (2012) and after (2013) implementing the Diabetes Inpatient Care and Education project. The impact on trainee doctors was evaluated using the Modified Kirkpatrick model. Just before the project began and again 3 months later, trainee doctors were surveyed to assess their knowledge and confidence in inpatient diabetes care.

RESULTS

Patient harm was found to have been reduced significantly when National Diabetes Inpatient Audit data for 2012 and 2013 were compared. Severe hypoglycaemia decreased from 15.4 to 9.7%, medication errors from 56.9 to 21.1% and insulin errors from 31 to 7%. Across the 96 trainee doctors surveyed, the mean (sd) knowledge and confidence scores increased significantly (P < 0.001 for both) from 57.1 (16.8) and 61.8 (14.9) to 68.4 (13.3) and 74.3 (11.7), respectively.

CONCLUSION

The Diabetes Inpatient Care and Education project and the Diabetes Inpatient Care and Education Care Pathway improved patient outcomes and the knowledge and confidence of trainee doctors in this hospital. The impact of a similar project in other hospitals needs to be evaluated.

Tides of change: improving glucometrics in a large multihospital health care system

BACKGROUND

This study explores the relationship between education for inpatient diabetes providers and the utilization of insulin order sets, inpatient glucometrics, and length of stay in a large health care system.

METHODS

The study included patients with and without the diagnosis of diabetes. An education campaign included provider-directed diabetes education administered via online learning modules and in-person presentations by trained individuals. Relationships among provider-attended diabetes education, order set usage, and inpatient glucometrics (hypo- and hyperglycemia) were analyzed, as well as length of stay.

RESULTS

Insulin use knowledge scores for all providers averaged 52%, and improved significantly to 93% (P < .001) by the end of the education intervention period. Likewise utilization of electronic basal-bolus order sets increased from a baseline of 20% for patients receiving insulin to 86% within 6 weeks (P < .01) of introduction of order sets. During the study, the incidence of hypoglycemia and hyperglycemia declined from 1.47% to 1.27% and from 23.21% to 17.80%, respectively. However, these improvements were not sustained beyond the completion of the education campaign.

CONCLUSIONS

Education of diabetes health care providers was provided in a large, multihospital system through the use of online learning modules. Adoption of standardized insulin order sets was associated with an improvement in glucometrics. This educational and quality initiative resulted in overall improvements in insulin knowledge, adherence to recommended order sets, inpatient glucometrics, and patient length of stay. These improvements were not sustained, reinforcing the need for repeated educational interventions for those involved in providing inpatient diabetes care.

Improvement in inpatient glycemic care: pathways to quality

The management of inpatient hyperglycemia is a focus of quality improvement projects across many hospital systems while remaining a point of controversy among clinicians. The association of inpatient hyperglycemia with suboptimal hospital outcomes is accepted by clinical care teams; however, the clear benefits of targeting hyperglycemia as a mechanism to improve hospital outcomes remain contentious. Glycemic management is also frequently confused with efforts aimed at intensive glucose control, further adding to the confusion. Nonetheless, several regulatory agencies assign quality rankings based on attaining specified glycemic targets for selected groups of patients (Surgical Care Improvement Project (SCIP) measures). The current paper reviews the data supporting the benefits associated with inpatient glycemic control projects, the components of a successful glycemic control intervention, and utilization of the electronic medical record in implementing an inpatient glycemic control project.