on glycemic control, with five-fold more hyperglycemia with
delayed insulin administration compared with administration
Recent work from our institution on barriers and facilitators
for the implementation of BBIT in demonstrated that nursing staff
identified the coordination of blood glucose testing and insulin
delivery with meals as a major barrier to diabetes management.
Thus, as a first step in addressing these barriers, the objective of
this quality improvement study was to examine the practice of
inpatient prandial insulin delivery from the nursing perspective
to identify care gaps affecting the optimal timing of prandial
insulin administration through process mapping.
We developed a process map depicting the steps and gaps
in prandial insulin administration on the inpatient internal
medicine unit. Process mapping is a quality improvement tool
that uses visual illustrations to represent the steps, events, and
operations that constitute a complete process.
is commonly used to describe interdisciplinary processes with
multiple, complicated steps performed by a variety of healthcare
Once established, a process map can identify
variation in delivery of care, care gaps, redundancies, and areas
Given that inpatient prandial insulin delivery
is a complex process involving coordination of multiple steps and
interdisciplinary roles, process mapping is a pragmatic method
to comprehensively describe this complex practice.
To create the process map, two team members (KL and SR)
directly observed nine registered nurses on an acute inpatient medicine
unit over a two-day period which included three meals. First, the
unit charge nurse identified bedside nurses caring for patients who
required prandial insulin. Second, these nurses were approached
by a study team member (KL or SR) and invited to participate.
Eligible nurses were informed that the goal of the observation was
to identify the steps in prandial insulin administration as part of a
quality improvement initiative. Third, among participating nurses,
each step of prandial insulin administration was recorded by the
observer and annotated with a time, location, and other relevant
details. Insulin orders were reviewed for all participating nurses.
Fourth, to cover all interdisciplinary team members involved
in prandial insulin administration, we conducted open-ended
interviews with representatives from pharmacy and food services
to understand their roles in this process. Fifth, the arrival of meal
trays on the inpatient internal medicine unit was recorded by the
unit clerk for each meal.
Finally, to characterize care gaps in prandial insulin
administration identified by the process map, one-on-one
interviews were conducted with five nurses who did not participate
in the observation phase. Interview participants were recruited
using a snowball sampling technique.
Nurses were provided
with the process map and asked to comment on each step. Nurse
responses were transcribed in real time.
This project received approval from ARECCI (A pRoject
Ethics Community Consensus Initiative) through Alberta
Innovates prior to initiation as it was assessed as a low-risk
quality improvement project.
The insulin delivery process map identified important variability
in the practice of prandial insulin administration (Figure 1).
Most notably, prandial insulin was often administered after the
patient had begun eating and occasionally after the meal was
completed, regardless of the type of insulin used. Further, there
were no observed differences in the timing of administration
of short-acting or rapid-acting insulins. Importantly, during
the observation period, there were no instances where prandial
short-acting insulin was administered 30 minutes prior to a meal
as specifically ordered by physicians.
Barriers to correct timing of short-acting insulin were
explored using narrative interviews with registered nurses from
the internal medicine inpatient unit. Transcription of common
nursing responses to the discrepancy in timing between physician
orders and real practice is provided in Table 1. The predominant
themes identified were nursing concerns of patient safety (i.e.,
hypoglycemia) and variability in meal delivery. All five nurses
uniformly described an inability to predict meal tray arrival as
a barrier to coordination of insulin delivery with meals. The
majority of nurses reported that it was “unsafe” to deliver any
formulation of insulin before a patient began eating his or her
meal due to the unpredictability of meal tray delivery or patient
factors that would preclude eating (e.g., nausea and vomiting),
thus putting the patient at risk for hypoglycemia. All nurses
interviewed were aware of the physician orders for different
timing of pre-meal insulin administration between short- and
Assessment of meal tray delivery timing on the internal
medicine inpatient unit revealed that meal tray arrival was, in
fact, consistent over a two-week period. Breakfast was delivered
at a mean of 8:46 a.m. (standard deviation [SD] 5 minutes), lunch
at a mean of 12:46 p.m. (SD 7 minutes) and dinner at a mean of
17:56 p.m. (SD 8 minutes).
Coordination of prandial insulin delivery with meals in hospital
is complex. Mismatches between insulin dosing and mealtimes
exposes patients to increased risk of hyperglycemia,
is associated with adverse outcomes.
Observation of prandial
insulin administration on our inpatient internal medicine unit
Canadian Journal of General Internal Medicine
38 Volume 14, Issue 3, 2019