Methods
Baseline measurement
We chose one of the HHCS four districts for piloting our project. There were 250 patients in this district out of which 150 patients were known diabetics. We wanted to monitor compliance to the eight parameters suggested by American Diabetes Association for improved diabetes care. All patients who were bed bound were excluded. This was due to logistical issues such as difficulty in arranging transportation for an eye clinic visit. Thirty patient files were randomly selected and reviewed from one district for monitoring of HbA1c, LDL, urine microalbumin, creatinine, eye examination, foot examination, weight and BP. Only 3% of the patients had all eight parameters checked for monitoring of diabetic complications in the last 1 year. Compliance with parameters in testing for microalbuminuria, eye examination, foot examination and HbA1c were 10%, 16%, 43% and 53%, respectively (figure 1).
Figure 1Monitoring for diabetic complications in home care baseline data. HbA1c, haemoglobin A1c; LDL, low-density lipoprotein.
A questionnaire was created to assess the baseline knowledge of the HCWs for monitoring of diabetic patients in home care. It was administered to 40 staff nurses from the same district as well as all 5 physicians in HHCS (figure 2). Out of the 40 staff nurses interviewed, 3% knew about the foot examination, 5% about renal function testing, 23% about yearly cholesterol screening, 30% about urine protein testing and 46% about HbA1c monitoring for diabetic patients.
Figure 2Healthcare workers’ knowledge of monitoring of diabetic parameters. HbA1c, haemoglobin A1c; HCW, healthcare worker; LDL, low-density lipoprotein.
Chart review of the randomly selected patients and Pareto analysis (figure 3) showed that the tests that were most frequently not done were urine protein, eye examination and foot examination. The Pareto analysis showed that urine protein testing and eye examination alone accounted for more than 75% of the tests not being done. Although there was some awareness about the need to check for proteinuria, it was not being routinely done. We found that parameters such as weight, LDL cholesterol, creatinine and BP were being monitored more consistently.
Figure 3Pareto analysis of monitored diabetic parameters in home care. BP, blood pressure; HbA1c, haemoglobin A1c; LDL, low-density lipoprotein.
Design
A project team was formed consisting of two physicians, one dietician, one clinical pharmacist, one nurse case manager and one quality reviewer from home care. Checklists for diabetes monitoring were used in various aspects of diabetes care, such as to monitor diabetic wound healing,4 improve adherence to diabetes care monitoring guidelines by physicians5 6 and provide guidance for self management.7 We planned to explore the idea of using a checklist for optimising diabetes care delivery through home care. A checklist (see online supplementary appendices 1 and 2) was created based on recommended screening guidelines,3 which included the following parameters: glycosylated haemoglobin, LDL cholesterol, urine microalbumin, creatinine, eye examination, foot examination and weight. Before using the checklist, many of the parameters were not being ordered and at times missed out completely.
Educational sessions were conducted for all HCWs. These addressed in general the implementation of the checklist and the parameters used in it. Focus was given to the areas where staff knowledge was deficient, such as foot examination, and on tests that were not being implemented despite sufficient knowledge, such as checking for proteinuria.
After the educational sessions, the nursing staff were assigned responsibility for completing the checklist, as they are at the frontline of care. They would review all parameters on the checklist, and if any parameter was not being monitored, they would make sure the appropriate tests and referrals were ordered and followed-up on.
The checklist was then piloted on the 150 diabetic patients in one district.
Strategy
The initial aim was to increase the percentage of elderly patients monitored for all diabetic complications in Home Healthcare (one district) from 3% to 30% by the end of December 2013. The rate of checklist completion was monitored as a process measure. The percentage compliance of monitoring for the six parameters to screen for complications was the outcome measure. Although we attained a checklist completion rate of 30% by the end of this time, there were still some parameters that were not being monitored.
From January 2014, the project was spread to all districts. Data were collected quarterly to give time to adjust to the new process and changes made.
PDSA cycle 1
PLAN: By implementing a checklist, diabetic patients will be monitored for parameters such as HBA1c, LDL cholesterol, kidney function, among others, as routine part of diabetes care to prevent complications.
DO: All nurses in the pilot district were educated on the use of the checklist. Nurses, as the primary caregivers, were responsible for implementing the checklist.
STUDY: Files of diabetic patients in three districts were selected randomly (n=70). The checklist completion rate improved from 0% to 36% in 3 months.
ACT: As the project seemed to improve diabetes monitoring, the decision was made to implement the change in all four districts. However, despite initial improvement in checklist completion rate, some parameters were not being monitored. Also, there seemed to be a drop in checklist completion rate in later months.
A major reason was felt to be family reluctance and concerns about new tests.
PDSA cycle 2
PLAN: To improve compliance to the parameters in the checklist that were least addressed.
DO: Feedback was provided about the results of the initial data collection and the tests that were missing. Importance was given to increasing awareness of family members regarding diabetes complications and prevention and the need to do specific tests such as eye examination, foot examination and urine protein testing. Focus would be given to addressing family concerns. Steps were taken to streamline the referral process. We provided ongoing educational sessions to the HCWs.
STUDY: Audit from all districts at the end of second quarter, which showed improved compliance to 68%. However, third and fourth quarter results were again disappointing with compliance of 36% and 41%, respectively.
ACT: On the basis of the feedback from the multidisciplinary team, we found that a major reason for fall in compliance was due to staff rotation and increased staff turnover. There was a need to establish guidelines as a resource for staff, to ensure sustainability.
PDSA cycle 3
PLAN: Developing diabetes monitoring guidelines specific to home care will improve compliance with checklist completion.(see online supplementary appendix 3 for Diabetes Guidelines).
DO: On the basis of the international guidelines for similar patients, guidelines were written for home care patients with specific categories including, healthy, complex and very complex diabetic patients. The checklist was revised to include these changes. Nurses were informed on the change in all districts. This took some time, during which there was no data collection.
STUDY: Data collection resumed in fourth quarter of 2015. There was an improvement in monitoring of all parameters, most significantly in the eye examination and urine protein testing. Details are presented in the Results section.