Implementation of Glycemic Management Guideline: A Multidisciplinary Quality Improvement Initiative for Patients with...

Patients with diabetes receiving bolus enteral feeding are at risk of glycemic variability due to inconsistent timing of capillary blood glucose (CBG) monitoring and insulin administration. Variations in inpatient practices contribute to episodes of hyperglycemia, hypoglycemia, increased healthcare costs, and patient discomfort.

To standardize glycemic management practices through implementation of a multidisciplinary guideline aligning CBG monitoring and insulin administration with enteral feeding schedules and evaluate its effectiveness across pilot and scale-up phases.

A multidisciplinary initiative was conducted in a tertiary hospital. A 3-month pilot across two wards involving 30 patients in the pre- and post- implementation periods was followed by a 2-month scale-up across five additional wards involving 40 patients in the pre- and post- implementation periods. Root cause analysis using fishbone diagram identified inconsistent feeding schedule, inconsistent CBG monitoring practices, and unclear protocols as key contributors to variability in care delivery. Interventions included standardized guideline, structured education, visual workflow aids, and train-the-trainer model. Pre- and post-implementation data were collected to evaluate changes in clinical practices and outcomes.

In the pilot phase, CBG reading per 100 patient-days decreased by 22%, with improvements in pre-feed CBG monitoring (59% to 68%) and pre-feed insulin administration (54% to 71%). During the scale-up phase, CBG monitoring per 100 patient-days decreased by 29.4%. Hyperglycemia decreased from 37.1% to 32.3%, while normoglycemia increased from 61.9% to 66.1%. Pre-feed CBG monitoring improved from 72% to 79%, and pre-feed insulin administration increased from 53% to 73%. Nurses' confidence in scheduling pre-feeding CBG monitoring and insulin administration also improved.

Implementation of a standardized multidisciplinary glycemic management guideline can improve workflow consistency, glycemic outcomes, nurses' confidence, and resource utilization across multiple wards. These findings support the feasibility and scalability of the implementation model for standardizing glycemic management in hospitalized patients receiving bolus enteral feeding.