CNESERIES. Instructions for Contniuing Nt4rsiiiJ! Education Eontact Houraap&Won page 254

Use of a Clinical Decision SupportSystem to Improve Hypoglycemia

ManagementRoberta L Harrison, 5on/o L Stalker, Rochelle Henderson, and Frank Lyeria

Currently, over 10.9 millionU.S. residents age 65 or olderhave a diagnosis of diabetes.An estimated 79 million U.S. resi-dents age 20 or older have pre-dia-betes (Centers for Disease Controland Prevention [CDC], 2011). In theUnited States, diabetes remains the7th leading cause of death. Seriouscomplications also are associatedwith diabetes, including heart dis-ease, kidney failure, vision loss, andamputation (CDC, 2011). A currentdebate centers on whether practi-tioners should enforce stringentglycmie control. A recent meta-analysis (Murad et al, 2012) foundstringent glycmie control carries anincreased risk of hypoglycemia.Therefore, one of the concernsaround stringent blood glucose con-trol is the increased risk for hypo-glycmie events. In the hospital set-ting, paper-based guidelines oftenpromote normal blood glucose.However, adherence to the paper-based hypoglycemia treatment guide-lines has been poor (Maynard,Huynh, & Renvall, 2008).

In this study, the research teamimplemented a nursing clinical deci-sion support system (CDSS) in theform of electronic hypoglycemiamanagement guideline advice.Interactive guidelines were embed-ded within the nursing documenta-tion section of the electronic healthrecord (EHR). The primary purposewas to improve nursing adherence tohypoglycemia management guide-lines and improve compliance track-ing. The secondary purpose was todetermine the impact of change ofwork shift on guideline adherence.

The number of persons with diabetes who enter the health care sys-tem continues to grow. Stringent glycmie management increasesthe risk for hypoglycemia. The use of a clinical decision support sys-tem to assist nurses in treating hypoglycemia accurately may beuseful in improving adherence to specific hypoglycemia manage-ment guidelines and compliance tracking.

Review of the Literature

HypoglycemiaHypoglycemia is defined as blood

glucose of less than 70 mg/dL(Pagana & Pagana, 2010). In the hos-pitalized patient, hypoglycemia isassociated with adverse drug reac-tions, decreased caloric intake, fail-ure to adjust medications that lowerblood glucose, and missing mealsdue to diagnostic testing requiringthe patient to be away from the unit(Anthony, 2007). More than 4O'K) ofpatients experiencing one hypo-glycmie episode will experience asecond episode during the same hos-pitalization (Maynard et al., 2008).

GuidelinesGuidelines to manage hypogly-

cmie episodes have been developedto allow nurses to intervene immedi-ately without having to contact the

physician first. Nurses who continueto use the paper-based guidelinesinternalize a process and no longerreview the document but ratherrely on memory (Rycroft-Malone,Fontenia, Seers, & Bick, 2009). Inaddition, these guidelines typicallyare housed in policy and proceduremanuals; as a result, nursing utiliza-tion and documentation have beensub-optimal. In a study examiningnursing adherence to practice guide-lines, Anthony (2007) found nurseshad poor compliance with paper-based hypoglycemia treatmentguidelines. In this descriptive study,210 retrospective medical recordreviews were completed; not onerecord was compliant with allrequirements in the practice guide-line. One proposed solution to thisproblem is to embed guidelineswithin the nursing documentationsection of a patient's EHR.

Roberta L. Harrison, PhD, RN, is Associate Professor, Southern Illinois University-Edwardsville, School of Nursing, Edwardsville, IL.

Sonia L. Stalker, MSN, CDE, APN-BC, is Diabetes Specialist, Anderson Hospital, Maryville, IL.

Rochelle Henderson, PhD, is Lecturer, Public Administration and Policy Analysis, SouthernIllinois University-Edwardsville, Edwardsville, IL.

Frank Lyeria, PhD, RN, is Associate Professor, School of Nursing, Southern Illinois University-Edwardsville, Edwardsville, IL.

Note: The authors received the AMSN Phillips Healthcare Research Grant for the researchreported in this article.

250 July-August 2013 Vol. 22/No. 4 M E D S U R GisTTjns I isra.

Use of a Clinical Decision Support System to Improve Hypoglycemia Management CNELyerla, LeRouge, Cooke, Turpin,

and Wilson (2010) developed aCDSS with an embedded protocol toimprove nursing adherence to guide-lines preventing ventilator-assistedpneumonia. The embedded protocolin the CDSS prompted the nurse toposition the angle of the bed correct-ly for ventilator-dependent patientsand document the angle in the clin-ical record. The study was completedin three phases, with 105 observa-tions of documentation and head-of-bed angles recorded at each phase.Participants included 42 patientsand 33 registered nurses. Adherenceto documentation and head-of-bedelevation was measured before inter-vention, 1-2 months after interven-tion, and 4-5 months after interven-tion. Significant improvements werenoted in protocol adherence at 1 and5 months after implementation.

In another study, Kwok, Dinh,Dinh, and Chu (2009) evaluated theuse of an asthma protocol embeddedinto clinical documentation. In thisstudy, 50 patients with asthma werecompared to a historical controlgroup of 50 patients with a dischargediagnosis of asthma. The 50 patientswith asthma who presented in theemergency department over a 6-month period were assessed byphysicians using the Asthma ClinicalAssessment Form and Electronicdecision support CDSS. Followingimplementation of the CDSS, themedical records of the study patientswere compared to a control group. Asignificant improvement in docu-mentation of key clinical parametersfor asthma management was notedin the study group.

Clinical Decision SupportSystem

An interactive guideline embed-ded within an electronic healthrecord is an example of a CDSS. Aclinical decision support system is acomputerized program utilized with-in the health care setting to supportdecision making. A nursing CDSS isused within the context of nursing tosupport nursing decision making.CDSS programs are based upon if-then rules that tell the computer whatactions to take given certain informa-tion (Kumar, Singh, & Sanyal, 2009).

Information is accessed and storedwithin the knowledge base compo-nent of the CDSS. CUnical decisionsupport systems often are used to gen-erate alerts, reminders, or advice.Information used and generated by aCDSS should be evidence based, cur-rent, and have the ability to be updat-ed. In this study, the diaberic educatorwas responsible for maintaining cur-rent evidence associated with hypo-glycemia management. As the man-agement standards changed, the dia-betic educator was charged to workwith programmers to ensure nurseshad access to current hypoglycemiamanagement guidelines.

Methods

study Design and SettingThe study took place at a small

community hospital in the Midwest.Approval from the hospital's institu-tional review board was obtainedprior to study iniriation. Subjectswere limited to hospitalized hypo-glycmie subjects over age 18.Patients who experienced blood glu-cose below 70 mg/dL but werereceiving intravenous (IV) insulinand following the IV insulin proto-col were excluded from the study asthe treatment protocol was differentfrom the hypoglycemia protocolused in this study. Using an inter-rupted time series design, three dif-ferent samples of 150 or more med-ical records of patients with diabeteswho had at least one incident ofblood glucose below 70 mg/dL werereviewed for hypoglycemia protocolimplementation and documenta-tion. The first review was completed6 months prior to implementing theintervention; the second review wascompleted 6 months followingimplementation; and the last reviewwas completed 7-12 months afterimplementation. The intent of thefinal review was to determine ifguideline adherence rates persistedover time.

InterventionThe purpose of this study was to

develop and integrate a nursingCDSS for managing hypoglycemiawithin the EHR to facilitate adher-

ence to the guideline. The CDSSinvolved a hypoglycmie manage-ment protocol embedded within theelectronic nursing documentationsection of the patient's EHR. TheCDSS was activated when a bloodglucose level of 70 mg/dl or lowerwas entered. The nurse then wouldbe asked a series of questions, eachone followed by advice in accor-dance with the programmed hypo-glycmie management guidelines.For example, an initial questionasked if the patient can swallow. Ifthe answer was "yes," oral glucosewould be included in the treatmentrecommendation. If the answer was"no," intravenous glucose would belisted as a recommended interven-tion. Additional information on thedevelopment and implementationof this CDSS is published elsewhere(Harrison & Lyeria, 2012).

Data CollectionReview of discharged electronic

health records was conducted forpatients who had a primary or sec-ondary diagnosis of diabetes ftomFebruary 2010 to August 2011. Adata collection tool was developedand used by the researchers. Bloodglucose documentation was re-viewed in each record for evidence ofhypoglycemia episodes (below 70mg/dL). Episodes occurring withinthe intensive care unit were exclud-ed because a different intravenousglucose protocol was utilized. Allepisodes and documented treat-ments were collected via the datacollection tool.

Testing/TrainingTen nurse volunteers tested the

initial CDSS prototype. Nurses wereprovided hypoglycemia scenariosand asked to follow the steps provid-ed by the CDSS. A debriefing sessionthen was held to gather feedback toguide changes regarding the se-quence of questions and associatedrecommendations. Once the finalversion of the CDSS had been identi-fied, a training manual and instruc-tional