International Journal of Healthcare Simulation

Background:

Even in the presence of established institutional guidelines, failure of compliance by the clinical teams plays an important role in the control of diabetes. The identified gaps include contextual and biomedical knowledge, attitudes, clinical inertia, confidence and familiarity with existing hospital resources and guidelines with regards to hospital diabetes care ^[1].

Aim:

We wanted to demonstrate the efficacy of low-dose high-frequency in situ simulation exercises through a pilot study in a ward setting to improve outcomes in patients with diabetes.

Simulation activity outline:

The exercise was a 15-minute session, delivered during working hours to individual nurses. This consisted of a 5-minute scenario, involving a standardized patient followed by a 10-minute debrief. Modified Diamond-model debrief with an advocacy-inquiry model was used by the debriefer, a trained fellow in simulation, and overseen by an expert. The scripted scenario involved a patient with Diabetic Ketoacidosis (DKA), with learning outcomes of recognizing DKA, managing the patient and adhering to the institutional guidelines including management of hypoglycaemia. The scenario was individualized based on the roles of the participants. Pre- and post-questionnaires were given to the participants. The simulation was repeated twice in the second week and once in the third week.

Methodology:

This mixed-method study was conducted in a UK teaching hospital, in a ward designated for patients with diabetes, as a part of a quality improvement programme. In the first week, patients with diabetes, admitted for DKA, were chosen and their blood sugar recordings, dysglycaemic episodes and adherence to guidelines were noted. Every week data were collected as in the first week. GNU pspp 1.0.1 [version 3] free software was used. The confidence scores were given as mean and standard deviation with confidence interval (CI) of 98.75%. A p-value of <0.0125 was considered significant based on the number of data points.

Results:

The in situ simulation was delivered to a total of nine ward staff. There was a significant improvement in the confidence levels at the end of the session. The number of blood sugar recordings were 1.4 per person-days in the first week, 2.07 in the second week and 3.6 in the third week (Table 1). Hypoglycaemic episodes correctly identified were 4.76%, 6.9% and 14.29% in the 3 weeks, respectively. Sugars >14 mmol/L were identified 28.57%, 37.93% and 57.14%, respectively, for the 3 weeks. Qualitative analysis showed protocol adherence issues and latent medication errors in addition to positive changes with regards to handover and diagnosis of hypoglycaemia.

Table 1:

Dysglycemic episodes and protocol adherence from medical records

Week	Age/ Sex	Patient	Days	Number of sampling	hypoglycaemic episodes	hyperglycaemic episodes	Treatment for hypoglycaemia as per protocol	Protocol adherence once sampled
1	40/F	1	5	9	1	3	No	Yes
	28/F	2	4	5	0	2	NA	No
	29/F	3	3	3	0	1	NA	No
	71/M	4	3	4	0	0	NA	No
2	64/M	5	2	3	0	0	NA	No
	72/M	6	6	18	0	10	NA	No
	31/F	7	2	3	1	0	No	Yes
	70/M	8	3	3	0	1	NA	No
	73/M	9	1	2	1	0	Yes	No
3	39/F	10	2	7	1	3	Yes	Yes
	68/M	11	2	6	0	0	NA	Yes
	77/M	12	4	15	3	5	Yes	Yes
	30/F	13	2	8	0	8	NA	Yes

Implication for practice:

Considering the T2 (increased recognition of diabetic emergencies and adherence to protocol) and T3 (improved patient outcomes) outcomes, the methodology was recommended as a modality of training the nursing staff involved in inpatient care of patients with diabetes. Future programmes including multi-disciplinary teams, to explore teamwork and communication, are planned.