In a healthcare facility environment, as nurses are in consistent contact with patients, family, and other health care providers, they are often the first professional to note, be notified, or even to offer with any unexpected changes with their patients. Hence, taking the initiative to start appropriate treatments regularly is essential. Yet, scheduled to rigorous practice standards and polices, nurses are limited to initiate some treatments, in particular when medication is included, even in disaster situations. Nurses frequently have to await medical personnel's diagnosis and/or instructions prior to taking any actions even in conditions they can handle treating, such as hypoglycemia. If hypoglycemia is not cured regularly, it may lead to fatal patient results. Therefore, the practice of delaying patients' treatment to wait for medical personnel's response and instructions should be modified. When hypoglycemia is detected, you should definitely contraindicated, nurses should start treatments, including supervision of dextrosol tablets, intravenous dextrose and subcutaneous glucagon. In the following paragraphs, the rationales for nurse initiated hypoglycemia treatment (NIHT), and tactical and evaluation strategies to use such practice will be mentioned.
A. The rationales for NIHT
According to Anthony (2008), hypoglycemia is defined as blood sugar (BG) level significantly less than 70mg/dL. It frequently occurs among hospitalized patients, specifically for those with Diabetes Mellitus. Dinardo et al. (2002) found about 700 shows of hypoglycemia per month at a school clinic; and Kresevic and Slavin (1989) found forty-six shows of hypoglycemia among thirteen hospitalized diabetic patients. In-hospital hypoglycemia may be induced by decreased calorie intake, sudden interruption of tube feeds, missed meals, medications, nil orally status, etc. Depending on the severity, the signs and symptoms of hypoglycemia vary. For moderate to modest hypoglycemia, a person can be asymptomatic or may present with distressing symptoms such as sweating, trembling, food cravings, and lightheadedness (Franz, 2003). For severe hypoglycemia, misunderstanding, convulsions and coma may occur (Boyle & Zrebiec, 2007). Egi et al. (2010) found "the more serious the hypoglycemia, the greater the risk of fatality" (p. 217). If the procedure for a mildly or reasonably hypoglycemic patient is delayed, severe hypoglycemia may end result leading to convulsions and/or coma resulting in potential brain damage and even fatality. Therefore, mild or moderate hypoglycemia should not be tolerated (Egi et al. , 2010). As nurses tend to be the first healthcare providers to be easily available in the hospital and can handle treating hypoglycemia, they should initiate treatment to avoid further deterioration and/or irreversible damages to hypoglycemic patients somewhat than waiting for medical personnel's instructions.
Numerous studies, done in several hospital wards, possessed shown hypoglycemia's relationship with an increase of mortality and length of medical center stay (LOHS). Turchin et al. (2009) found that hypoglycemia is associated with an increased LOHS and higher mortality rate both during and after entrance for patients with diabetes; and Kagansky et al. (2003) discovered that not only was hypoglycemia common among hospitalized older patients, but also forecasted increased cumulative mortality for inpatients at three and six months. This further facilitates the importance of treating in-hospital hypoglycemia promptly. When nurses aren't restricted to start treatments, the risk for patients progressing to an increased amount of hypoglycemia can be reduced. Thus, decreased patient mortality and LOHS may result. Furthermore, aggressive detection and management of hypoglycemia was found to be associated with cost savings for inpatients with diabetes (Songer et al. , 2007), less medical professional time use, reduced LOHS, and better glycemic control (Korytkowski, 2007). Therefore, NIHT will probably be worth buying as it contributes to favorable patient final result and, at exactly the same time, decreases healthcare cost.
Additionally, Smith et al. (2005) found insufficient prescribing is linked to hyperglycemia and hypoglycemia in medical and operative wards. Medical professionals who are inexperienced in treating hypoglycemia may prescribe limited dosing of medications and/or diet in treating hypoglycemia. Because of this, a patient's hypoglycemic status may be long term leading to unfavorable effects. If all nurses, and, of course, doctors, are educated to take care of hypoglycemia correctly, the occurrence of under-treatment can be minimized. In fact, once nurses' knowledge in the treatment of hypoglycemia is assured, they should be allowed to start treatment so that hypoglycemia can be reversed effectively and the concerns of inadequate prescribing can be minimized.
Lastly, hypoglycemia, no matter its severeness, is a fairly straightforward condition to control (Boyle & Zrebiec, 2007). Patients with diabetes or their family members often take care of hypoglycemia outside the hospital environment, even in disaster situations. If a hypoglycemic person is mindful, management may only entail the supervision of oral glucose. Obviously, nurses or anyone without appropriate training are capable of providing such treatment. For more severe cases, the supervision of intravenous dextrose or subcutaneous glucagon may be involved. When beyond your hospital, diabetics may carry a glucagon crisis kit that can be used by a person with minimal training to manage severe hypoglycemia. When non health care providers are permitted to start treatment of hypoglycemia, nurses, who've sufficient understanding of hypoglycemia and other medical problems, shouldn't be constrained in initiating such treatment.
B. Plan to implement NIHT
The procedure for implementing NIHT, including the supervision of subcutaneous glucagon, intravenous dextrose and dextrosol tablets without physician's order, requires comprehensive planning. Before this change is suggested, one must examine the organization's readiness for change and discover the main element players included (Dulaney & Stanley, 2005). If there are currently other changes taking place for those who will be putting into action NIHT, the business and its nursing staff may be less open and more hesitant to adopt additional changes, even if it's regarded as best practice. Thus, putting into action the change at the right timing and place is important. The outcome of NIHT may be less advantageous when it's implemented by workers who are already overcome by other changes. Regarding to Dulaney and Stanley (2005), an "effective change agent should research potential driving a vehicle and restraining forces that will impact the proposed change" (p. 163). These makes must be well looked into before NIHT is proposed to prepare one in addressing any foreseeable issues.
One of the major causes to research is the estimated cost for NIHT. Practice change within an organization can be expensive. Staff members will need to spend additional hours in training and conversation regarding NIHT; new documents will need to be published when practice criteria are modified; and new materials or instruments may be purchased. Money may not remain designed for an organization to adopt new change so one must be prepared to seek sponsorship and support. Hence, one should seek for funding from beyond your organization to pay the expenses of NIHT before its execution.
To ensure the security of NIHT, a hypoglycemia treatment protocol (HTP) will be developed. HTP is designed to enhance the quality of treatment for inpatient with hypoglycemia and to prevent deterioration from moderate to severe hypoglycemia. It will clearly specify nurses' role in this particular new practice, and direct them towards utilizing the practice properly. One should talk to endocrinologists, diabetic nurse specialists, dieticians, and experts from another firm that had implemented NIHT when expanding HTP in an attempt to increase the credibility of the process. HTP, for example, should evidently define the kind of treatment to start depending on the specific BG level, patient's degree of consciousness and consumption position; any contraindications that nurses should look for; the approved activities for registered and enrolled nurse; the total amount and path of carbohydrate or medication to administer for the precise selection of BG; the occurrence of monitoring after treatment, etc.
Furthermore, data collection regarding the effectiveness, problems, and cost of the existing in-hospital hypoglycemia treatment will be performed. These data will be compared to the expected costs and advantages of NIHT. Previous researches on NIHT and data from other organizations that acquired implemented NIHT will be accumulated. These data, as well as HTP, will be provided to the business as well as the nurse regulatory body and the section of health. Since NIHT consists of increasing the scope of practice for nurses, the federal government and nurse regulatory body will need to be engaged. The benchmarks of nursing may need to be modified and strict practice guideline for NIHT will need to be developed to ensure the protection of such practice change.
Once a federal act is in place, the next step will be choosing the appropriate setting to execute NIHT. NIHT will be piloted in an inpatient team, for example, general medical and vascular surgery unit which tend to have a higher range of patients with Diabetes Mellitus, and for that reason, higher prevalence of hypoglycemia. After the pilot analysis is completed and given that NIHT is shown to be safe and beneficial, it will be unveiled to other departments of the institution gradually, with or without revision of the HTP.
Prior to utilizing NIHT, in-hospital education regarding HTP and hypoglycemia will be provided, and other healthcare providers will be informed about nurses' new range of practice. When all nursing personnel is educated, HTP will need effect. Resources involved with NIHT will be produced easily accessible in the taking part ward, and the NIHT project associates will be made available around the clock to provide continuous support, encouragement and advice.
C. Obstacles to apply NIHT
The process of putting into action NIHT will be very challenging as "resistance to change is often a natural reaction for all of us" (Gardner, 2009, p. 420). Workers may be tolerant as NIHT will change them away from their standard practice or comfort zone. "When change occurs, the old way of doing things concludes; the sense of grief and reduction that goes with this change must be acknowledged, and support must be wanted to those who find themselves afflicted" (Dulaney & Stanley, 2005, p. 164). Therefore, it is essential to provide ongoing support and guidance to assist personnel in adopting the new way of treating hypoglycemia. As nurses become more acquainted with NIHT and HTP, the level of resistance may diminish over time. Apart from the staff members putting into action NIHT, it is equally important to keep the customers of the NIHT job team encouraged and enthusiastic. Any negative attitudes may impact the change adversely leading to less favorable final results.
Another challenge that one may face is obtaining an endorsement from the nurse regulatory body and the federal government. As NIHT requires increasing the scope of practice for nurses, the federal government and nurse regulatory body need to weigh its advantages against down sides when implemented. Other than research evidence, holds from other health care providers, especially medical doctors, will be helpful. As NIHT consists of nurses to recommend, voices of medical doctors helping the practice will be convincing. When medical doctors, who are the authorized employees to suggest medications, are also in support of NIHT, public concerns may be minimized. However, obtaining support from medical doctors together may be an even greater challenge. Some medical professionals may have a lack of self confidence in nurse prescribing, doubting nurses' competency, and some may view NIHT as an intrusion to their own practice. Hence, nurses need to show their potential and competency in their day-to-day practice to get trust in other healthcare providers.
Finally, staff's lack of adherence to HTP may be another challenge. A report completed by Anthony (2007) in a clinic that had applied a treatment protocol very much like HTP reported a minimal adherence to practice guideline. Personnel may overlook the guide for various reasons, for cases, lack of knowledge and familiarity with the new treatment standard protocol, lack of time, or misbelieve that the old ways of doing things is still acceptable. Hence, enough education and ongoing support of HTP is essential to assist personnel in moving for the new practice as well as sustaining the move.
C. Analyzing the efficiency and cost-effectiveness of NIHT
The seeks of NIHT are to improve patient end result after severe hypoglycemic episode(s) and at exactly the same time reduce clinic cost. The analysis of NIHT will give attention to the efficacy and cost-effectiveness of such practice change. The evaluation depends on the Cost-Effectiveness Analysis (CEA) with an objective to compare the efficiency and cost-effectiveness of NIHT versus physician initiated or instructed hypoglycemia treatment (PIHT). The test of this review includes patients older sixteen and above who possessed experienced at least one episode of hypoglycemia throughout their hospitalization in two hospital wards with high prevalence of hypoglycemia. NIHT will be integrated in a single ward, and the other ward will continue its typical practice of PIHT, where no practice change is required. The study will last for twelve months to allow someone to record all relevant data and the NIHT job team will monitor and evaluate the efficiency of both interventions.
The costs related to both interventions will be assessed and likened. For NIHT, it involves the use of nurses' time to receive training and also to treat and keep an eye on patients with hypoglycemia, use of educator's time for coaching, and use of NIHT task team's time while on call around the clock. On the other hand, PIHT involves the use of physicians' time for ordering and/or initiating treatment, and the use of nurses' time for calling physicians and/or applying physician's order. One also needs to are the physician's time used when NIHT is contraindicated or if it does not reverse hypoglycemia in the end identified interventions are implemented. The number of cases which NIHT fails or is contraindicated must be obviously saved with reason(s) for failing or contraindication. The expense of medical professional after NIHT fails may also be estimated and contained in calculating the cost for NIHT.
The resources used for both interventions may also be measured. A few of these resources include medications, syringes, intravenous lines, glucometer, food and drinks, etc. The quantity of use and the cost for these resources will be likened. From these data, one can identify any treatment dissimilarities between PIHT and NIHT and also to estimate the total cost for every single intervention. Finally, with other data like the average period to reverse hypoglycemia, one can compare the cost and success of both interventions and identify any inadequate and inconsistent treatment and/or lack of adherence to HTP.
As mentioned above, the average time needed for NIHT and PIHT to assist hypoglycemic patients to restore a normal BG level will be assessed. Enough time will be assessed from the original recognition of hypoglycemia to whenever a normal BG level is sustained after the recommended monitoring is completed. Patients will be categorised into mildly, reasonably, or significantly hypoglycemic according with their initially diagnosed BG level. The amount of instances which patients improvement to an increased amount of hypoglycemia will be noted. This dimension allows one to regulate how effectively and efficiently NIHT and PIHT treat hypoglycemia.
Health related results such as LOHS and mortality rate will be compared. Although LOHS and mortality rate may be affected by many other factors, measurement of these outcomes allows one to determine whether NIHT and PIHT affect these factors independently. In fact, these factors may represent patients' health end result after the interventions. For LOHS, the trouble of a business will be reflected, for example, a lot more days an individual stays in a healthcare facility the higher the expense will be. Hence, LOHS is assessed to compare the cost-effectiveness of the two interventions. To avoid inaccurate findings, you need to pay special attention to age the study test and any underlying co-morbidities to eliminate their influence on mortality rate and LOHS. For patients with extreme old and/or co-morbidities, their conditions should be analyzed carefully and, if possible, to be excluded in the sample.
Lastly, patient and staff satisfaction will be assessed. A straightforward questionnaire will get to, when possible, all patients and staff who had experienced or carried out NIHT and PIHT. The questionnaire will look at patients' and staff's belief of and satisfaction with both interventions. When expanding the questionnaire, one must consider that hospitalized patients are of different intellectual level, education background, and cognitive potential. One should keep carefully the articles of the questionnaire simple and easily comprehensible normally these may yield inaccurate results when patients and staff misinterpret or don't realize the presented questions. The questionnaire also needs to not be too much time as staff, who will tend to be busy at the job, and patients, whose health will tend to be jeopardized, may be unwilling or unable to complete. This, in truth, will also lead to inaccurate studies.
When executing the evaluation for NIHT and PIHT, one needs to keep in brain the results from PIHT group do not symbolize the potency of PIHT for all the areas. Doctors that are of different area of expertise and education backdrop will have variable experiences and understanding of hypoglycemia and therefore, may lead to variable results. Based on the evaluation results from PIHT, one can identify medical professionals' knowledge on the treatment for hypoglycemia only in the particular ward. Furthermore, one must consider whether a year will do for collecting all essential data. If insufficient data is accepted, one may need to extend the time for the study as limited data may deliver inaccurate results. Additionally, estimating the time for NIHT and PIHT in reversing hypoglycemia will be very challenging and is also, in fact, prone to error. Such estimation depends on nurses' and health professionals' charting and/or do it yourself reporting, and for that reason is prone to mistake if data are not recorded accurately or if staff misinterpret the described timeframe to assess.
Hypoglycemia, when not treated in a timely manner, can lead to life-threatening implications. With adequate information and education, nurses are more than capable of treating such uncomplicated condition. However, implementing NIHT is not easy and may be very frustrating and challenging. One must be very patient as enough time needs to be spent in planning and fighting with each other for such change. Though treating hypoglycemia successfully with appropriate treatment is important, this problem is most beneficial to be prevented. With the target in primary health care in recent years, patient education on hypoglycemia should be marketed at the same time as NIHT being executed.