Reports From the Field

Impact of Standardized Screening Protocols for Cystic Fibrosis–Related Diabetes in a Pediatric Population

Journal of Clinical Outcomes Management. 2015 August;22(8)

References

1. Moran A, Dunitz J, Nathan B, et al. Cystic fibrosis–related diabetes: current trends in prevalence, incidence, and mortality. Diabetes Care 2009;32:1626–31.

2. Cawood TJ, McKenna MJ, Gallagher CG, et al. Cystic fibrosis-related diabetes in adults. Ir Med J 2006;99:83–6.

3. Koch C, Rainisio M, Madessani U, et al. Investigators of the European Epidemiologic Registry of Cystic Fibrosis. Presence of cystic fibrosis-related diabetes mellitus tightly linked to poor lung function in patients with cystic fibrosis: data from the European Epidemiologic Registry of Cystic Fibrosis. Pediatr Pulmonol 2001;32:343–50.

4. Marshall BC, Butler SM, Stoddard M, et al. Epidemiology of cystic fibrosis-related diabetes. J Pediatr 2005;146:681–7.

5. Milla CE, Billings J, Moran A. Diabetes is associated with dramatically decreased survival in female but not male subjects with cystic fibrosis. Diabetes Care 2005;28:2141–4.

6. Lewis C, Blackman SM, Nelson A, et al. Diabetes-related mortality in adults with cystic fibrosis. Role of genotype and sex. Am J Respir Crit Care Med 2015;191:194–200.

7. Moran A, Brunzell C, Cohen, RC, et al. Clinical Care guidelines for cystic fibrosis–related diabetes. A position statement of the American Diabetes Association and a clinical practice guideline of the Cystic Fibrosis Foundation, endorsed by the Pediatric Endocrine Society. Diabetes Care 2010;33:2697–708.

8. Nash J, Messier R, Casella SJ, et al. Learning and Leadership Collaborative: CFRD. Cystic fibrosis related diabetes (CFRD) evidence-based practice and smart change idea compendium 2012. Bethesda, MD: Cystic Fibrosis Foundation; McLean, VA: Pediatric Endocrine Society; Lebanon, NH: Dartmouth Institute Microsystem Academy; May 2012.

9. WHO Expert Committee on Diabetes Mellitus: Second Report of the WHO Expert Committee on Diabetes Mellitus. Geneva: World Health Organization; 1980 (Tech. Rep. Ser no. 646).

10. Cystic Fibrosis Foundation, Dartmouth Medical School: Center for the Evaluative Clinical Sciences, Dartmouth/Hitchcock Medical Center. Action guide for accelerating improvement in cystic fibrosis care: clinical microsystems. 2006.

11. Langley GJ, Nolan KM, Nolan TW, et al. The improvement guide: a practical approach to enhancing organizational performance. San Francisco, CA: Jossey-Bass; 1996.

12. Cohen-Cymberknoh M, Blau H, Shoseyov D, et al. Intravenous monthly pulse methylprednisolone treatment for ABPA in patients with cystic fibrosis. J Cyst Fibros 2009;8:253–7.

13. Center Specific Patient Registry Report for 2011. Bethesda, MD: Cystic Fibrosis Foundation; 2012.

14. Parker VA, Wubbenhorst WH, Young GJ, et al. Implementing quality improvement in hospitals: The role of leadership and culture. Am J Med Qual 1999; 14:64–9.

15. Kern AS, Prestridge AL. Improving screening for cystic fibrosis-related diabetes at a pediatric cystic fibrosis program. Pediatrics 2013;132:e512–8.

16. Center Specific Patient Registry Report for 2012. Bethesda, MD: Cystic Fibrosis Foundation; 2013.

17. Schwarzenberg SJ, Thomas W, Olsen TW, et al. Microvascular complications in cystic fibrosis-related diabetes. Diabetes Care 2007;30:1056–61.

Strategy for Change

We applied the principles of clinical microsystems and conducted numerous tests of change following the Plan-Do-Study-Act (PDSA) technique [10,11]. We organized a core team consisting of 6 individuals: our CF center director (pulmonologist); a hospital-employed pediatric endocrinologist; an outpatient CF clinic nurse coordinator; the hospital’s CF coordinator (pediatric nurse practitioner); a hospital-employed, certified diabetes educator (nurse); and the hospital’s CF dietitian. The core team met weekly throughout the year-long project and ensured other CF care providers were kept up-to-date on the changes implemented with the project.

Interventions

Outpatient Screening

To achieve a thorough understanding of the clinic processes, we informed patients and families of our project and invited them to participate in a phone survey, which consisted of open-ended, scripted questions regarding their experiences with outpatient screening. Topics included scheduling lab appointments, obtaining annual lab work and the methods of communicating lab results. In addition to family surveys, the clinic staff examined each step of the lab scheduling process.

The results from the surveys and lab review were used to construct a fishbone diagram ( Figure 1 ) yielding 4 screening barriers: communication, appointment flow, transportation and scheduling, and other patient barriers. These barriers led to a high-level flowchart for outpatient CFRD screening and created a framework to initiate PDSA cycles ( Figure 2 ).

The OGTT was added to a previously established protocol for all patients to complete their annual labs at their first visit of the year. We stressed the importance and rationale for the OGTT in an annual clinic letter sent to families. The family was also sent a reminder letter with fasting instructions, a copy of the annual lab orders, and a reminder telephone call before the appointment. Based on family input regarding delays in the turn-around time for venous blood samples, a point of care (POC) glucose protocol was implemented. Laboratory personnel drew annual blood work, completed a POC blood glucose (in addition to the serum glucose), and administered the oral glucose load if the POC glucose was < 200 mg/dL.

Subsequent to completion of our project, we learned that our lab had inadvertently administered a 37.5-g dose for the OGTT instead of the recommended 75-g dose. To identify patients who may have had CFRD but were not diagnosed due to the low oral glucose dose, we have screened all patients with the corrected dose since January 2013.

To improve communication between the pulmonary and endocrine teams, weekly meetings were scheduled. The teams reviewed patients who had recently completed their annual laboratory tests or recently saw an endocrinology provider. After review of lab values, the patient families were mailed letters informing them of their child’s glucose test results which were categorized as normal, impaired, or abnormal suggesting CFRD. If the patient did not complete the OGTT, the family was mailed a letter reiterating the importance of screening. In the event of an abnormal OGTT suggesting CFRD, the results were discussed with the family during a clinic appointment. The endocrinologist and diabetes educator were subsequently notified, and an endocrine clinic appointment was arranged with the family to discuss the results and care plan. An electronic dashboard (spreadsheet) was created to track lab values and clinic visits for patients with impaired blood glucose tolerance as well as CFRD. The dashboard was reviewed and updated on a quarterly basis.