In 2011, 10 patients with CFRD were identified: 6 patients were diagnosed retrospectively based on a review of glucose levels collected in 2010 prior to the release of the new guidelines; 1 was diagnosed via inpatient screening; 3 were diagnosed via outpatient screening. In 2012, 5 patients with CFRD were identified: 4 were diagnosed via inpatient screening and one was diagnosed via outpatient screening. In 2013, 5 patients were identified: 1 diagnosed via inpatient screening and 4 diagnosed via outpatient screening. All diagnosed patients met the criteria of having a fasting blood sugar ≥ 126 mg/dL or a 2-hour postprandial ≥ 200 mg/dL that persisted for more than 48 hours.
Discussion
This collaborative initiative resulted in the development of structured screening protocols leading to overall screening improvement. A standardized screening protocol is fundamental to the identification and subsequent treatment of a patient with CFRD. Patients with CFRD may have decreased mortality when diagnosed early and treated aggressively, underscoring the necessity for CF centers to improve screening protocols [1,6].
Determining the best methods for implementation may vary from center to center, but the key factors we have identified from this project include strong leadership and team commitment—elements that have previously been identified as being predictive of positive quality improvement outcomes [14].
Education of staff, families, and patients is also an important factor. Education played a significant role during the inpatient screening PDSA cycles. For example, a time intensive but worthwhile training was conducted for the physicians and nurses on the order sets. Education for the patients and families during inpatient stays led to a better understanding of the rationale for, and support of, the additional blood draws.
The importance of family involvement was evident as we refined our outpatient protocol. Input from the phone surveys allowed us to identify barriers in our process that led us to establish more efficient clinic visits with reduced time in the lab, improved clinic flow and increased patient satisfaction. Other important factors were co-location of the endocrine and pulmonary clinics and flexibility of scheduling to facilitate seeing patients in both clinics on the same day.
Although we uncovered an error in oral glucose dosing, we were able to appropriately screen the majority of these patients within the next year. At the conclusion of 2013, our outpatient protocol had facilitated a screening rate of 95%, surpassing the 2012 rate of 77%. Interestingly, 2 of the patients diagnosed with CFRD in 2011 were diagnosed by HbA1c criteria, with normal OGTT results, perhaps due to the substandard glucose dose. Only 5 additional patients screened positive for CFRD at the end of 2013, which is the same number identified in 2012. It is unclear whether they would have been diagnosed earlier with the recommended dose of oral glucose or if they developed CFRD due to the progression of their disease.
A limitation of this project may be its reproducibility at other institutions. It is likely that the success of this project was due to the strong relationship between the endocrinology and pulmonary teams, committed leadership, institutional support for co-location of the clinics, and the team’s competency in quality improvement techniques with guidance from the LLC. The process of developing, implementing, and sustaining screening protocols was time-intensive and may be difficult to replicate in another center without similar resources available.