DNP 815 DPI Project Milestone : Outline of 10 Strategic Points

i.                    Homelessness is a major public health problem that continually affects many individuals in high-income countries. According to Gutwinski et al. (2021), approximately two million individuals have been labeled homeless in high-income nations in the past decade. In the United States (U.S), the lifetime prevalence of homelessness is projected at 4.2%, with about 550,000 people lacking fixed, regular, and satisfactory residence on any given night.

ii.                   Statistics from the Department of Housing and Urban Development (HUD) show that about 1.4 million people in the U.S stayed in homeless shelters at least once in 2017 (Peng et al., 2020). Point-in-time projections show that about 1/3 of homeless individuals were unsheltered in 2017.

iii.                Homeless persons are at higher risk of traumatic injuries, infections, and violence and are highly likely to develop multi-morbidities, disabilities, and premature death (Aubry et al., 2020).

iv.                Social support has been shown to help reduce substance abuse among homeless people.

(b) Theoretical foundations (models and theories to be the foundation for study); General strain theory

(c) Review of literature topics with a key theme for each one;

i. Social support: increased or improved social support is associated with decreased cases of substance abuse among the homeless.

ii. Interventions: As it stands, there is no current single intervention that can effectively be used alone to improve the outcomes among homeless individuals.

iii. Prevalence of mental disorders and substance abuse: The current evidence shows that homeless individuals are more likely to suffer from mental disorders such as depression and engage in substance abuse hence addiction.

(d) Summary:

While the impact of permanent supportive housing on other aspects has been studied, little has been done regarding the impact on substance abuse among homeless people. The implication is that more studies need to be done to study such impacts.

Population: Homeless adults patients engaged in substance abuse

H1: There is a significant relationship between the implementation of permanent supportive housing and the incidences of substance abuse among homeless adults.

H0: There is no relationship between the implementation of permanent supportive housing and the incidences of substance abuse among the homeless adults

PSH increases a person’s ability to have a house. This credibly improves a number of conditions that negatively impact health, including exposure to harsh environmental conditions and substance abuse.

Application of Continuous glucose monitoring in the management of diabetes type II

Theoretical Foundation

Literature Synthesis

Practice Change Recommendation

List the primary points for six sections.

i)       Background of the practice problem/gap at the project site

Several chronic conditions negatively impact the lives of patients. Among such conditions is diabetes. Diabetes has been shown to cause numerous other complications such as kidney disease, heart disease, and stroke (Skinner et al., 2020). The other concern about diabetes is that it affects millions of people, making them not able to live normal lives. The implication is that various researchers and stakeholders have, in the past and at present, been in pursuit of effective ways or strategies to better manage diabetes. Non-the less, diabetes is still among the most prevalent chronic conditions. The interventions currently in use among patients living with diabetes majorly focus on helping patients attain better healthcare outcomes such as better glycemic control and keeping in check the risky lifestyle behaviors that may hinder the control and management of the condition.

ii)     Significance of the practice problem/gap at the project site

As earlier highlighted, diabetes causes other undesirable problems apart from making those who live with it to spend higher amounts of money on treatment and management. Therefore, the need to control and manage the disease has attracted the attention of several stakeholders, including nurses, doctors, and other researchers in the medical and nursing fields. There have been advancements in the management of diabetes, largely due to the new innovative technologies that have been applied in diagnostics and treatment (Haque et al., 2021). However, the annual number of people who get the disease still runs into millions. In addition, the prevalence rates have been rising in recent years, while several others die annually due to diabetes. The negative impacts caused by the disease can be lowered through using nursing interventions based on the current technology and technological applications such as continuous glucose monitoring, which can dictate the rate of practitioners ordering Continuous glucose monitoring as directed by the results to further improve outcomes.

iii)   Theoretical Foundations (choose one nursing theory and one evidence-based change model to be the foundation for the project):

Nursing theories are key in implementing nursing interventions as they offer a framework upon which the aspects of interventions can be based. Therefore, this project will use Dorothea Orem’s self-care theory. The theory is mainly about an individual’s ability to perform self-care as “the practice of activities that individuals initiate and perform on their own behalf to maintain life, health, and well-being (Butts & Rich, 2018). Dorothea’s theory has three interconnected sub-theories; the theory of self-care, the self-care deficit theory, and the theory of nursing systems.

iv)   Create an annotated bibliography using the “Preparing Annotated Bibliographies (APA 7th)” located in the Student Success Center. https://www.gcumedia.com/lms-resources/student-success-center-content/documents/writing-center/preparing-annotated-bibliographies-apa7-mla8-turabian9.pdf utilizing the five (5) original research articles that support the evidence-based intervention. This will be the foundation of the Literature Synthesis you will have to do in DNP-820A.

Beck, R. W., Riddlesworth, T. D., Ruedy, K., Ahmann, A., Haller, S., Kruger, D., … & DIAMOND Study Group. (2017). Continuous glucose monitoring versus usual care in patients with type 2 diabetes receiving multiple daily insulin injections: a randomized trial. Annals of Internal Medicine, 167(6), 365-374. https://doi.org/10.7326/M16-2855.

This study by Beck et al. (2017) was carried out with the major objective of determining the effectiveness of continuous glucose monitoring in adults with type 2 diabetes who were getting insulin injections. By employing a randomized controlled trial as the research design, these researchers recruited a total of one hundred and fifty-eight patients with type 2 diabetes. Seventy-nine patients were randomized into the usual care group, with the remaining half recruited into the intervention group. While the continuous glucose monitoring group used a Dexcom G4 platinum continuous monitoring system to monitor their glucose concentrations, the control groups engaged in glucose self-monitoring. The analysis of the data showed that the individuals in the intervention group experienced a better reduction in the HbA1c levels as compared to the control group (p values of 0.022), showing that the intervention was efficacious.

Gilbert, T. R., Noar, A., Blalock, O., & Polonsky, W. H. (2021). Change in hemoglobin A1c and quality of life with real-time continuous glucose monitoring use by people with insulin-treated diabetes in the landmark study. Diabetes Technology & Therapeutics, 23(S1), S-35. https://doi.org/10.1089/dia.2020.0666

The study by Gilbert et al. (2021) aimed to assess the changes in  HbA1c levels upon using a continuous glucose monitoring system. The patients recruited were two hundred and forty-eight patients, with sixty having type 2 diabetes. The participants were requested to upload their point of care HbA1c measurements to an online portal. They then used the continuous glucose monitoring devices to monitor their HbA1c values and uploaded them to the portal. Upon data analysis, the researchers noted that there was a significant reduction in the levels of HbA1c levels (p-value of <0.001). Therefore, this study also indicated the importance of continuous glucose monitoring in the management of diabetes.

Heinemann, L., Freckmann, G., Ehrmann, D., Faber-Heinemann, G., Guerra, S., Waldenmaier, D., & Hermanns, N. (2018). Real-time continuous glucose monitoring in adults with type 1 diabetes and impaired hypoglycemia awareness or severe hypoglycemia treated with multiple daily insulin injections (HypoDE): a multicentre, randomized controlled trial. The Lancet, 391(10128), 1367-1377. https://doi.org/10.1016/S0140-6736(18)30297-6

This study was done by Heinemann et al. (2018). This study’s objective was to find out whether real-time continuous glucose monitoring can be used effectively in reducing the severity and incidences of hypoglycemia. In a six-month randomized controlled study, the researchers randomly assigned 75 individuals to a real-time continuous glucose monitoring group, while 74 were assigned to the control groups. The individuals in the real-time continuous glucose monitoring group were taught how to use the monitoring system. They then used the real-time continuous monitoring devices for the period of study. On the other hand, the individuals in the control group used a self-monitoring blood glucose. Upon the analysis of the data, it was noted that the individuals in the intervention group reported a significant reduction in hypoglycemic events (p-value of <0.0001).

Martens, T., Beck, R. W., Bailey, R., Ruedy, K. J., Calhoun, P., Peters, A. L., … & MOBILE Study Group. (2021). Effect of continuous glucose monitoring on glycemic control in patients with type 2 diabetes treated with basal insulin: a randomized clinical trial. JAMA, 325(22), 2262-2272. doi:10.1001/jama.2021.7444

This article presents the findings of the research done by Martens et al. (2021). This study was done with the aim of finding the impacts of continuous glucose monitoring in improving individuals’ HbA1c levels when compared to the impact of blood glucose meter monitoring. In a randomized controlled trial, these researchers recruited a total of 175 people with type 2 diabetes. While the individuals in the intervention group used continuous glucose monitoring, the ones in the control group engaged in blood glucose meter monitoring. This study was done for a period of eight months. Upon the analysis of the data, it was noted that the individuals in the intervention group showed a substantial reduction in the HbA1c levels (p-value of 0.02). There was also a significant difference between the intervention and control groups (p-value of 0.001).

Grace, T., & Salyer, J. (2022). Use of Real-Time Continuous Glucose Monitoring Improves Glycemic Control and Other Clinical Outcomes in Type 2 Diabetes Patients Treated with Less Intensive Therapy. Diabetes Technology & Therapeutics, 24(1), 26-31. https://doi.org/10.1089/dia.2021.0212.

Authored by Grace & Salyer (2022), this study focused on using real-time continuous glucose monitoring in the management of patients with diabetes type to improve glycemic control. The researchers recruited patients with type 2 diabetes with basal insulin only or the noninsulin therapy. At six months, the researcher found relevant outcomes. For example, the participants showed a considerable reduction in the HbA1c levels (p-value <0.001). Therefore, the use of real-time glucose monitoring was connected with significant glycemic improvements among patients living with type 2 diabetes.

v)      Practice Change Recommendation: Validation of the Chosen Evidence-Based Intervention

The standards of diabetes care have been used at the facility for years as a preference. However, this approach is to produce the expected outcomes. As such, this research proposes the use of continuous glucose monitoring as an intervention to help the patients have improved HbA1c levels.

vi)   Summary of the findings written in this section.

From the annotations, it is evident that the use of continuous glucose monitoring as an intervention in the management of diabetes leads to better outcomes. For example, the researchers reported significant improvement in the HbA1c levels upon the use of continuous glucose monitoring.

Describe the variables/groups to project in one sentence.

It is not known if the translation  of continuous glucose monitoring to increase the rate of practitioners’ ordering continuous glucose monitoring would impact HbA1c levels among patients with diabetes type II.

Among adult patients with type 2 diabetes in an outpatient clinic, will the translation of Beck et al.’s research on continuous glucose monitoring increase the rate of practitioner’s ordering continuous glucose monitoring impact HgbA1C, compared to current, in 12 weeks

Evidence-Based Question:

Provide the templated statement.

To what degree will the implementation of continuous glucose monitoring impact HbA1c levels among adult patients with type two diabetes in the outpatient clinic in Arizona?

Setting

Location

Inclusion and Exclusion Criteria

Identify sample, needed sample size, and location (project phenomena with small numbers and variables/groups with large numbers).

i)       Sample and Sample Size: The plan is to recruit an appropriate number of participants. Therefore, seventy participants living with type II diabetes will be recruited. One of the potential biases is the lack of randomization due to time constraints. Another potential bias is that the samples will be from one center, hence a lack of generalizability. The bias can be mitigated by recruiting patients from more than a center.

ii)     Setting: The setting for the study is in Chinyere Awa, MD, outpatient Clinic, Houston

iii)   Location:  Houston

iv)   Inclusion Criteria

v)      Patients must be at least 18 years and have diabetes. The patient should also not form part of another study.

vi)   Exclusion Criteria

Individuals using technological management of diabetes, those who do not want to sign the consent forms, and those who have a mental disability will be excluded.

i)       Independent Variable (Intervention): continuous glucose monitoring

ii)     Dependent Variable (Measurable patient outcome): HbA1c levels

This project will use a quality improvement approach.  You must be able to explain and cite the difference between research and quality improvement (one paragraph each).

i)       Quality Improvement: A quality improvement is an initiative or project focused on improving patient care efforts and outcomes.

ii)     Research: Research entails replicating or testing new ideas to improve the standard practice and current knowledge.

iii)   Summarize:  This proposed project focuses on the application of continuous glucose monitoring to improve patient outcomes such as HbA1c levels among patients living with diabetes.

Provide the templated statement.

The purpose of this quality improvement project is to determine if the implementation of continuous glucose monitoring would impact HbA1c levels among adult patients with diabetes. This project will be piloted over a twelve-week period in an urban primary care clinic in Arizona.

i)       The gender and age of the patients will be collected. The patient’s knowledge of continuous glucose monitoring will also be evaluated.

ii)     The patients’ glycemic control will be measured, and the baseline data will be obtained from the electronic health records.  Data from EHR has been shown to be reliable and valid.

iii)   The reliability of the Revised Brief Diabetes Knowledge Test instrument is (α ≥ 0.70), while the validity ranges from 0.83 to 0.96

iv)   Describe the step-by-step process you will use to collect the data, explain where the data will come from, and how you will protect the data and participants.

1. Baseline data will be obtained from the facility’s EHR.

2. The patient’s HbA1c will be measured after the intervention, and the two values will be compared. The results will also be compared between the intervention and the control group.  For protection, data will be coded, while access will only be given to authorized persons.

v)      Various potential ethical issues include informed consent, which is one of the exclusion criteria, where the patients who refuse to sign the form will be excluded. While no potential conflict of interest is expected, there is a possibility of anonymity of data vs. confidentiality.

vi)   The project will adhere to the principle of Belmont by ensuring that no harm is done to the patients. Patients will also be encouraged to participate in the study without coercion freely. Besides, none will be unfairly excluded from participating in the study. Patient data will also be protected to remain confidential and unauthorized access blocked.

The participant’s data will be analyzed using the IBM SPSS statistics software. Pre- and post-test results data will be described using descriptive statistics. In addition, paired sample t-test and Pearson’s correlation will be used. A statistician will also be used.

Potential data bias can result in the possible improved glycemic control could be as a result of the intervention and other self-care activities that the patient undertakes outside the study. One way of mitigating data is through the use of an appropriate study design.

Butts, J. B., & Rich, K. L. (2018). Philosophies and theories for advanced nursing practice. Jones & Bartlett Publishers.

Gilbert, T. R., Noar, A., Blalock, O., & Polonsky, W. H. (2021). Change in hemoglobin A1c and quality of life with real-time continuous glucose monitoring use by people with insulin-treated diabetes in the landmark study. Diabetes Technology & Therapeutics, 23(S1), S-35. https://doi.org/10.1089/dia.2020.0666

Grace, T., & Salyer, J. (2022). Use of Real-Time Continuous Glucose Monitoring Improves Glycemic Control and Other Clinical Outcomes in Type 2 Diabetes Patients Treated with Less Intensive Therapy. Diabetes Technology & Therapeutics, 24(1), 26-31. https://doi.org/10.1089/dia.2021.0212.

Haque, W. Z., Demidowich, A. P., Sidhaye, A., Golden, S. H., & Zilbermint, M. (2021). The Financial Impact of an Inpatient Diabetes Management Service. Current Diabetes Reports, 21(2), 1-9. https://doi.org/10.1007/s11892-020-01374-0.

Heinemann, L., Freckmann, G., Ehrmann, D., Faber-Heinemann, G., Guerra, S., Waldenmaier, D., & Hermanns, N. (2018). Real-time continuous glucose monitoring in adults with type 1 diabetes and impaired hypoglycemia awareness or severe hypoglycemia treated with multiple daily insulin injections (HypoDE): a multicentre, randomized controlled trial. The Lancet, 391(10128), 1367-1377. https://doi.org/10.1016/S0140-6736(18)30297-6

Martens, T., Beck, R. W., Bailey, R., Ruedy, K. J., Calhoun, P., Peters, A. L., … & MOBILE Study Group. (2021). Effect of continuous glucose monitoring on glycemic control in patients with type 2 diabetes treated with basal insulin: a randomized clinical trial. JAMA, 325(22), 2262-2272. doi:10.1001/jama.2021.7444

Skinner, T. C., Joensen, L., & Parkin, T. (2020). Twenty‐five years of diabetes distress research. Diabetic Medicine, 37(3), 393-400.  https://doi.org/10.1111/dme.14157.