(96) Improving Cystic Fibrosis Related Diabetes Treatment Initiation through Pulmonary Nurse Intervention

Background: In 2019, the Pediatric Endocrinology (Endo) and Pulmonology (Pulm) departments created a clinical practice guideline (CPG) to provide the most up-to-date management of Cystic Fibrosis Related Diabetes (CFRD). This CPG covered screening and treatment. To guide the referral process, a nursing (RN) protocol was created in 2019 that included having a Pulm RN place referrals to Endo for patients with an abnormal Oral Glucose Tolerance Test (OGTT), order diabetes testing supplies, and educate families on monitoring blood glucose (BG) prior to the first Endo appointment (appt). This was done to ensure Endo had data at the first appt to be able to initiate treatment. Treatment was defined as either starting insulin or making diet or exercise changes to manage BG.

The aim of this quality improvement project was to determine whether Pulm RN initiation of CFRD protocol prior to first Endo appt will result in initiation of CFRD treatment by Endo at their first appt.

Methods: After implementing the Pulm RN CFRD protocol, evaluation revealed that the Pulm RN did not follow the protocol. The protocol was reviewed again with all Pulm RNs which showed that a trial with a dedicated Pulm RN might yield more reliable results and consistency if following the protocol. In May 2021, a dedicated Pulm RN began initiating CFRD protocol on all abnormal OGTT results for all people with CF seen in our pediatric program.

Using retrospective chart review of patients with abnormal OGTT before and after CPG initiation (2018 to present) we gathered data to determine whether Pulm RN interventions prior to first Endo appt led to treatment initiation at first Endo appt. We looked at whether the patient received BG monitoring equipment and education from Pulm RN and if they monitored their BG prior to first Endo appt, and whether treatment was initiated at first Endo appt. Patients who were admitted immediately following abnormal OGTT result were excluded from results due to not qualifying for protocol initiation.

Results: Between May 2021 and March 2022, six patients met criteria for Pulm RN initiated CFRD protocol. An additional patient did not meet criteria but needed a referral for high A1C, so protocol was followed, and they were also included in the results.

One patient did not attend their scheduled Endo appt and did not monitor BG prior, despite receiving Pulm RN education and equipment. One other patient did not have the protocol initiated despite meeting criteria and was instead seen by Endo within 17 days of abnormal OGTT without monitoring BG prior. This patient did not receive treatment at first Endo appt, but instead BG monitoring was initiated. By April 2022, the remaining five patients had the protocol initiated and attended their first Endo appt. All five patients received BG monitoring education from Pulm RN and did monitor their BG prior to first Endo appt. Of these five patients, 100% had treatment initiated at the first Endo Appt.

Of the 2 patients who qualified for the protocol from October 2019 – April 2021, one transferred care and the other did not receive treatment at their first Endo appt.

Conclusions: Pulm RN initiation of BG equipment and monitoring education prior to first Endo appt reduced the time to starting treatment. Insurance barriers to equipment access were identified and need additional investigation to improve.

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