Modelling the use of variable rate intravenous insulin infusions in hospitals by comparing Work as Done with Work as Imagined

Mais Iflaifel; Rosemary H Lim; Clare Crowley; Francesca Greco; Kath Ryan; Rick Iedema

doi:10.1016/j.sapharm.2021.06.008

Modelling the use of variable rate intravenous insulin infusions in hospitals by comparing Work as Done with Work as Imagined

Res Social Adm Pharm. 2022 May;18(5):2786-2795. doi: 10.1016/j.sapharm.2021.06.008. Epub 2021 Jun 11.

Authors

Mais Iflaifel¹, Rosemary H Lim², Clare Crowley³, Francesca Greco⁴, Kath Ryan⁵, Rick Iedema⁶

Affiliations

¹ Reading School of Pharmacy, University of Reading, PO Box 226, Whiteknights, Reading, Berkshire, RG6 6AP, UK. Electronic address: m.h.m.iflaifel@pgr.reading.ac.uk.
² Reading School of Pharmacy, University of Reading, PO Box 226, Whiteknights, Reading, Berkshire, RG6 6AP, UK. Electronic address: r.h.m.lim@reading.ac.uk.
³ Pharmacy Department, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxford, Oxfordshire, OX3 9D, UK. Electronic address: clare.crowley@ouh.nhs.uk.
⁴ Reading School of Pharmacy, University of Reading, PO Box 226, Whiteknights, Reading, Berkshire, RG6 6AP, UK. Electronic address: f.greco@reading.ac.uk.
⁵ Reading School of Pharmacy, University of Reading, PO Box 226, Whiteknights, Reading, Berkshire, RG6 6AP, UK. Electronic address: k.m.ryan@reading.ac.uk.
⁶ Centre for Team Based Practice & Learning in Health Care, King's College London, London, SE1 1UL, UK. Electronic address: rick.iedema@kcl.ac.uk.

PMID: 34147370
DOI: 10.1016/j.sapharm.2021.06.008

Abstract

Background: Variable rate intravenous insulin infusions (VRIIIs) are widely used to treat elevated blood glucose (BG) in adult inpatients who are severely ill and/or will miss more than one meal. VRIIIs can cause serious harm to the patient if used incorrectly. Recent safety initiatives have embraced the Resilient Health Care (RHC) approach to safety by understanding how VRIIIs are expected to be used (Work as Imagined, 'WAI') and how it is actually used in everyday clinical care (Work as Done, 'WAD').

Objectives: To systematically compare WAI and WAD and analyse adaptations used in situ to develop a model explaining VRIII use.

Methods: A qualitative observational study video-recording healthcare practitioners using VRIII. The video data were transcribed and inductively coded to develop a hierarchical task analysis (HTA) to represent WAD. This HTA was compared with a HTA previously developed to represent WAI. The comparison output was used to develop a model of VRIII use.

Results: While many of the tasks in the WAD HTA were aligned with the tasks presented in the WAI HTA, some important ones did not. When misalignment was observed, permanent adaptations (e.g. signing as a witness for a changed VRIII's rate without independently verifying whether the new rate was appropriate) and temporary workarounds (e.g. not administering intermediate-acting insulin analogues although the intermediate-acting insulin prescription was not suspended) were the most frequently observed adaptations. The comparison between WAI and WAD assisted in developing a model of VRIII use. The model shed light on strategies used to imagine everyday work (e.g. incident reports, VRIII guidelines), how everyday work was accomplished (e.g. context-dependent adaptations) and how these contributed to both successful and unsuccessful outcomes.

Conclusions: This study provided in-depth understanding of the tasks required while using VRIIIs, and responses and adaptations needed to achieve safer care in a complex environment.

Keywords: Hierarchical task analysis; Resilient health care; Variable rate intravenous insulin infusion; Work as done; Work as imagined.

Publication types

Observational Study
Research Support, Non-U.S. Gov't

MeSH terms

Adult
Hospitals
Humans
Hyperglycemia* / drug therapy
Infusions, Intravenous
Insulin* / therapeutic use
Qualitative Research

Substances

Insulin