NU800 Unit 2 PICOT Worksheet, Steroid Hyperglycemia Example

Per Reading, Per Patient-Day or Per Patient: A PICOT Question Worksheet for a Glucocorticoid Hyperglycemia Project on Two Composite Medical Units, and Why the Patient-Day Won

[Student Name]

Purdue University Global

NU800: DNP Project Proposal

Unit 2 PICOT Question Worksheet

[Instructor Name]

[Date]

The units and figures are composite; numbers are bracketed.

Question Type

This is an intervention question: it asks whether a change in nursing practice alters a measured result. The Johns Hopkins model distinguishes intervention questions from questions about meaning, prognosis or diagnosis, and the type determines what evidence will answer it (Dang et al., 2021). The anchor is the Unit 1 gap sentence, which in short says that the afternoon peak of steroid hyperglycemia goes unmonitored on both units and that high readings, when found, receive correctional insulin only.

Population

Final wording: adults on 4 North and 4 South receiving a systemic glucocorticoid at a dose equivalent to [20] mg of prednisone or more per day. It answers to the gap sentence's "patients started on high-dose glucocorticoids." It rules out patients on insulin infusions, patients in diabetic ketoacidosis or a hyperosmolar state on admission, pregnant patients and patients receiving comfort care only, since each has a separate glucose plan.

Intervention

Final wording: a four-part bundle. First, an electronic order set triggered by any qualifying glucocorticoid order, which starts glucose checks before lunch and before dinner for [48] hours for every patient, continuing if any reading exceeds 180 mg/dL. Second, an escalation rule: two readings above 216 mg/dL prompt the nurse to page the prescriber with a pharmacy-approved suggestion for morning NPH insulin timed to the steroid dose. Third, a taper prompt that reminds the prescriber to reduce NPH as the steroid is reduced. Fourth, a discharge check for patients newly hyperglycemic. The bundle follows guidance that monitoring be timed to the afternoon rise and that intermediate-acting insulin given with the morning steroid can match its effect (Roberts et al., 2018). It answers to both halves of the gap sentence, detection and response.

Comparison

Final wording: usual care during the [16] baseline weeks, drawn retrospectively from the glucometer export and charts. It rules out a concurrent control unit, since both units share hospitalists and the order set cannot be switched on for one alone.

Outcome

Final wording, primary: hyperglycemic patient-days per 100 monitored glucocorticoid patient-days, where a hyperglycemic patient-day has any reading above 250 mg/dL and a monitored patient-day has at least two readings including one after [1100].

This is the hardest row, because three counting methods were possible. Counting per reading gives the share of individual readings above 250; it rises and falls with how often patients are checked, so a patient checked four times a day counts four times as much as one checked once. Counting per patient gives the share of patients with any reading above 250 during the stay; it hides whether hyperglycemia lasted one day or six. Counting per patient-day asks, for each day a patient is on steroids, whether that day included a reading above 250. Applied to the same month of baseline data, the three methods gave [14] percent of readings, [22] hyperglycemic patient-days per 100, and [48] percent of patients. The patient-day was chosen because it reflects both how many patients and how many days are affected, it matches how nurses experience the problem, and it is the unit in which the ADA hospital standards and many inpatient projects report glycemic measures (American Diabetes Association Professional Practice Committee, 2024).

A second problem shapes the denominator. The bundle will greatly increase afternoon checking, and more checking will find hyperglycemia that was always there. If the denominator were all glucocorticoid patient-days, the rate would rise simply because detection improved. Restricting the denominator to monitored patient-days, those with an afternoon reading, compares like with like: in both periods, the question is how often a properly monitored day is hyperglycemic.

Counting per patient-day measures what patients live through; restricting to monitored days keeps better detection from looking like worse care.

Secondary: the share of eligible patient-days with a reading before lunch or dinner. Balancing: hypoglycemic patient-days, any reading below 70 mg/dL, per 100 glucocorticoid patient-days, since NPH that outlasts a tapered steroid can cause lows.

Time

Final wording: [12] implementation weeks after [two] weeks of education, compared with [16] baseline weeks. It rules out claims about sustainment beyond the project period.

The Final Question

In adults on two medical units receiving high-dose glucocorticoids (P), does a nurse-driven afternoon glucose monitoring and escalation bundle (I), compared with usual care (C), reduce hyperglycemic patient-days per 100 monitored glucocorticoid patient-days (O) over [12] weeks (T)?

References

American Diabetes Association Professional Practice Committee. (2024). 16. Diabetes care in the hospital: Standards of care in diabetes 2024. Diabetes Care, 47(Suppl. 1), S295-S306. https://doi.org/10.2337/dc24-S016

Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2021). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (4th ed.). Sigma Theta Tau International.

Roberts, A., James, J., Dhatariya, K., & Joint British Diabetes Societies for Inpatient Care. (2018). Management of hyperglycaemia and steroid (glucocorticoid) therapy: A guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care group. Diabetic Medicine, 35(8), 1011-1017. https://doi.org/10.1111/dme.13675