NU802 Unit 2 DNP Site Needs Assessment Example

Four Hundred Starters a Year Outside the Pilot: A Unit 2 Site Needs Assessment for Spreading an Insulin Discharge Bundle

[Student Name]

Purdue University Global

NU802: DNP Project I

Unit 2 Site Needs Assessment

[Instructor Name]

[Date]

The hospital, units, figures and stakeholders are composite and illustrative; the studies and standards cited are real.

The Site

The hospital is a 300-bed regional referral center with ten adult inpatient units: four medical-surgical units, a cardiac step-down unit, an oncology unit, an orthopedic unit, a surgical unit, a renal and transplant unit and a short-stay observation unit. It serves Dubuque County and a rural area reaching into Wisconsin and Illinois. Diabetes care in the hospital is guided by the system's glucose management policy, last revised in 2024, which follows the American Diabetes Association's hospital standards. Those standards call for a structured discharge plan beginning at admission, with education in survival skills such as insulin administration, glucose monitoring and treating lows, and with follow-up arranged before the patient leaves (American Diabetes Association Professional Practice Committee, 2025).

The bundle began on 5 West and 6 West, two of the medical-surgical units, and still runs only there. The eight remaining units, including the other two medical-surgical units, 4 West and 3 West, are called the spread units in this assessment, and they carry on with usual practice.

The Problem in the Site's Own Data

A 12-month extract from the electronic record, for the year ending in August, identified every adult discharged from the spread units after starting insulin during the stay. There were 403 such patients. The largest numbers came from the cardiac step-down unit, 96, the oncology unit, 81, mostly patients on high-dose steroids, the renal and transplant unit, 64, and the surgical unit, 58. The other units each discharged fewer than 45.

Fifty-seven of the 403 patients, about 14 percent, came back to the hospital's emergency department or were admitted within 30 days with hyperglycemia, hypoglycemia or ketoacidosis coded. That figure counts only visits to this hospital, so the real rate is higher. On the pilot units, the same measure fell from about 14 percent to a little under 10 percent after the bundle began.

A chart audit of 60 randomly chosen spread-unit discharges on new insulin found that a supervised self-injection was documented for 34, or 57 percent. A written plan in plain language was found in 22 charts. The pen was dispensed before the last day of the stay for 18 patients. A follow-up call within three days was documented for nine.

On the spread units, the patient most likely to leave without a supervised injection is the one most likely to come back.

Who Is Affected

The population is not uniform. Oncology patients on steroids often need insulin only while on the steroid and are discharged on rapidly changing doses. Renal and transplant patients have complex regimens and a higher risk of lows. Cardiac step-down patients are older, and many are discharged home with a spouse who gives the injections. Rubin (2015), reviewing readmission among patients with diabetes, lists lower socioeconomic status, public insurance, heavy comorbidity, urgent admission and recent prior hospitalization among the risk factors, and every spread unit has patients with several of them. The bundle's equity review, carried out on the pilot units, found that pens reached Medicaid and uninsured patients later and that check-ins missed patients over 80, so those groups need specific attention on the spread units.

Current Practice on the Spread Units

Discharge on new insulin on the spread units depends on the nurse who happens to be assigned. Teaching uses a generic pen from the floor stock, not the patient's own pen. Written instructions come from a two-page handout last revised in 2019, which explains insulin in general and does not include the patient's own doses. Pens are ordered with the discharge prescriptions and filled at the patient's pharmacy after discharge. The hospital's single diabetes educator sees patients only on consult, and follow-up calls are made by the discharging unit when time allows.

Stakeholders

The project needs agreement or active support from nine groups. As sponsor, the chief nursing officer sets unit priorities. The eight unit managers decide staff time for teaching. Unit educators would train staff. The diabetes educator owns teaching content and follow-up. Pharmacy controls when pens are dispensed. Hospitalists and the oncology and renal physicians write discharge orders and doses. Case management arranges follow-up. Information services builds the readiness flag and text follow-up on each unit. The patient and family advisory council reviews patient materials.

Stakeholder interviews and earlier stakeholder analysis suggest three groups need the most work: oncology physicians, who worry that a fixed bundle will not fit rapidly changing steroid doses; pharmacy, which is concerned about returned pens when insulin is stopped; and the managers of the two units with the lowest staffing.

Strengths, Weaknesses and Resources

Strengths. The site has a working bundle with a year of results, a readiness flag in the electronic record, a tested text follow-up tool and executive support. Teamwork scores on the safety culture survey were high.

Weaknesses. One diabetes educator covers the whole hospital. Response to error scored low on the culture survey. Two spread units have high nurse turnover, and the oncology unit's insulin regimens differ from those the bundle was built for.

Opportunities. Drincic et al. (2017) reported that, in their Omaha hospital, the patients whom diabetes educators saw were readmitted least often of any group, and that training staff nurses as diabetes resource nurses extended that expertise. A similar resource-nurse role on each spread unit could address the educator shortage.

Threats. A sepsis bundle is going live on six of the same units this year. Insurance changes in January often alter which pens are covered.

Readiness Judgment

The site is ready in its commitment and its tools but only partly ready in its people and processes. Leadership supports the project, the electronic record already carries the readiness flag and the follow-up tool works. What the spread units lack is time for teaching, a teaching pen that matches the patient's own and expertise close to the bedside. The assessment therefore recommends that the proposal include three things before any spread unit goes live: a diabetes resource nurse on each spread unit, a steroid-specific version of the plan developed with the oncology physicians and a go-live calendar that keeps each unit away from its sepsis bundle start.

Conclusion

Four hundred patients a year start insulin on units that have none of the bundle's parts, and about one in seven of them returns with a glucose problem. The audit shows that the gaps are specific and measurable: teaching on the wrong pen, generic instructions, pens filled after discharge and little follow-up. The site has the leadership and tools to close those gaps, and the proposal can be built around the people and processes it still lacks.

References

American Diabetes Association Professional Practice Committee. (2025). 16. Diabetes care in the hospital: Standards of care in diabetes-2025. Diabetes Care, 48(Suppl. 1), S321-S334. https://doi.org/10.2337/dc25-S016

Drincic, A., Pfeffer, E., Luo, J., & Goldner, W. S. (2017). The effect of diabetes case management and Diabetes Resource Nurse program on readmissions of patients with diabetes mellitus. Journal of Clinical & Translational Endocrinology, 8, 29-34. https://doi.org/10.1016/j.jcte.2017.03.003

Rubin, D. J. (2015). Hospital readmission of patients with diabetes. Current Diabetes Reports, 15(4), 17. https://doi.org/10.1007/s11892-015-0584-7