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Why SQUIRE 2.0
The Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) are publication guidelines for reports of efforts to improve the quality, value and safety of health care. They emphasize three components: the use of formal and informal theory in planning, implementing and evaluating the work; the context in which the work is done; and the study of the intervention itself (Ogrinc et al., 2016). This excerpt follows SQUIRE's main sections to report a DNP project. The project, hospital and data are illustrative.
Introduction
Problem. On two medical units, hypoglycemia (blood glucose below 70 mg/dL) occurred in 6.1% of patient-days among patients receiving insulin. Many events happened before breakfast in patients whose meal intake had dropped.
Rationale. The project's theory of change was that hypoglycemia often follows a mismatch between insulin and reduced eating. Giving nurses a structured way to recognize low intake and hold or reduce prandial insulin with provider agreement should reduce events.
Specific aim. Reduce hypoglycemic patient-days among insulin-treated patients from 6.1% to below 4.0% within 20 weeks.
Methods
Context. Two 32-bed medical units in a community teaching hospital, with an established glycemic management committee.
Interventions.
- A nurse-driven protocol linking meal intake (documented as a percentage) to prandial insulin, with provider-approved hold parameters.
- A hypoglycemia risk flag in the record for patients with kidney impairment, steroid tapers or nothing-by-mouth status.
- A bedtime glucose check with a snack prompt below a set threshold.
Study of the interventions. Process data (protocol use) and outcome data (hypoglycemic patient-days) were plotted weekly.
Measures. Outcome: percentage of insulin-treated patient-days with any glucose below 70 mg/dL. Process: percentage of meals with documented intake. Balancing: percentage of patient-days with glucose above 300 mg/dL.
Analysis. Run charts with a baseline median, interpreted using standard probability-based run chart rules for shifts and trends (Provost & Murray, 2022).
Ethical considerations. The institutional review board determined the project to be quality improvement, not human subjects research.
Results
- Process: documented meal intake rose from 58% of meals at baseline to 91% by week 8.
- Outcome: after the protocol launched in week 4, a shift appeared: 8 consecutive weekly points below the baseline median from week 9. The mean rate of hypoglycemic patient-days over weeks 9 to 20 was 3.7%.
- Balancing: severe hyperglycemia remained stable (about 5% of patient-days).
- Unintended effects: night-shift nurses reported uncertainty about holding insulin when meal intake was unknown, which led to a clarifying change in week 10.
Discussion
Summary. A nurse-driven protocol linking insulin to meal intake was associated with a sustained reduction in hypoglycemia without an increase in severe hyperglycemia.
Interpretation. Results fit the theory of change, since improvement followed rising documentation of intake.
Limitations. A before-and-after design on two units can't exclude other influences, such as a change in hospital insulin formulary during the period; the time-series display reduces but doesn't remove this concern.
Conclusions. The protocol has been adopted on both units and is being spread to the surgical service.
References
Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986–992. https://doi.org/10.1136/bmjqs-2015-004411
Provost, L. P., & Murray, S. K. (2022). The health care data guide: Learning from data for improvement (2nd ed.). Jossey-Bass.
