SQuID (Subcutaneous Insulin in Diabetic Ketoacidosis): Clinician Acceptability
Authors: Richard T Griffey, Ryan M Schneider, Margo Girardi, Gina LaRossa, Julianne Yeary, Laura Frawley, Rachel Ancona, Taylor Kaser, Dan Suarez, Paulina Cruz-Bravo
Journal: Academic Emergency Medicine, September 2024
Conclusions: The SQuID protocol was highly accepted by both ED and inpatient clinicians. The majority of ED clinicians preferred it over IV insulin. The high acceptability across various domains indicates that SQuID may be a sustainable and effective intervention for managing low- to moderate-severity DKA in non-ICU settings.
Methods: A cross-sectional survey was conducted from March to November 2023 at an urban academic hospital. Surveys were distributed to ED and inpatient clinicians (both RNs and MDs) who had used or encountered the SQuID protocol. The survey employed Sekhon's Theoretical Framework of Acceptability, assessing eight domains using a 5-point Likert scale. The survey included questions about prior experience with SQuID, clinician preferences between SQuID and intravenous (IV) insulin, and a free-text section for feedback. Descriptive statistics, such as proportions with 95% confidence intervals and medians with interquartile ranges (IQR), were used to summarize responses, and thematic analysis was conducted on free-text responses.
Results:
- The overall response rate was 80% (107 out of 133 participants): 34/42 ED RNs, 13/16 floor RNs, 47/57 ED MDs, and 13/17 floor MDs.
- First-time users of SQuID ranged from 7.7% (hospitalist MDs) to 35.3% (ED RNs).
- The majority of ED clinicians preferred SQuID over IV insulin (67% vs. 12%, with 21% expressing no preference).
- Across all eight domains of the Theoretical Framework of Acceptability, clinicians consistently rated SQuID highly, with a median score of 4 (IQR 4-5) across all clinician types.
- The overall percentage of positive responses (4s and 5s on the Likert scale) was 92%: ED RNs (89%), floor RNs (89%), ED MDs (97%), and floor MDs (87%).
Thematic Analysis of Comments:
- Affective attitude: Clinicians found SQuID preferable and expressed satisfaction with its ease of use.
- Burden: SQuID was considered easy to administer, requiring less effort than IV insulin.
- Self-efficacy: Clinicians reported confidence in their ability to use SQuID effectively.
- Perceived effectiveness: Many clinicians felt SQuID improved patient outcomes in DKA management.
- Ethicality: Clinicians viewed the protocol as fair and beneficial to patients.
- Intervention coherence: The protocol made logical sense to clinicians in the context of DKA treatment.
- Opportunity cost: SQuID did not interfere with other patient care activities, enhancing its acceptability.