Implementation of a Diabetes Education Toolkit for Pain Management Patients: An Evidence-Based Quality Improvement Project

There are about 98 million Americans with prediabetes and more than 38 million Americans with type 2 diabetes. Diabetes can lead to surgical complications, poor wound healing, infections, and suboptimal recovery outcomes. Experts estimate that only about 5% of patients with diabetes receive education regarding their condition. This project aimed to implement a diabetes education toolkit to increase the number of patients with diabetes who received diabetes education before outpatient pain procedures. Local Problem: Providers at a pain clinic in the western United States, serving patients of varying socioeconomic status, races, and educational backgrounds, report that they never or seldom provide diabetes education to patients. Clinic stakeholders identified that 10-20% of patients at the project site have diabetes and undergo procedures in the operating room. This project aimed to address the gap in diabetes education provided by healthcare providers at the clinic, thereby improving patient outcomes and reducing complications associated with diabetes. This was an evidence-based practice quality improvement (QI) project. A diabetes education toolkit was developed to facilitate diabetes education for patients before having a procedure at the pain clinic. It was implemented over a seven-week period. Thirteen participants, including providers, nurses, and medical assistants, participated. Interventions: A pre-intervention survey was distributed to medical staff at the pain clinic to identify perceived facilitators and barriers to implementing a diabetes education toolkit. A customized toolkit was developed to meet the needs of the medical staff at the clinic. Upon implementation, patient charts were audited weekly to evaluate how often diabetes education was provided. Weekly plan, do, study, act (PDSA) cycles were utilized to enhance the toolkit. Participants were contacted weekly to assess what went well and what prevented them from providing education. Barriers were addressed weekly to facilitate stricter adherence to providing diabetes education. Following a seven-week implementation period, a post-intervention survey was distributed to evaluate the feasibility, usability, and satisfaction of the diabetes education toolkit. This QI project included thirteen participants at the pre- and post-surveys. Before implementing the diabetes education toolkit, all (100%) of the medical staff members reported that none or a few of the patients with diabetes received diabetes education. Post-implementation, 92.3% reported that most or all of the patients with diabetes received education. Patient chart audits during weeks one and two of the toolkit implementation revealed that about 40% of patients with diabetes received diabetes education. By weeks six and seven of implementation, over 90% of patients with diabetes received diabetes education. Implementing a diabetes education toolkit in this pain clinic drastically increased the number of patients with diabetes who received education regarding their disease. The project's strengths include high provider satisfaction with the toolkit, its usability in the clinic setting, and the significant increase in patients receiving diabetes education. The clinic's resources and capacity supported the feasibility of implementing the toolkit. Clinic stakeholders will continue collaborating to enhance and build on the diabetes education toolkit, ensuring its continued usability and satisfaction among both providers and patients.

1 Implementation of a Diabetes Education Toolkit for Pain Management Patients: An Evidence-Based Quality Improvement Project Karlee Burton, Jennifer Clifton, Nancy Allen College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III April 18, 2025 2 Abstract Background There are about 98 million Americans with prediabetes and more than 38 million Americans with type 2 diabetes. Diabetes can lead to surgical complications, poor wound healing, infections, and suboptimal recovery outcomes. Experts estimate that only about 5% of patients with diabetes receive education regarding their condition. This project aimed to implement a diabetes education toolkit to increase the number of patients with diabetes who received diabetes education before outpatient pain procedures. Local Problem Providers at a pain clinic in the western United States, serving patients of varying socioeconomic status, races, and educational backgrounds, report that they never or seldom provide diabetes education to patients. Clinic stakeholders identified that 10-20% of patients at the project site have diabetes and undergo procedures in the operating room. This project aimed to address the gap in diabetes education provided by healthcare providers at the clinic, thereby improving patient outcomes and reducing complications associated with diabetes. Methods This was an evidence-based practice quality improvement (QI) project. A diabetes education toolkit was developed to facilitate diabetes education for patients before having a procedure at the pain clinic. It was implemented over a seven-week period. Thirteen participants, including providers, nurses, and medical assistants, participated. Interventions A pre-intervention survey was distributed to medical staff at the pain clinic to identify perceived facilitators and barriers to implementing a diabetes education toolkit. A customized toolkit was 3 developed to meet the needs of the medical staff at the clinic. Upon implementation, patient charts were audited weekly to evaluate how often diabetes education was provided. Weekly plan, do, study, act (PDSA) cycles were utilized to enhance the toolkit. Participants were contacted weekly to assess what went well and what prevented them from providing education. Barriers were addressed weekly to facilitate stricter adherence to providing diabetes education. Following a seven-week implementation period, a post-intervention survey was distributed to evaluate the feasibility, usability, and satisfaction of the diabetes education toolkit. Results This QI project included thirteen participants at the pre- and post-surveys. Before implementing the diabetes education toolkit, all (100%) of the medical staff members reported that none or a few of the patients with diabetes received diabetes education. Post-implementation, 92.3% reported that most or all of the patients with diabetes received education. Patient chart audits during weeks one and two of the toolkit implementation revealed that about 40% of patients with diabetes received diabetes education. By weeks six and seven of implementation, over 90% of patients with diabetes received diabetes education. Conclusion Implementing a diabetes education toolkit in this pain clinic drastically increased the number of patients with diabetes who received education regarding their disease. The project’s strengths include high provider satisfaction with the toolkit, its usability in the clinic setting, and the significant increase in patients receiving diabetes education. The clinic’s resources and capacity supported the feasibility of implementing the toolkit. Clinic stakeholders will continue collaborating to enhance and build on the diabetes education toolkit, ensuring its continued usability and satisfaction among both providers and patients. 4 Keywords: diabetes, education, toolkit, quality improvement, pain clinic 5 Implementation of a Diabetes Education Toolkit in Pain Management Patients: An Evidence-Based Quality Improvement Project Problem Description Inadequate diabetes management can result in a heightened risk of complications during and after surgery, poor wound healing, infections, and suboptimal recovery outcomes (Wang et al., 2019). Patients with diabetes often require surgical interventions for various reasons, including pain interventions in the operating room (OR). However, many lack adequate education about their chronic condition and its implications for intra and postoperative care. This project aims to implement a diabetes education toolkit to increase the number of patients with diabetes who receive diabetes education, thereby improving patient outcomes and reducing complications. A pain clinic in the western United States performs about 200 procedures per month in the OR, many of which involve sedation by an anesthesiologist and steroid injections. Before this project, the clinic’s stakeholders tracked the number of patients with diabetes who had completed procedures in the OR over the last four years. Their findings show that of the approximately 200 procedures each month, about 10-20% of the patients have been diagnosed with diabetes. This poses a significant challenge to patients who undergo procedures in the OR without first receiving proper diabetes education, as inadequate diabetes management can lead to serious risks and complications. Diabetes education is vital in this population as procedural outcomes are optimized when patients with diabetes aim to keep their blood sugars within the recommended ranges. However, only 5% of patients with diabetes receive diabetes education nationally (Jaffe, 2020). The findings from the clinic’s retrospective chart review are consistent with these national results and demonstrate a need for established diabetes education for patients with diabetes at the pain clinic. 6 This education gap creates a pressing need for a targeted QI project to enhance diabetes education for patients scheduled for pain management procedures. By providing brief, tailored education about diabetes management, including blood sugar monitoring, medications, eating a healthy diet, and regular exercise, patients will be better informed on how to care for themselves in general, especially when leading up to undergoing pain procedures. Providing diabetes education in this context has the potential to help patients with diabetes achieve blood sugars within recommended ranges which would then help reduce complications, increase patient safety, and ultimately improve overall procedural and surgical outcomes for patients with diabetes (Sriphrapradang et al., 2019; Wang et al., 2019). Available Knowledge Type 2 Diabetes is not only widespread but also imposes a staggering economic burden on the United States, costing billions of dollars each year in medical expenses, lost productivity, and long-term health complications. Despite the significant prevalence of this chronic condition and its financial implications, many patients with diabetes lack essential education about effective management strategies and the specific risks associated with their condition. This lack of knowledge can have serious consequences, as diabetes affects multiple body systems, including cardiovascular, renal, and neurological functions, thereby significantly increasing the risk of complications during medical procedures. The risk is particularly pronounced during procedures in the OR, where physiological stress can exacerbate the effects of diabetes. The National Diabetes Statistics Report for 2022 indicated that the number of Americans with diabetes had risen to 37.3 million, or 11.3% of the U.S. population (Diabetes Research Institute, 2023). Diabetes is associated with significant health and economic impacts. Research has consistently demonstrated that achieving and maintaining recommended glucose targets 7 before surgery is crucial for improving surgical outcomes (Wang et al., 2019). For instance, studies indicate that patients who effectively manage their blood sugar levels experience fewer complications, such as infections and delayed recovery (Bodner & Gianchandani, 2014). In contrast, hyperglycemia in the immediate preoperative period has been strongly linked to an increased incidence of postoperative complications, highlighting the need for emphasized diabetes education (Caolibaseanu et al., 2018). The lack of diabetes education represents a significant gap in care, as it prevents patients from understanding how to prepare for surgery effectively and manage their diabetes in the context of their upcoming procedures. In a literature review by Choudhry et al., substantial increases in blood glucose numbers were identified following intra-articular steroid injections, with peak values reaching as high as 500 mg/dL (Choudhry et al., 2016). Furthermore, a review by Crowley et al. highlights the importance of preoperative assessment and optimization for surgical patients with diabetes. Their findings reveal that patients with diabetes experience the highest rates of post-surgical infections, indicating a pressing need for targeted educational interventions to enhance patient preparedness and outcomes (Crowley et al., 2023). Additionally, patients with blood sugars within recommended limits experience decreased variability and faster return to baseline glucose levels than patients whose blood sugar is not within recommended ranges (Aleem et al., 2017). By addressing diabetes educational gaps, the safety and effectiveness of surgical and steroid procedural interventions to treat pain for patients living with diabetes can be significantly improved. Providing brief, tailored education about diabetes management, including blood sugar monitoring, taking medication, eating healthy, and regular exercise, can help patients achieve better outcomes. 8 Rationale This project's selected evidence-based practice model was the Johns Hopkins EBP Model. This model was well-suited for facilitating evidence-based practice change due to its structured approach, which incorporates the best available evidence into practice. The Johns Hopkins EBP Model promotes a cycle of inquiry, practice, and learning (Dang et al., 2021). This model is ideal for healthcare settings as continuous improvement is essential. The model encourages practitioners to ask clinical questions, search for the best available evidence, and critically appraise it before applying it to medical staff practices or patient care (Dang et al., 2021). This model provides a systematic approach to ensure practical interventions are tailored to the clinic's and patient's needs. Inquiries allowed for evaluating current practices at the pain clinic to see if they were safe and of high quality and if improvements could be made. About 20% of the pain clinic patients were reported to have a diagnosis of diabetes. However, an evaluation of the clinic’s practices showed that diabetes education was rarely offered to the patients. The practice component of the model can be broken down by the acronym PET, which stands for practice question, evidence, and translation. The practice question was developed using the PICO method. Evidence was gathered and appraised to support the proposed practice change. The evidence supported optimized recovery from procedures in the OR when patients with diabetes maintained their blood sugars within target ranges. A diabetes education toolkit was developed during the translation phase to translate the evidence into practice. Learning involves the ongoing process of seeking the most recent evidence and working to improve the practices at the clinic. The Johns Hopkins Evidence-Based Practice Model (JHEBPM) 9 effectively translates evidence into practice through searching, appraisal, synthesis, and implementation. In addition to utilizing the JHEBPM, rapid cycle changes were used. Plan, do, study, act (PDSA) cycles were used weekly to improve the project. Study participants were contacted via email and in person to gather information on clinic needs and feedback regarding the implementation of the project. This helped tailor the project to the clinic’s flow and needs. Specific Aims This evidence-based practice QI initiative aimed to implement a toolkit for providers and medical staff to increase the number of patients receiving diabetes education before pain procedures in the OR. A secondary aim of this initiative was to increase patient knowledge by addressing four pillars related to improved diabetes management. These four pillars included healthy eating, regular exercise, medication, and monitoring blood sugar. A tertiary aim was to increase patient referral rates to diabetes education classes. The project evaluated the toolkit's feasibility, usability, and satisfaction through pre- and post-intervention surveys and participant feedback. Methods Context This project occurred at three pain management clinics in urban North Las Vegas, Las Vegas, and Henderson, Nevada. At its initiation, the study participants included one physician, two physician assistants, one nurse practitioner, two nurses, and seven medical assistants. At the project’s conclusion, the study expanded its participants to include two physicians, two physician assistants, one nurse practitioner, one nurse, and eight medical assistants. The change in the number of participants resulted from the practice expanding and hiring new employees during the intervention period. 10 The three pain clinics involved in this study have a diverse patient population, including individuals from various ethnic backgrounds, such as African American, White, Hispanic, Ethiopian, and Korean communities. The clinics do not take insurance; they only accept patients referred by personal injury attorneys. Because of this, many patients seen in the clinics do not have health insurance and have not been managed by primary care providers. Additionally, these patients often come from a low socioeconomic status and poor educational background, with some of the patients’ highest level of education being middle school. Implementation of diabetes education allowed this patient population an opportunity to learn more about diabetes and helped them understand how to manage their condition better. Given these clinics' diverse and underserved patient population, implementing diabetes education was particularly impactful as some patients had limited diabetes education before coming to the pain clinic. Diabetes disproportionately affects the African American population (McLaurin et al., 2024). Racial health disparities were addressed through standardized education to all patients with a diagnosis of diabetes at a consultation or a follow-up visit. To ensure that all patients with diabetes received disease education, the medical assistant would review their intake paperwork. This included gathering their medical history, which included any past diagnosis of diabetes. During the visit, the provider once again asked the patient if they had diabetes. The physicians, physician assistants, and nurse practitioners led the clinical patient visits. The nurses and medical assistants helped room the patients and obtain vital signs. The provider at each location led the clinical team and was responsible for deciding who would deliver diabetes education to patients. Ultimately, it was the provider’s responsibility to ensure that education took place. 11 For four years before this project, stakeholders had been auditing the number of patients seen with diabetes as they recognized a problem in the growing volume of patients with diabetes and the lack of standardized interventions or education being provided to address their needs. Despite the large population of patients with diabetes, education resources were lacking. This project was the only initiative regarding diabetes education taking place during this time, and stakeholders well supported it. Interventions Phase one involved meeting with clinic stakeholders to identify a need at the clinic and discuss potential areas of improvement. It was determined that the number of patients with diabetes seen in the clinic was being tracked, but nothing was done for them beyond that indicator. Clinic stakeholders wanted to provide something to help this patient population. Phase two included a literature review and analysis of current research regarding care for patients with diabetes. The evidence identified that optimized healing amongst patients with diabetes, especially following surgical and interventional injection procedures in the OR, occurs when these patients' blood sugars are within optimal ranges. Given the evidence and the clinic's goals, it was determined that a diabetes education toolkit for medical staff would best suit the clinic and its needs. Phase three involved the development of a pre-implementation survey (Appendix A). Survey questions included information about participants' perceived facilitators and barriers to implementing a diabetes education toolkit. Additional demographic information was gathered regarding the participant’s certifications, years of employment, age, and overall satisfaction at the clinic. The pre-survey was distributed to all participants one week before implementation took place. Survey results were analyzed and taken into consideration when creating the 12 education toolkit. Project implementation began after adjustments were made to include participant feedback. Participants received one-on-one training on the toolkit's contents, with dedicated time spent with each provider, nurse, and MA to emphasize the importance of diabetes education within the pain clinic. The four key pillars of diabetes education—medications, eating a healthy diet, physical activity, and blood sugar monitoring—were reviewed with the providers, nurses, and MAs. A demonstration was conducted to illustrate how to deliver diabetes education effectively, and guidance was provided on accessing shortcuts for charting. Phase four included the development of a diabetes education toolkit. A content expert was consulted to determine the most valuable and accurate information to include in the toolkit. The Association of Diabetes Care and Education Specialists (ADCES) developed seven self-care behaviors for patients with diabetes. The project's content expert helped identify four of the seven pillars to include in the diabetes education toolkit. The four pillars in the toolkit were healthy eating, being active, taking medication, and blood sugar monitoring (Self-care tips, 2023). In addition to addressing these four pillars for improving diabetes care, referral to a diabetes education program was included. The education program was through the American Diabetes Association. Patients were given a QR code and URL, allowing them to register for a class on a day and time that worked with their schedule. When the patient checked out from their visit with the front desk staff, they were offered technological assistance to help register for a class. Patients with lower reading levels were encouraged to attend the free diabetes education classes, as the interactive, hands-on format was considered more beneficial than printed handouts. However, printed materials were still provided to ensure they had additional resources. The printed materials were available in English and Spanish (Appendix C). The toolkit offered a 13 template for providers to chart when diabetes education was given to the patient efficiently. To flag patients with diabetes in the chart, a checkbox titled “Diabetes” was listed next to the patient’s picture in their chart. This checkbox was toggled for all patients with diabetes to help with easy identification of who needed further education. Another checkbox titled “Diabetes Education Provided” was listed under the “Diabetes” box to help keep track of who had received diabetes education. Once diabetes education was provided, the provider or medical staff member would check the “Diabetes Education Provided” checkbox. This allowed for more efficient auditing regarding how often diabetes education occurred. It also enabled participants to quickly identify which patients had already received diabetes education, preventing unnecessary repetition during subsequent visits. Finally, a post-survey was sent to study participants to assess the project's feasibility, usability, and satisfaction (Appendix B). Study of the Interventions This DNP evidence-based QI project utilized pre- and post-surveys using REDCap and weekly chart audits to evaluate potential change statistics regarding the number of patients receiving diabetes education and the usability, feasibility, and accessibility of the brief diabetes education toolkit. Surveys included basic demographic questions and evaluated the staff’s perception of the frequency at which diabetes education was provided, their confidence in it, and staff members’ perceived facilitators and barriers to providing diabetes education via qualitative and quantitative measures. Post-implementation surveys assessed the usability, feasibility, and accessibility of the diabetes education toolkit. Surveys were completed voluntarily. All questions were required for completion except for open-ended questions. The usability of the diabetes education toolkit was further assessed through weekly auditing of patient charts over the seven-week implementation phase. The number of patients 14 who received diabetes education was compared to those who qualified for diabetes education. All patients with a diagnosis of diabetes were deemed candidates for diabetes education. Communication with key stakeholders occurred weekly for three months before and biweekly during implementation. Following the project implementation phase, key stakeholders were contacted monthly for two months. Ongoing communication with key stakeholders regarding changes occurred in person and via email. Neither discussion groups nor individual interviews were used to gather qualitative data. Open-ended questions were utilized in the preand post-surveys to collect qualitative data. A cost-benefit analysis included participant time, the cost of printed materials, and the average procedure cost. Before this DNP project, no structures were established to offer a systematic approach to diabetes education at the pain management clinic. Before implementing this DNP project, staff members reported never or rarely providing diabetes education. Therefore, it is reasonable to assume that the observed outcomes of this DNP project likely resulted from the seven-week implementation of the diabetes education toolkit at the pain clinic. Comparison groups were not used in this QI project. Measures Pre-intervention and post-intervention surveys were created and distributed through REDCap. This secure, web-based platform enables users to design and manage online surveys and databases for data collection. The pre-intervention survey was developed to determine facilitators and barriers to utilizing a diabetes education toolkit, and data on how often participants educated patients with diabetes was gathered. The survey contained three closedended demographic questions, five closed-ended questions with five-item Likert response 15 categories, three select-all-that-apply questions, one yes or no question, and three optional freeresponse questions (Appendix A). The post-intervention survey assessed how often participants provided diabetes education, facilitators, and barriers to providing diabetes education. Additionally, closed-ended questions assessed the toolkit's satisfaction, feasibility, and usability. The last two survey questions included two optional open-ended questions asking participants to describe challenges they encountered while utilizing the diabetes education toolkit and suggestions to improve the toolkit or process of implementing diabetes education (Appendix B). Analysis Descriptive statistics were used to describe the study sample. A content analysis was conducted on the pre-implementation survey questions. The answers were read, categorized, organized, and summarized. Descriptive statistics were also used to describe the answers received from the Likert-scale questions on the pre- and post-implementation surveys. These were grouped according to percentages of participants with a particular answer and described based on frequency. Answers to the open-ended questions in the pre-implementation survey were read word for word, categorized, organized, and summarized. Weekly use of the diabetes education toolkit was analyzed using descriptive statistics. Finally, a content analysis was conducted on the post-implementation open-ended feasibility, usability, and satisfaction survey questions. Responses were read and coded, and then the responses were categorized, organized, and summarized. Ethical Considerations This project was deemed to be QI in nature and not subject to institutional review board oversight. There were no conflicts of interest concerning this study. 16 Results Thirteen clinic employees received the pre- and post-surveys via work-related e-mail. The pre-survey was distributed following a brief, informal discussion on the toolkit's purpose in the clinic. Thirteen (100%) individuals completed the pre-survey, and thirteen (100%) completed the post-survey. However, from the pre-survey to the post-survey, the clinic lost one registered nurse and gained one provider. Demographic data are reported in Table 1. At the time the presurvey was distributed, these individuals included eight (61.5%) medical assistants, two (15.4%) registered nurses, and three (23.1%) providers. At the time of the post-survey, the individuals involved included eight (61.5%) medical assistants, one (7.7%) registered nurse, and four (30.8%) providers. At the time of the pre-survey, nine (69.2%) of participants had one to three years of experience in their role, three (21.1%) participants had four to five years of experience in their role, and one (7.7%) participant had ten or more years of experience in their role. At the time of the post-survey, seven (53.8%) participants had one to three years of experience in their role, four (30.8%) participants had four to five years of experience in their role, one (7.7%) participant had six to ten years of experience in their role, and one (7.7%) participant had ten or more years of experience in their role. Table 2 shows the current practices, barriers, and facilitators. At the pre-survey, barriers were reported as follows: six (46.2%) participants reported time, six (46.2%) participants reported patient engagement, six (46.2%) participants reported cultural and language barriers, five (38.5%) participants reported patient literacy, two (15.4%) participants reported staff resistance to change, and zero (0%) participants reported other. At the post-survey, barriers were reported as follows: five (38.5%) participants reported time, three (23.1%) participants reported patient engagement, five (38.5%) participants reported cultural and language barriers, three (23.1%) participants reported patient literacy, two (15.4%) participants reported staff resistance 17 to change, and two (15.4%) participants reported other. The two (15.4%) participants who reported other barriers expounded on that reply with “providing materials” and “not having the file to print more [handouts] when needed.” At the pre-survey, participants reported the following perceived facilitators: twelve (92.3%) participants reported trained staff, ten (76.9%) participants reported printed resources, seven (53.8%) participants reported integration into workflow, six (46.2%) participants reported the diabetes education checkbox, six (46.2%) participants reported community resources, seven (53.8%) participants reported a supportive environment, and zero (0%) participants reported other. At the post-survey, participants reported the following experienced facilitators: ten (76.9%) participants reported trained, twelve (92.3) participants reported printed resources, six (46.2%) participants reported integration into workflow, eleven (84.6%) participants reported the diabetes education checkbox, one (7.7%) participant reported community resources, two (15.4%) participants reported a supportive environment, and zero (0%) participants reported other. At the pre- and post-surveys, participants were asked what proportion of patients with diabetes they provided or helped provide with diabetes education. The pre-survey responses are as follows: nine (69.2%) participants reported none of them, four (30.8%) participants reported a few of them, zero (0%) participants reported most of them, and zero (0%) participants reported all of them. The post-survey responses are as follows: zero (0%) participants reported none of them, one (7.7%) participant reported a few of them, ten (76.9%) participants reported most of them, and two (15.4%) participants reported all of them. This information is found in Table 2 and Figure 2. Throughout the seven-week implementation, data was collected weekly through chart audits. The data are as follows: during week one, the toolkit was utilized eight out of twenty 18 (40%) times; week two, ten out of twenty-four (41.7%) times; week three, nineteen out of twenty-seven (70%) times; week four, seven out of ten (70%) times; week five, twelve out of sixteen (75%) times; week six, twenty-one out of twenty-three (91%); and week seven, twenty out of twenty-two (90.9%) times during week seven. This is shown in Figure 2. The feasibility, usability, and satisfaction of the diabetes education toolkit were assessed post-survey. All the participants reported that the toolkit was easy to use and well-liked. The majority (84.6%) of participants were interested in continuing to use the toolkit and felt it encouraged patient interactions regarding diabetes education. This data is shown in Table 3. Discussion Summary During the implementation period, all providers, RNs, and MAs at the pain clinics interacted with patients who had diabetes, and everyone either used or facilitated the diabetes education toolkit. Before implementing the toolkit, most providers, RNs, and MAs reported that no patients received diabetes education at the clinics. However, following implementation, most participants reported that most patients with diabetes received diabetes education before undergoing pain procedures in the OR. All patients with diabetes who received diabetes education were instructed on healthy eating, regular exercise, medication, and blood sugar monitoring. They were also shown how to sign up for an in-person diabetes education course. A strength of this project was the number of patients with diabetes who received diabetes education. Over seven weeks, 97 patients with diabetes at the pain clinic received diabetes education. All providers and clinic staff (100%) reported satisfaction with the toolkit and said it was easy to use. All providers and clinic staff would like to continue using the diabetes education toolkit. 19 Interpretation The results of this project were expected and aided by the support and buy-in from the participants. They were interested and willing to add another component to the typical workflow as they could see the benefit of including diabetes education. This allowed for little to no friction during the initial implementation of the toolkit. Although participants were ready and willing to introduce the diabetes education toolkit into the workflow, there were still growing pains. Weekly PDSA cycles helped mitigate roadblocks and allowed for successful uptake of the toolkit. These results are consistent with a similar study that provided a diabetes education toolkit for providers in an inpatient setting at the University of Vermont Medical Center. This study reported that implementing a diabetes education toolkit reduced barriers to providing inpatient diabetes patient education (Brinkman, 2021). This project increased the frequency at which providers at the pain clinics provided diabetes education to patients with diabetes. Providers and clinical staff reported that the diabetes education toolkit was easy to use and increased patient-provider interactions regarding diabetes. The study participants would like to continue to use the toolkit. In seven weeks, providers and clinical staff went from reporting that nearly 0% of patients with diabetes were receiving diabetes education to over 90% receiving diabetes education. The anticipated outcomes aligned with the observed outcomes of this project. The costs of continuing with the diabetes education toolkit are minimal. They include printing costs and a few minutes of staff members’ time to assemble the handouts and provide teaching. Unfortunately, providers were unable to bill for this education. However, they reported that it took less than five minutes to complete and that they could integrate this screening into their visits without significant cost of time. At a post-project check-in three months post- 20 intervention, providers and clinical staff members were still utilizing the toolkit and had plans to continue its use indefinitely. Post-survey responses indicate that participants were satisfied with the toolkit and that it is feasible and usable moving forward. Limitations This project does include several limitations. First, the sample size was relatively small (n=13). Of these 13 participants, providers made up only three of the participants preintervention and four of the participants post-intervention. Second, the implementation time was limited to seven weeks. An extended implementation period may have provided additional data to help identify other barriers. Identification of potential barriers could help this project be even more successful in the future. Other limitations include patient demographics, limited follow-up time, and variability in implementation (e.g., differences in how clinic staff presented the toolkit). To adjust limiting factors, education regarding the toolkit was provided to all participants involved in the study. The same handouts were to be used for all patients with diabetes. Because there was limited follow-up time with a short seven-week implementation, an additional follow-up was scheduled to take place three months post-implementation to see if it was still being used and to assess any barriers if it was not still being used. Another limitation to consider is the relevancy of the toolkit’s information. The information must stay up to date, so future use of this diabetes education toolkit should be updated regularly with current guidelines. Conclusions This project aimed to increase provider-led diabetes education for patients with diabetes. It ensured that every patient diagnosed with diabetes who visited the clinic received standardized 21 education on diabetes management and strategies to promote healing. Clinic auditors identified diabetes education as an area of weakness before implementing the toolkit. Before implementing this toolkit, most providers reported that none of the patients they treated received diabetes education. Following the toolkit's implementation, all providers reported that most of the patients they saw with diabetes received diabetes education. Most of the participants utilized and liked the diabetes education toolkit and wanted to continue using it. This project could be translated to other settings. The clinical director will take over this project and consider moving forward with potential next steps. Avenues to explore in the future may include assessing the effectiveness of the diabetes education toolkit on the patient’s HbA1c, as this project only assessed the frequency at which the provider delivered diabetes education. Moving forward, this toolkit could be translated into more languages. For this project, it was only offered in English and Spanish. An electronic copy of the educational materials may also be beneficial. Patient education materials were limited to printed handouts in this setting. Another area to explore would be screening all patients for diabetes, as many people have diabetes or prediabetes and are unaware. 22 Acknowledgments I want to thank the clinical staff members of DiMuro Pain Management, whose commitment and dedication allowed this project to flourish and enhance patient care. Additionally, I am incredibly grateful to Nancy Allen and her expertise as my content expert, who helped me develop this diabetes education toolkit, and Eli Iacob, who helped me navigate and disseminate the project’s data. Finally, I express immense gratitude to my project chair, Jennifer Clifton. She has been an incredible mentor, leader, and guide throughout this project, and I thank her for her patience and constructive feedback along the way. Thank you for your time and encouragement. I could not have done it without you! 23 References Association of Diabetes Care & Education Specialists. (2023). 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Medicine, 98(14). https://doi.org/10.1097/md.0000000000015089 25 Tables and Figures Table 1: Demographics for medical professionals in Nevada Pain Clinic Pre-Survey n=13 (%) Post-Survey n=13% 18-25 5 (38.5%) 5 (38.5%) 26-35 7 (53.8%) 6 (46.2%) 36-45 1 (7.7%) 2 (15.4%) 1-3 9 (69.2%) 7 (53.8%) 4-5 3 (21.1%) 4 (30.8%) 6-10 0 (0%) 1 (7.7%) 10+ 1 (7.7%) 1 (7.7%) Nurse 2 (15.4%) 1 (7.7%) Provider 3 (23.1%) 4 (30.8%) MA 8 (61.5%) 8 (61.5%) Age (years) Experience (years) Employment Status 26 Table 2 Assessment of Barriers, Facilitators, and Current Practices Pre-Survey N=13 n (%) Post-Survey N=13 n (%) 6 (46.2) 6 (46.2) 6 (46.2) 5 (38.5) 2 (15.4) 0 (0.0) 5 (38.5) 3 (23.1) 5 (38.5) 3 (23.1) 2 (15.4) 2 (15.4) 12 (92.3) 10 (76.9) 7 (53.8) 6 (46.2) 6 (46.2) 7 (53.8) 0 (0.0) 10 (76.9) 12 (92.3) 6 (46.2) 11 (84.6) 1 (7.7) 2 (15.4) 0 (0.0) None 9 (69.2) 0 (0.0) A Few 4 (30.8) 1 (7.7) Most 0 (0.0) 10 (76.9) All 0 (0.0) 2 (15.4) Barriers and Facilitators Perceived or Experienced Barriers Time Patient Engagement Cultural & Language Barriers Patient Literacy Clinician Resistance to Change Other Perceived or Experienced Facilitators Trained Staff Printed Resources Integration into Workflow Diabetes Education Checkbox Community Resources Supportive Environment Other What proportion of patients with diabetes do you help provide or provide diabetes education to? 27 Table 3 Post-Intervention Question Assessing Feasibility, Usability, and Satisfaction Question Post Survey (N=13) n (%) How usable was the toolkit? Easy to use Complicated to use Confusing 13 (100) 0 (0.0) 0 (0.0) Do you like the toolkit? Yes No 13 (100) 0 (0.0) Are you interested in continuing to use the diabetes education toolkit? Yes No 11 (84.6) 2 (15.4) Did the toolkit encourage interactions with patients regarding diabetes education? Yes No 11 (84.6) 2 (15.4) 28 Figure 1 Percentage of Patients with Diabetes Who Received Diabetes Education 29 Figure 2 Participant Self-Reported Deliver of Diabetes Education to Patients with Diabetes Patients With Diabetes Who Received Diabetes Education (SelfReported By Study Participants) 12 10 8 6 4 2 0 None A Few Most Pre Post All 30 Appendix Appendix A Pre-intervention survey disseminated to clinic providers, RNs, and Mas 31 32 Appendix Appendix B Post-intervention survey disseminated to clinic providers, RNs, and MAs 33 34 Appendix Appendix C Patient handouts in English and Spanish on healthy eating, being active, taking medication, and blood sugar monitoring and QR code to sign up for diabetes education classes 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 Diabetes Education Classes https://diabetes.org/tools-resources/diabetes-education-programs 56 Appendix Appendix D Poster 57 Appendix Appendix E Executive Summary