Date of Completion
Fall 2026
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
First Advisor
Dr. Amanda Graham
Abstract
Problem: Chronic kidney disease (CKD) is a progressive condition associated with increased risk for end-stage kidney disease, cardiovascular complications, hospitalization, and substantial healthcare costs. Proteinuria is an important marker of kidney damage and contributes to CKD progression. Although evidence-based guidelines support sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapy in eligible patients with CKD, an outpatient nephrology clinic identified underutilization of SGLT2i therapy among patients with proteinuric kidney disease. Pre-implementation practice relied primarily on renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, with inconsistent use of adjunct SGLT2i therapy.
Aim of the Project: The purpose of this quality improvement (QI) project was to increase guideline-concordant SGLT2i prescribing among eligible adult patients with CKD in an outpatient nephrology clinic over an eight-week implementation period. The project aimed to translate Kidney Disease: Improving Global Outcomes (KDIGO) recommendations into routine clinical workflows and reduce variation in prescribing practices.
Review of Evidence: Landmark randomized controlled trials, including CREDENCE and DAPA-CKD, showed that SGLT2i therapy reduces kidney disease progression and adverse renal and cardiovascular outcomes when incorporated into CKD management. Additional meta-analytic evidence demonstrated reductions in albuminuria, slower decline in estimated glomerular filtration rate, and decreased risk for kidney failure across diverse CKD populations, including patients with and without diabetes. Despite these benefits, SGLT2i therapy remains underutilized in clinical practice, supporting the need for structured approaches to improve guideline adoption.
Project Design: A pre-implementation/post-implementation QI design was used to compare SGLT2i prescribing before and after implementation. Measures included prescribing outcomes, provider education completion, alert burden, visit length, prescribing appropriateness, and implementation costs.
Intervention: The intervention involved implementing a structured, guideline-concordant SGLT2i prescribing pathway incorporating EHR best-practice alerts, clinical decision-support tools, standardized workflow processes, and provider education. The team incorporated pharmacy collaboration, medication-access referrals, registered nurse support, and the federal 340B program to address medication affordability and access barriers.
Significant Findings: New SGLT2i prescriptions increased from 84 during the eight-week pre-implementation period to 113 during implementation, representing 29 additional prescriptions and a 34.5% increase from baseline. All five participating providers completed the pre-implementation education, contributing to efficacy with process measures. Alert burden was minimal, visit length was unchanged, and implementation relied primarily on existing organizational resources.
Implications for Nursing: The project demonstrated the value of nursing leadership, interprofessional collaboration, and EHR decision support in translating evidence into practice. Sustaining standardized workflows, provider education, medication-access support, and ongoing outcome monitoring may improve guideline-concordant CKD care and support long-term renal and cardiovascular outcomes.
Recommended Citation
Martin, Tamara, "Improving Guideline-Directed Sodium–Glucose Cotransporter-2 Inhibitor Use in Reducing Proteinuria in Chronic Kidney Disease" (2026). All Doctor of Nursing Practice (DNP) Scholarly Projects. 87.
https://fuse.franklin.edu/dnp-project/87
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