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Michael Poulin Maine Medical Center Portland, Maine

Michael Poulin Maine Medical Center Portland, Maine. Michael Poulin is a Supervisor, Systems Analyst with Maine Medical Center and has 24 years experience in healthcare.

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Michael Poulin Maine Medical Center Portland, Maine

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  1. Michael PoulinMaine Medical CenterPortland, Maine Michael Poulin is a Supervisor, Systems Analyst with Maine Medical Center and has 24 years experience in healthcare. Michael has been involved in numerous Pharmacy and Hospital system application implementations from a configuration and analytical viewpoint. Michael has build a variety of medication management related order sets including the “Insulin Comprehensive Linked Set”, highlighted here, today.

  2. Electronic Insulin Order SetSCM Implementation Process and Demonstration Michael Poulin Supervisor, Systems Analyst Maine Medical Center

  3. History of Glycemic Management Project at MMC • Initial CSSP (Clinical Services Strategic Planning) Proposal written by John Devlin, MD which is funded for three (3) years beginning FY2008 • 4 Hours MD • 20 Hours Project Manager • 20 Hours CDE • Year 1 “Getting Insulin Right” • Year 2 Coordinate w/Outpatient • Year 3 MaineHealth

  4. History of Glycemic Management Project at MMC (continued) • Gathered Clinicians and reviewed evidence based practice to create guidelines. • Used CTICU/R1 and SCU as base for creating new Insulin Management Tool • CTICU/R1 using insulin with tight glycemic control (80 mg/dL to 120 mg/dL) • SCU using Insulin Drips (Yale Protocol) • Vascular initiative is folded into project

  5. Year 1 “Getting Insulin Right” • Focus Groups • Nutrition Services - CHO diet orders • Develop insulin order set in SCM • Clinical Decision Support Tools • Subcutaneous Insulin • Intravenous Insulin • Transition from IV to SC Insulin • Hyperglycemic Emergencies (DKA, Hyperosmolar Hyperglycemia) • Hypoglycemia • Enteral Tube Feeding (ETF) • Total Parental Nutrition (TPN) • Patient on Glucocorticoids • Perioperative Glycemic Management • Other Diabetes Medications (Oral/Injectable): Contraindications • Patient Education: Survival Skills – Steps To Discharge • Hypoglycemia protocol • Education; RN, MD/DO, Pharm • Roll out

  6. Project Team • Many disciplines involved in team • Physicians, PA’s, NP’s, Nurses, CNA’s, Pharmacists, Dieticians, Lab, and IS. • Team met weekly to review clinical content and to refine processes. • Ad hoc meetings to review subsets of info, when needed. • IS Analyst worked with team to translate the desired clinical practice into an electronic process.

  7. Project Issues/Challenges • Changes in Clinical Practice • Introduction of Basal, Prandial, and Correctional dosing methodology. Simultaneously need to eliminate Sliding Scale practice. • Nutrition orders change from Calorie Counting per day to Carbohydrates per meal.

  8. Project Issues/Challenges • Converting data into electronic process • Complex ordering algorithms – require much analysis to assure appropriate processing of data. • Revised electronic flowsheet to document administration of insulin and quest to incorporate Glucometer test results into flowsheet • No prior experience from which to base creation of electronic process • System limitations encountered - not always able to accommodate request of team.

  9. Project Issues/Challenges • Resource Coordination • Resource Timelines • Largest initiative to date utilizing SCM software

  10. Stop Sliding Scale Dosing(current practice using SCM)

  11. Basal, Prandial and Correctional Dosing..thinking like the Pancreas.. • Releases a continual, low level amount of insulin • providing BASAL • Burst of insulin in response to the rise in glucose after a meal • NUTRITIONAL or prandial • Pancreas responds to and corrects a rise in blood glucose from other sources • CORRECTIONAL

  12. A sample Visio diagram representing one of the many algorithms used in the programming the SCM Order Set for Glycemic Management

  13. The result of all those Visio diagrams: 907 pages of programming… (those sheets you see below have info on BOTH sides!)

  14. In Summary… • Order Set configured in SCM based upon input from Glycemic Management team • Programming done in SCM to support the algorithms derived from the Visio diagrams – resulting in approximately 55,000 lines of code (or 907 pages!)

  15. BMI Example = 22 and the order set automatically fills in appropriate BMI Range field (<25)

  16. Glycemic Control Algorithm: You may select a different BMI range as needed for patient 3 Choices are BMI<25 (TDD <40), BMI 25-30 (TDD 40-80), BMI>30 (TDD >80)

  17. Glycemic Control Algorithm: Target glucose90-130 mg/dl or 120-180 mg/dl

  18. HELP These notes give support and clear explanation

  19. Glycemic Control Algorithm BMI done glucose target doneNext : Nutrition Status selection

  20. Next selectionIV to SC transition day? Answer Yes or No

  21. CHECK HERE to use recommended orders Form fields are locked and turn gray

  22. Hemoglobin A1c Hemoglobin A1c result is displayed (within 6 months) If result is older than 60 days or there is no result then a lab is ordered (as seen above)

  23. Diet Order Any existing diet order will be shown here Diet order has been pre-selected based on your earlier selection Nutrition Consult is automatically ordered

  24. IV Insulin selection Note the Calculator icon – see next slide for functionality

  25. Basal dosing

  26. Basal dosing Choose your Rx agent hover mouse over choice to read support information

  27. You may type or calculate the Glargine dose here

  28. Dose calculator is activated with click on icon

  29. Basal is now set at 15 units

  30. Nutritional factors The next screen choices are pre-selected for breakfast, lunch and dinner

  31. Prandial- Breakfast The appropriate item is checked based on BMI and previous selections

  32. Prandial- Lunch

  33. Prandial- Dinner

  34. Correctional hover mouse to read support information

  35. Meals Bedtime

  36. Hypoglycemia protocol

  37. Nurse to physician orders

  38. When you want them…Oral agents

  39. Click insulin algorithm to view selection summary

  40. Click OK to process

  41. Submit and you are finished

  42. A section of the “Orders” tab once order set has been submitted.

  43. Documentation Form for Prandial Dose (SCM eMAR)

  44. SCM Glucose Management Flowsheetindicating documentation of Prandial Dose of Insulin

  45. and more selections available on Glucose Management Flowsheet

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