Optimal Glycemic Control: Making it a Priority and Making it Happen

1. Optimal Glycemic Control:Making it a Priority and Making it Happen Mary Harkins Becker, MD Medical Director, MaineHealth Lisa Letourneau, MD, MPH Senior Medical Director, MaineHealth May 31, 2006

2. Goals of this session • Review the case for addressing inpatient glycemic control • Outline current care delivered to inpatients with elevated blood sugars • Outline optimal care for these patients • Discuss working together to narrow this gap

3. Inpatient glycemic control = maintaining blood sugars in hospitalized patients in a target range to improve patient outcomes and decrease hospital costs

4. Why address elevated blood sugars? • Epidemic of diabetes in US and ME • > 10% of Mainers have diabetes • > 30% of inpatients have diabetes

5. Inpatients with elevated blood sugars… • Fall into 3 categories: 1. Patients with known diabetes 2. Patients with previously unrecognized diabetes 3. Patients with elevated blood sugars in response to stress • 25% of these patients will develop DM w/in 6 months

6. Why address elevated blood sugars? • What do the experts say? • “Compelling evidence continues to accumulate to suggest that poorly controlled glucose levels are associated with increased morbidity and mortality, as well as higher costs.” -Consensus Recommendations: Position Statement American Academy of Clinical Endocrinologists and the American Diabetes Association, February 2006

7. Some Outcomes Data: • Single BS > 220mg/dl on 1st post op day, sensitive predictor of nosocomial infection • Admission BS> 110 mg/dl associated with increased mortality in acute CVA patients • Consensus Recommendations: Position Statement American Academy of Clinical Endocrinologists and the American Diabetes Association, February 2006

8. Some Cost Data: • Poor glucose control leads to increased LOS • For every 50mg/dl increase in BS in DM pts having CABG 0.75 additional hospital day • Poor glucose control leads to increased rates of sepsis compared to tightly controlled patients in the ICU • Consensus Recommendations: Position Statement American Academy of Clinical Endocrinologists and the American Diabetes Association, February 2006

9. Why address elevated blood sugars? • Anticipated quality of care benchmark of CMS and JCAHO in the near future

10. Why Change? Meet Ms. D. • 56 yr old mother, wife, & bookkeeper • Known diabetes, recently placed on sc insulin • Admitted for knee replacement • Admission BS: 220

11. Post Op Day 1 • AM BS = 280mg/dl • Ms. D has no appetite, nurse holds insulin order fearing hypoglycemia • No repeat testing done

12. Post Op Day 2 • Ms. D has an inferior MI • Transferred to cardiology service • AM blood sugar 245mg/dl • Cardiologist can find no documentation of Ms. D’s insulin regime in chart • She makes her best guess and begins Ms. D on sc insulin and a sliding scale

13. Post Op Day 3 • 6 AM BS = 235 mg/dl • 9am insulin dose given with extra insulin for BS> 150 • Also eats breakfast • Repeat pm blood sugar = 150mg/dl • Ms. D is NPO for cardiac cath in am, nurse holds insulin fearing hypoglycemia

14. Post Op Day 4 • AM BS 338 mg/dl • Ms. D’s op site is red warm and oozing • Endocrine consult is ordered for help controlling blood sugars • No Hb A1C is found on chart

15. Ms. D’s Hospital Course • 14 day stay • Blood sugars routinely >200 • Multiple complications • No diabetes education done • No direct communication with PCP for follow up care of her diabetes

16. Ms.D: Atypical or Too-familiar ? “Usual” care… • Oriented to acute admission, procedure • Focus on physician’s treatment, not patient’s role in management • Interaction frustrating for both patient and doctor • Systems not in place to proactively identify patient needs, provide support & education

17. Ms. D. Revisited: A More Prepared Patient • Ms. D. receives patient info on value of tight inpatient glycemic control as part of pre-operative visit • Discusses plan for glycemic control during stay with her PCP and orthopedist prior to admission • On admission, discusses plan for ongoing glucose monitoring with admitting RN

18. A More Prepared Care Team • Admitting nurse notes BS of 220, activates standing insulin order set • Peri-operative team monitors BS’s every 4 hrs, adjusts insulin according to order set • Ms. D resumes self-monitoring on post-op Day 2, discusses results with nursing team • Post-op nursing staff assess Ms D’s diabetes knowledge, offers TARGET Diabetes Patient Ed materials

19. Transitioning the Care Team • Nursing staff notify Ms D’s PCP nurse care manager at time of discharge, notes lack of previous diabetes self-management training • Care manager calls Ms D next day to answer questions, sched’s home visit for wound check, reinforce goals and ADEF appt • 2 wks later: Ms D seen in PCP office

20. Ms. D. – A Better Ending… Living Well with Diabetes 5 Yrs later: • Ms. D able to continue working, caring for family • Blood sugar, BP, and lipids at or near goal • Planning early retirement trip with husband, able to visit new granddaughter and take her for a walk

21. Getting from Here to There: Key Change Ideas • Healthcare system design: Identify interdisciplinary team and clarify roles • Clinical Information Systems to improve care • Decision support: Incorporate evidence-based guidelines into workflow • Self-management support: Educate and support self-management skills • Community: Partner with community resources

22. Are You Ready?? • Is improved inpatient glycemic control recognized as an improvement opportunity? • Is there organizational commitment to address the issue? • Is it on the QI plan?

23. How Can MaineHealth Help? • Clinical direction • e.g. Inpatient Glycemic Control Workgroup • Data for improvement • E.g. Standards for data collection, facilitated data sharing • Facilitate cross-institutional learning • Technical assistance • Other??