A Journey Toward Better Glycemic Control in the Hospitalized Patient

1. A Journey Toward Better Glycemic Control in the Hospitalized Patient Dee M. Brown MSN, RN, CDE Independent Contractor for Diabetes Education

2. Objectives • Identify steps involved in changing the culture of diabetes care in the hospitalized patient • Identify ways to incorporate current standards & guidelines for achieving improved glycemic control through education and EMR tools • Correlate the potential for improved glycemic control to a potential revenue increase from reduced length of stay and cost avoidance

3. The BeginningProblems Identified • Blood glucose levels on most inpatients with diabetes were above recommended targets • Majority of patients were managed with “sliding scale” insulin alone or with oral medications • Subcutaneous and Insulin Infusion order sets rarely utilized • BG testing often done without correlation to meals or insulin delivery

4. The BeginningTackling the Problems • A multidisciplinary team was formed • Members included: Nursing, Hospitalist, Dietary, Pharmacy, IT, Lab, Endocrinology, Nursing education, Quality and an Industry representative providing quality support • The Chief Nurse Executive was an ad hoc member of the committee, providing information to the hospital administration and upper management • Began observational study of BG checks, tray delivery and timing of insulin

5. Review of Literature and Revision of Order Sets • Committee began review of literature in Diabetes Care “Clinical Practice Recommendations” • Society of Hospital Medicine Workbook for Improvement • AACE/ADA Guidelines

6. Subcutaneous Insulin Order Set • Step by step approach • Step 1- type of diabetes D/C oral Meds obtaining an A1C if not done within last 2-3 months • Step 2 – Blood Glucose Monitoring BG Targets: Premeal <140 mg/dL, Random <180 mg/dL • Step 3- Physician to assess TDD insulin needs Pt remains on insulin regimen OR if • newly dx or on oral use wt. based: 0.3 or 0.4 unit/kg • Step 4 –Basal insulin 50% of step 3 • Step 5- Prandial insulin 50% of step 3 divided equally before each meal • Step 6- Add Correctional insulin to scheduled Prandial • Correctional insulin is based on the total daily dose of insulin - low, med, high

7. Applied and Accepted into theGlycemic Control Mentored Implimentation Program (GCMI) with Society Of Hospital Medicine • Goal of GCMI was: • To support the development and implementation of glycemic control in the hospitalized patient • Assigned a mentor • Had access to a national database for one year

8. Process Mapping

9. Changing Culture • Medical Directors began speaking to various physician committees and groups to explain order sets, insulin protocols and benefits of better control • We began the “Let’s Do A 180” campaign • Our mentor with SHM allowed us to use this slogan and design to help spread the word.

10. Tri-Fold Poster Board to Introduce Insulin Order Set • Each nursing unit displayed a tri-fold poster on a tripod • Poster provided information on importance of good glucose control in hospitalized patient • Goals of non ICU Patient: pre-meal<140, 2 hour post meal <180, or random <180 • Stop oral medication for diabetes on admission • Obtain Hemoglobin A1C on admission if not done with in last 2-3 months

11. Changing Culture through Education and Tools • Diabetes Resource Nurse was formed • Developed Diabetes Resource Box for each unit • Mandatory competency for nursing in following subcutaneous order sets and reinforcing terminology of basal/bolus/correction • Designed training and in-service for physicians and nurses • Started “180”campaign • Developed Hyperglycemia Guidelines

12. Diabetes Resource Nurses • Each unit provided a nurse to be a Resource Nurse for diabetes • Five hour seminar to train Resource Nurses in teaching diabetes survival skills • Diabetes Resource Nurses meet monthly • Responsible for training other nurses on their units • Resource to other nurses on their unit • Are not the sole educator for diabetes on their unit • Diabetes Educator still available for consults

13. Resource Nurse Recognition displayed on each unit

14. Diabetes Resource Box • Choice of 3 different meters to be provided to patient • Demo insulin pens & pen needles • Getting Started with Diabetes Self-Management booklet • Coupons for insulin • Referral to out patient diabetes education • Videos

15. Survival Skills Booklet

16. Educating Physician & Nurses • Mandatory competency for nursing • Power Point presentations for physicians • Hyperglycemia Management Procedure • Flag chart for 2 consecutive BG>180 • Call physician for 2 consecutive BG >300

17. StaffEducation and Training • Mandatory hospital wide competency for all nurses • Revised education for all patient care assistants “Let’s Do a 180” Hyperglycemia Management of the Hospitalized Patient Nursing Education

18. Physician Education Glycemic Health Awareness in the Inpatient Setting • ACCE/ADA Glycemic Targets for Hospitalized Pt. with Diabetes • ACCE/ADA Recommended Management in Hospital Setting • Conceptual Insulin Action Profile • Human Insulin and Insulin Analogs • Developing post D/C plan • Example of initiation of insulin therapies • Our hospital newly developed Hyperglycemia Management Procedures

19. Chart Flag • Note to physician • Two consecutive blood glucose readings >180mg/dL • Gentle reminder to consider change in insulin • Two consecutive blood glucose readings > 300mg/dL call to physician

20. Nurse Resource Card • Goal 140-180 • Pre-meal <140 • Random <180 • Hypo <70 Severe (< 40 requires Lab draw) • Treat Rule of 15: ½ c apple juice or 1 cup milk • Recheck: IN 15 minutes DO NOT WAIT FOR ANYTHING • Critical >400 requires lab draw • Flag chart for 2 consecutive BG > 180 • Call MD for 2 consecutive BG >300 or <70 • Never stop basal insulin for patient with type 1 • Never hold basal insulin without physician order • Prandial held when patient NPO, Correctional is given Reminder to do a 180 in thinking and… Keep Blood Glucose under 180 Reminder of goals and treatment

21. EMR Diabetes Education Assessment Tool

22. Assessment Tool Cont.

23. Outcomes • Outcomes were measured in Patient Days and Patient Stays • Goals: • ⇩ number of patient stays with BG >299mg/dL • ⇓ number of hypoglycemic events < 70mg/dL • ⇩ number of hypoglycemic events < 40mg/dL • ⇧ Percent of patient stays in target range (70-180mg/dL)

24. Percent of Stays with Uncontrolled Glucose

25. Percent of Patient Stays in Controlled Range

26. Take Home Message Decreasing Hyperglycemia Did Not Increase Hypoglycemia!

27. How Does All This Lead to Better Care and Revenue? • Inpatient Diabetes Management Programs (IDMP) will: • ⇩ Length of stay • Length of stay may avoid treatment cost and open beds to other revenue producing patients

28. Lessons Learned • Hospital Administration support is a MUST! • Develop a multidisciplinary committee • Do Gap Analysis and timeline first • Establish reasonable and measurable goals • Assign each member of the committee task and hold accountable • Have bi-weekly committee meeting to stay committed and on task

29. Thank You! • Questions?