A Close look at the MMC DKA Protocol

1. A Close look at the MMC DKA Protocol “Clinician driven performance improvement”

2. Identify the opportunity Establish the team Set specific goals Literature review Develop local practice guidelines Define sources of data Develop quality measures Data reporting Implement changes Monitor results Designing a hospital-wide clinical improvement project

3. Short Version • Team of experts • Literature search • Define current process • Identify gaps • Develop solutions • Establish measures • Implement changes • Monitor results

4. Identify the opportunity • Clinical Pathways top 25 DRG’s • Facilitated Evidence Based care • Required critical self assessment and analysis • Reduced variations in practice • Offered basic performance improvement

5. Physician experts: Endocrinologist Emergency medicine Internal and Family Medicine Performance Improvement Project Manager Data Analyst Nursing experts: Diabetes Clinical Nurse Specialist Medical unit Special Care Unit Emergency department Nurse analyst Nutrition Services Establish the team

6. Set specific goals • Decrease LOS for patients with diabetes • Dr. Phil approach to problem solving: • “can’t fix what you don’t acknowledge” • We did not know what we were trying to fix

7. Goal Setting“don’t wait for the home run, just get to first base” • Literature review • Evidence based guidelines • Standards of care • Define current processes • Identify gaps • Identifies opportunities for improvements • Go after low hanging fruit

8. Literature review • “Hyperglycemic crisis in patients with diabetes mellitus” • “ Effect of Physician specialty on outcomes in diabetic ketoacidosis” • “Using a severity of illness scoring system to access intensive care unit admissions for diabetic ketoacidosis” • Venous vs. arterial blood gas in assessing pH

9. Summary of findings • ADA published clinical practice guidelines • pH is an important diagnostic tool • Potassium should be assessed prior to insulin • Endocrinologists are valuable in complex DKA • Severity of illness score improves resource utilization • Nutritional consults are a JCAHO standard

10. Develop local practice guidelines • Identify variations / gaps in current processes • Flowchart reality • Flowchart “best practice” – 80% rule • Brainstorm opportunities for improvement • Let go of sacred cows • Ask why do we do it this way • Involve other experts to help identify solutions • Ask “what would it look like if…..”

11. EBM • Insulin dosing protocol • pH is important diagnostic tool • Obtain potassium results before insulin • Consult endocrinologist for complex cases • Calculations for a Severity of Illness Score • Nutritional consult is a standard

12. Gaps • Our process • Arterial blood gases not standard • WHY? • difficult to draw • patient dissatisfier - painful • time consuming to obtain – requires RRT • Insulin dosing before serum K+ results • WHY? • knee jerk response: • lab takes too long to turn around results – 1 hour • lab expert: time limitations inherent in running serum-based labs • time to draw (tube does not always get to lab quickly) • time to clot • time to spin

13. Brainstorming • Venous blood gas is an acceptable alternative to ABG for the majority of DKA patients • Point of care testing • Venous pH, Glucose, Electrolytes • iSTAT – analyzer used in NICU for rapid results • “Standby” machine for neonatal transports • could we move it to the emergency room?

14. Solutions • Identified “Chiron” analyzer in lab for whole blood • Venous pH • Electrolytes • Glucose • Hct • Ionized calcium • Developed new lab item: • DKA panel • Whole blood sample – routine phlebotomy • no time to clot • no time to spin • 5 min turn around time after arrival in lab • Developed DKA Calculator

15. Define sources of data • Chart audit • Data collection forms • ADT data • Electronic order entry data

16. Develop quality measures • Total admits • SCU admits • ED treat and DC • Utilization of rescue drugs • Mannitol • Glucagon • D50 • NaHCo3

17. Data Reporting • Select a sample of cases for review • Develop practice and outcomes reports • Develop ongoing monitoring program

18. Implement changes in clinical practices • Use of venous sample for pH • Obtain potassium results before insulin • DKA panel – whole blood testing for pH, K+, and glucose • Insulin dosing and weaning protocol • Consult endocrinologist for complex cases • Calculations for a Severity of Illness Score • Nutritional consult is a standard

19. Monitor Results • Develop ongoing monitoring program • Team responsible to analyze data • Revise plan as data indicates

20. Clinical performance improvement is a continuous process that does not have an end point