Diabetes

Presented by:Judi Kort, RN1Diabetes

Hello, my name is Judi Kort. I am a registered nurse. I have been working on the Acute Care Unit. In September, I started working in Diabetes Education and as the new Diabetic Champion.1DIABETES TEAMJudi Kort, ChampionDr. Thompson, Physician ChampionBrad VanSickles, CNOBarb Warheit, OPI CoachStacy Beatty, Clerical SupportJane Magee, RN/ICUJanice Mickley, Acute CareRon Howard, PharmacyLinda OBrien, PharmacyDonna Miller, RN, TCCBillie Sheppard, LaboratoryJulie Ryhal, Education2

This is our present team.2AIM STATEMENTWork to reduce hyperglycemic and hypoglycemic events for patients admitted with diabetes

Assess the continuum of care of patients with diabetes by reviewing availability of HbA1c

3In our second program year, we will work to build a Diabetes Management Program that will:

3R1: Hyperglycemic rate per 1000 patient days (trend in the rate per 1000 patient days over nine months of data submitted at the end of the program year)4This is the data collected from last year.45R2: Hypoglycemic rate per 1000 patient days (trend in the rate per 1000 patient days over nine months of data submitted at the end of the program year)And these are our hypoglycemic rates for last year. As you can see, there is no pattern, no steady rise or fall because we did not have a diabetes program in place. 56R3: Percent of patients with a discharge diagnosis of diabetes who either had an HbA1c within the past 90 days prior to admission or received an HbA1c prior to discharge over nine months of data submitted at the end of the program year6Mentor: Dr. Renu Joshis Recommendations7

Hyperglycemia in the hospital is associated with worse outcomes; the improvement in glycemic control does improve many measuresIntensive control of Hyperglycemia is associated with Hypoglycemia; GOAL of a good program: Good Control without Hypoglycemic EpisodesInternal goals should be set based on your own internal glucose data; the right target for intensive control is debatable : 80-120 or 100-140 or 140-180 mg/dlSliding scale coverage alone is ineffective; it must be done in conjunction with basal/bolus insulin

So really, we didnt have a program per se for diabetes. At the end of last year it was decided that we needed a program. Research was done and it was found that Pinnacle Healthcare was awarded the Joint Commission Gold Seal of Approval for advanced patient diabetes management.This program was developed over 10 years by Dr. Renu Joshis. GCMC was able to consult with Dr. Joshi and after our critical analysis they decided to follow her recommendation.7Mentor: Dr. Renu Joshis Recommendations(contd)8

Every patient who is not in the ICU should be on basal insulin after 24 hours of sliding scaleBasal calculations should be provided on a PREPRINTED ORDER SHEET and on the back of the PROTOCOLNurses are advised to call the physician if they were not on basal insulin after 24 hours and if glucose was greater than 150 (GCMC internal target) House-wide glucose data is the first step in reaching the goal of good glycemic control; must be done electronically, due to the sheer volume of data and the need to have the capability to manipulate the data by unit, physician, etc. So really, we didnt have a program per se for diabetes. At the end of last year it was decided that we needed a program. Research was done and it was found that Pinnacle Healthcare was awarded the Joint Commission Gold Seal of Approval for advanced patient diabetes management.This program was developed over 10 years by Dr. Renu Joshis. GCMC was able to consult with Dr. Joshi and after our critical analysis they decided to follow her recommendation.8

The Path to Building an Inpatient Diabetes ProgramIdentify and invite a physician championIdentify and invite nurse champions from each care unitDevelop standardized Diabetes Order SetsEducate Physician/NursingCalculate house-wide glucose dataEnhance diabetic diet - carb counts/food choices/snacks99Identify and Invite a Physician ChampionFamily Healthcare PartnersJoined the practice in August, 2011Previously, West Virginia University, Charleston Area Medical Center10

The approached Dr. Cheryl Thompson who is part of the Family Healthcare Partners group. She joined the practice in August. She brings experience from West Virginia University, Charleston Area Medical Center.10Identify/Invite Care Area Nurse Champions Judi Kort, Acute CareJanice Mickley, Acute CareDonna Miller, TCCJane McGee, ICU

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I was asked to be the nurse champion and started in September.11Develop Standardized Diabetes Order SetsResearched and developed by Dr. Thompson, Physician ChampionPresented initially to the Medical Staff in October; input incorporated into Order SetsFinal revisions approved by the Medical Staff November 15thMedical Executive Committee approval November 19thImplemented December 3rd

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This is our Subcutaneous Insulin management orders. We did have a set before that was very basic, but this one covers the standard of care. As basel-bolus, ordering HbA1C diet and appropriate sliding or correctional scale. There are also recommendations at bottom to encourage nursing to engage medical staff with trends.1415

Adults not in DKA. Some of the ICU nurses said this is basically what they do, but now its is all in a protocol.15Physician/Nurse EducationBulletin Board in Physician LoungeNursing Education UpdateGeneral Diabetes InformationPhysician Order Sets

16Before this was implemented, emails were sent to nursing and medical staff to educate them on changes.There was also an educational bulletin board placed in physicians lounge.1617

Updates were posted.1718

18House-wide Glucose Data; Set Internal Target for Intensive ControlMedical Staff set Internal Target for Intensive Control at 150

Internal Target will be adjusted as progress is made

House-wide Glucose Data a challenge to collect

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19House-wide Glucose Data ChallengesLab glucose values and glucometer glucose values are stored in different modules of our information system (CPSI).We were waiting for the new glucometers, as we knew that the glucometer data would cross an interface and collect in the Lab module (connectivity), so that we could pull one ad hoc report with all glucose values each month.Glucometer project was delayed due to software programming.Work-around designed to allow house-wide glucose numbers to be obtained brainstorming occurred on how to collect the data manually.

2020House-wide Glucose Data ChallengesLab glucose values can be pulled monthly to an ad hoc report in CPSI, exported into Excel for statistical analyses.Glucometer glucose values must be pulled by each patient, printed out of the Point-of-Care module, and then hand-entered onto the Excel SpreadsheetProcess is manual and time consuming, but is bridging the gap until the new glucometers go live in February, 2013

2121Average Glucose Levels(Acute Care and ICU)22Manual Data CollectionElectronic Data Collection22Carb Counts/Snacks/Diabetic Diet EnhancementsWorking collaboratively with AVI to assure diabetic-appropriate food choices / snacks

Working to assure accurate carb counting for the diabetic patient

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Spoke with dietician and some changes were made to ensure that they were nutritionally appropriate

Carb CountsFor insulin pumpsFor educational purposesPhysician had ordered some carb intakes to be covered with fast-acting insulin

Current operating system being used by AVI here not able to print on ticket

Manually printed on each ticket by diet clerk

AVI will be providing us with a manual that will give us carb values of their food to help if we question an amount

They will also put a red dot on the bottom of the ticket to signal the hostess not to take the tray until the nurse pulls the ticket so the nurse can evaluate the tray.

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Today I ate two bowls of dog food, a sandwich crust, some spaghetti that fell on the floor, half of your cat food, a wet tea bag, three bugs and the inside of a sneaker.How many carbs is that?A little humor is never a bad thing!24R1 hyperglycemic rate per 1,000 patient days (trend in the rate per 1,000 patient days over nine months of data submitted at the end of the program year (C1)25Diabetes Order Set Implemented December 3rdFor the first time our hyperglycemic rate is trending downward; since the physician orders were not approved by the Medical Staff until November and not implemented until December, we believe that this downward trend could be associated to Dr. Joshis presentation and subsequent discussion with the medical staff in April of last year on strict glycemic control and how to change practice to achieve it; this downward trend at the beginning of this program we believe is a result of individual physicians changing their practice before we formally institued the order sets.25R2 hypoglycemic rate per 1,000 patient days (trend in the rate per 1,000 patient days over nine months of data submitted at the end of the program year) (C2)26Our hypoglycemic rate is also trending downward26R3 - percent of patients with a discharge diagnosis of diabetes who either had a HbA1c within 90 days prior to admission on the chart or received an HbA1c prior to discharge (C8)27The HbA1cs are monitored daily through chart audits. Pharmacy helps identify patients and Utilization Review is also helping for secondary diagnoses that are controlled with diet and exercise.

If an HbA1c is not found in the sytem, the physicians office is contacted in case they had blood work outside the GCMC system. If not, then an order is requested for testing.

As you can see we continue to trend upward, most months in the high 90s.2728Recent estimates project that as many as one in three American adults will have Diabetes in 2050

Diagnosed Diabetes cost the USA $174 Billion each year (an increase of 32% since 2007)

$1 out of every ten health care dollars is attributed to Diabetes care.

The risk for stroke and death from heart disease is 2 to 4 times higher among people with diabetes

Diabetes is the leading cause of kidney failure

More than 60% of non-traumatic lower limb amputations occur in people with Diabetes.

Diabetes is the leading cause of new cases of blindness among adults ages 20-74 years oldAmerican Diabetes Association American Diabetes Month 2012

28Strengths:29Finding a Best Practice Mentor and following her recommendations

Being open to implementing evidenced-based practice Physician willing to take leadership role; nursing staff willing to champion the effort on their respective units

Medical Staff consensus to approve order sets and set house-wide glucose target

Glucometer interface to provide house-wide glucose data

Although this is my first year as champion of this initiative, I feel that we are well on our way to building an effective inpatient diabetes management program. We are following the wisdom Dr. Joshi brought to us at the end of last program year and there has been a real TEAM effort to get us this far

We all know we still have a journey ahead of us and we still have many opportunities to improve the glycemic management of our patients when they are in our care, but the data is telling us we are on the right course.29Opportunities:30 Tighten glycemic control as data warrants

Strengthen Hypoglycemic protocols

Improve diet program

Increase awareness of the importance of good glycemic control in the hospitalized patient

Although this is my first year as champion of this initiative, I feel that we are well on our way to building an effective inpatient diabetes management program. We are following the wisdom Dr. Joshi brought to us at the end of last program year and there has been a real TEAM effort to get us this far

We all know we still have a journey ahead of us and we still have many opportunities to improve the glycemic management of our patients when they are in our care, but the data is telling us we are on the right course.30Lessons Learned:31Search out an evidence-based path and listen

Dont ever think that just because you are not as large as the best-practice system that you cannot learn from them and improve what you can at a pace you can

Implement steps and keep going in the face of roadblocks

31ROI for Blood Glucose ManagementCalculate decreased length of stay/additional resourcesCalculate avoidable readmissionsAssess possibilities for improvement in reimbursement with improved documentationAssess if we have avoided cost for a Never Event. (As of July 31, 2008, hospital-acquired manifestations of poor glucose control, which are considered preventable events, will no longer be covered by CMS. This is based on the view that effective glucose management can be achieved with evidence-based guidelines and sound medical practice in the hospital setting .) Centers for Medicare & Medicaid Services. Hospital-acquired conditions

32Between now and year-end we will assess how investing in a Inpatient Diabetes Management Program has either generating cost savings or revenue generation for us.

Thank you for your attention; are there any questions..

And now I would like to introduce Liza Wagner, she will be presenting our work on the VTE Indicator 32