Diabetes

1. Diabetes Presented by: Judi Kort, RN

2. DIABETES TEAM Judi Kort, Champion Dr. Thompson, Physician Champion Brad VanSickles, CNO Barb Warheit, OPI Coach Stacy Beatty, Clerical Support Jane Magee, RN/ICU Janice Mickley, Acute Care Ron Howard, Pharmacy Linda O’Brien, Pharmacy Donna Miller, RN, TCC Billie Sheppard, Laboratory Julie Ryhal, Education

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

4. R1: 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)

5. R2: 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)

6. R3: 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 year

7. Mentor: Dr. Renu Joshi’s Recommendations • Hyperglycemia in the hospital is associated with worse outcomes; the improvement in glycemic control does improve many measures • Intensive control of Hyperglycemia is associated with Hypoglycemia; • GOAL of a good program: Good Control without Hypoglycemic Episodes • Internal 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/dl • Sliding scale coverage alone is ineffective; it must be done in conjunction with basal/bolus insulin

8. Mentor: Dr. Renu Joshi’s Recommendations(cont’d) • Every patient who is not in the ICU should be on basal insulin after 24 hours of sliding scale • Basal calculations should be provided on a PREPRINTED ORDER SHEET and on the back of the PROTOCOL • Nurses 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.

9. The Path to Building an Inpatient Diabetes Program Identify and invite a physician champion Identify and invite nurse champions from each care unit Develop standardized Diabetes Order Sets Educate Physician/Nursing Calculate house-wide glucose data Enhance diabetic diet - carb counts/food choices/snacks

10. Identify and Invite a Physician Champion Family Healthcare Partners Joined the practice in August, 2011 Previously, West Virginia University, Charleston Area Medical Center

11. Identify/Invite Care Area Nurse Champions Judi Kort, Acute Care Janice Mickley, Acute Care Donna Miller, TCC Jane McGee, ICU

12. Develop Standardized Diabetes Order Sets Researched and developed by Dr. Thompson, Physician Champion Presented initially to the Medical Staff in October; input incorporated into Order Sets Final revisions approved by the Medical Staff November 15th Medical Executive Committee approval November 19th Implemented December 3rd

16. Physician/Nurse Education Bulletin Board in Physician Lounge Nursing EducationUpdate General Diabetes Information Physician Order Sets

19. House-wide Glucose Data; Set Internal Target for Intensive Control Medical 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

20. House-wide Glucose Data Challenges Lab 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.

21. House-wide Glucose Data Challenges Lab 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 Spreadsheet Process is manual and time consuming, but is bridging the gap until the new glucometers go live in February, 2013

22. Average Glucose Levels(Acute Care and ICU) Manual Data Collection Electronic Data Collection

23. Carb Counts/Snacks/Diabetic Diet Enhancements Working collaboratively with AVI to assure diabetic-appropriate food choices / snacks Working to assure accurate carb counting for the diabetic patient

24. “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?”

25. R1 – 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) Diabetes Order Set Implemented December 3rd

26. R2 – 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)

27. R3 - 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)

28. Recent 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 old American Diabetes Association “American Diabetes Month 2012”

29. Strengths: • Finding 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

30. Opportunities: • 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

31. Lessons Learned: • Search out an evidence-based path and listen • Don’t 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

32. ROI for Blood Glucose Management Calculate decreased length of stay/additional resources Calculate avoidable readmissions Assess possibilities for improvement in reimbursement with improved documentation Assess 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