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Glycemic Control Teams Available Models

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					Glycemic Control Teams:
    Available Models
   Sarah L. Sherington PharmD
Jacqueline Thompson RN, MAS,CDE
 Glycemic Control Team
      SWMC model
     Sarah L. Sherington PharmD
Glycemic control team/surgical services
Southwest Washington Medical Center
     TEAM Approach to the Treatment
    of the Hospitalized Diabetic Patient

                          Pharmacist
          Physician




                                  CDE

Endocrinologist
Team Approach
• Physician: champion for the team. Resource for guidance
  with challenging patients
• Pharmacist: management of patients without internal
  medicine involvement. Resource for physicians needing
  help with challenging patients
• Certified Diabetes Educator: education for newly
  diagnosed diabetics, patients using insulin for first time,
  poorly controlled diabetics
• Nurses: Identification of patients with poorly controlled
  blood glucose, no basal insulin ordered or none diabetics
  with no blood glucose checks ordered
Why a Pharmacist Model?

• De-central pharmacists manage most of
  the clinical activities related to medication
  use
• Accessible 24 hours a day
• Have prescriptive authority for in-patients
Role of Glycemic Control Pharmacist
• Identifies all surgery patients who are
  diabetic or have a recorded elevated blood
  glucose
• Surgery patients include all patients
  admitted to the two surgery floors or
  medical/surgery floor not followed by a
  PCP and all CABG patients transferred
  from CCU
• Resource for physicians and nurses with
  patients with poor glycemic control
Management of the Surgical Patient
Pre operative
• Instruction sheet given to all diabetics
  – Hold oral diabetic medications day of surgery
  – Give full dose of glargine (Lantus®) the night
    before surgery
  – Give half usual dose of NPH or regular insulin
    day of surgery
  – In order to reduce complications such as
    infection, you may be given insulin during
    your hospitalization, even if you are not
    currently using insulin
Inpatient Management of
Hyperglycemia
• Hold oral diabetic medications
• Intravenous insulin therapy
  – Best therapy for patients with a critical illness,
    changing status or severe hyperglycemia
• Scheduled insulin
  – Basal and prandial/nutritional insulin
• Supplemental insulin
  – Increase in daily insulin requirement attributed to
    illness, stress or treatment
Insulin Management

• Day of surgery
• Basal insulin:
  – Insulin at home: usual insulin dose
  – No insulin at home: 0.2unit/kg for most
    patients. Elderly, liver failure or poor renal
    function: 0.15unit/kg
• Correction dose insulin:
  – Based on BMI or insulin use at home
Management

• Nutritional status is assessed
• Eating or brief NPO: any dextrose
  containing fluids are changed to non
  dextrose containing fluids
• Prolonged NPO: continue dextrose
  containing fluid
• Home regimen reviewed
• Hold all oral diabetic medications
Subsequent Insulin
Management
• Based on blood glucose from previous 24
  hours
• Basal insulin
  – Increase if fasting blood glucose elevated
• Prandial insulin
  – Transition to eating meals: consider ordering
    rapid acting insulin after meals if unsure how
    much patient will eat
  – Increase if pre meal blood sugar elevated
Monitoring
• Patient is eating: blood glucose before meals and
    at bedtime
•   Patient is NPO: blood glucose q 4h or q 6h
    depending on whether regular or aspart insulin
    ordered
•   Labs: HgA1C (if not done in last 30 days)
•   Basic Metabolic Panel if on metformin
    (Glucophage®) or not done prior to surgery
•   0300 blood glucose if glargine(Lantus®) ordered
Discharge
• Diabetic patient with HgA1C <8%:
     – continue on usual home regimen
•   Diabetic patient with HgA1C>8%:
     – referral sent to patient’s PCP
     – patient to follow up with PCP or SWMC Diabetes Clinic
•   Diabetic patient requiring change in insulin/medication
    regimen:
     – referral letter to PCP
     – patient to follow up with PCP
•   Non diabetic patient with elevated blood glucose during
    hospitalization or HgA1C>6%:
     – education on blood glucose monitoring
     – referral letter to patient’s PCP
     – patient to follow up with PCP
How well are we doing?
Patient Numbers


• CDEs : average 8 patients/day
• Pharmacists: average 14 patients/day
                                      8th Floor Surgical: Average Blood Sugar
                                             February 2007 - June 2007

                              179.9
                  180


                  175



                  170

                                              168.5
                  165
                                                             161.9
Average (mg/dl)




                  160
                                                                              156.9
                  155



                  150
                                                                                            150.7

                  145


                  140



                  135


                  130


                             b0
                                  7       r   07            r0
                                                                 7
                                                                         y   07             07
                        Fe             Ma              Ap             Ma              Jun
                                       8th Floor Surgical: Percent Glucose Readings by Range
                                                      February 2007 - June 2007
                                           < 40 mg/dl                 40 - 69 mg/dl                70-180 mg/dl                >= 200 mg/dl

          80                                                                                                                                        78.2
                                 70-180 mg/dl                                                                           74.6

          70                                                                          68.9

                                                         63.1
          60

                          59.3

          50
Percent




          40

                                     >=200 mg/dl
          30
                              26.9
                                                                                      21.8
          20                                              22.7                                                          16.2
                                                                                                                                                     13.8

          10   <40 / <70 mg/dl


                                                                0.7                          1.1                             0.8                         1.1
                              0.0                  0.0                          0.0                               0.2                         0.2
           0


                     b0
                          7                        r     07                         r0
                                                                                         7
                                                                                                                y       07                          07
                Fe                              Ma                             Ap                            Ma                               Jun
                                       7th Floor Surgical: Average Blood Sugar
                                              February 2007 - June 2007

                  180


                  175



                  170


                  165
Average (mg/dl)




                  160


                  155



                  150
                               145.7
                  145                          147.9
                                                                               141.3         143.9
                                                              139.4
                  140



                  135


                  130

                               07          r   07            r0
                                                                  7
                                                                          y   07             07
                        Fe
                           b            Ma              Ap             Ma              Jun
                                      7th Floor Surgical: Percent Glucose Readings by Range
                                                     February 2007 - June 2007
                                          < 40 mg/dl                40 - 69 mg/dl                70-180 mg/dl                >= 200 mg/dl

          100
                                 70-180 mg/dl

           90
                                                                                    84.8                              84.9
                                                                                                                                                  81.6
                                                       80.1
           80             84.4

           70
Percent




           60


           50


           40


           30


           20                                   >=200 mg/dl

                                                                                                                                                   11.2
                                                                                    8.3                               8.7
           10              9.0
                <40 / <70 mg/dl
                                                        11.1
                                                              2.6                          1.9                              1.9                        1.3
                              0.4                0.1                          0.4                               0.2                         0.2
            0

                         07                        r   07                         r0
                                                                                       7
                                                                                                              y       07                          07
                  Fe
                     b                          Ma                           Ap                            Ma                               Jun
Goal: BG 70-180mg/dl
• General Surgical floor:
  – September 2006: 62% patients with blood glucose
    within range
  – June 2007: 82% patients with blood glucose within
    range

• Orthopedic Surgical floor:
  – September 2006: 62% patients with blood glucose
    within range
  – June 2007: 78% patients with blood glucose within
    range
Average Length of Stay
                    Ave Length of Stay (ALOS) Comparison - Surgery Patients with and without Insulin

            12.00




            10.00




             8.00


                                                                                                                  W/Insulin
ALOS




                                                                                                                  W/O Insulin
             6.00
                                                                                                                  Linear (W/Insulin)
                                                                                                                  Linear (W/O Insulin)


             4.00




             2.00




             0.00
                     JUN-    JUL-   AUG-   SEP-   OCT- NOV-     DEC-    JAN-   FEB-   MAR-   APR-   MAY-   JUN-
                      06      06     06     06     06   06       06      07     07     07     07     07     07
       W/Insulin      9.70   8.44   8.22   8.31   9.42   8.59   8.59    8.09   9.59   9.36   7.88   8.28   7.77
       W/O Insulin    3.79   3.93   3.79   3.93   4.57   4.06   3.93    3.61   4.15   3.76   4.04   3.80   3.49
                                                                Month
Physician v. Pharmacist
Management
  •   Average Blood glucose of 34 patients
      managed by Pharmacist v. 25 patients
      managed by MD
  •   Pharmacist Managed patients: 153mg/dl
       SD = 46.8, N = 584 data points across 34
      patients, Standard Error = 1.936
  •   MD managed patients: 156mg/dl
      SD = 51.4, N = 485 data points across 25
      patients, Standard Error = 2.33
Hypoglycemia
Hypoglycemia    MD     PharmD


BG < 40mg/dl    1.6%   0.2%


BG 41-69mg/dl   1.2%   0.7%
Team Responsibilities
   • Development of a policy & procedure for insulin
     pump users while they are inpatients
   • Expand the insulin infusion protocol usage and
     facilitate staff education on the protocol
   • Development of a process for communicating a
     discharge plan which may include co-ordination
     with the SWMC Diabetes Center for newly
     diagnosed and other appropriate patients
   • Update Diabetes Survival Skills protocols and
     education materials on a regular basis
Team Responsibilities
  • Collection of program data on a continuous basis for
      outcomes tracking and research.
  •   Provision of drug information to health professionals and
      patients .
  •   Provision of education programs for health care professionals
      to meet requests and identified needs including programs to
      maintain a high level of awareness among SWMC inpatient
      care staff.
  •   Update inpatient diabetes care protocols, policies and
      procedures, and standing orders on a regular basis.
  •   Continually update clinical activities.
Hiccups
• No announcement made to remind physicians
  the service was beginning:
  – Surgeons taken by surprise
• No plan for help when the glycemic control
  pharmacist not available:
  – Extensive education to pharmacists including the
                          t
    night pharmacist
  – Development of a step by step process to assist out
    of hours coverage
The Future

• Application for prescriptive authority for
  pharmacists to write out patient
  prescriptions
• Establishment of a follow up discharge
  program
  – 2 weeks post discharge follow up phone call
  – inpatient team able to follow up with patients
    in the SWMC Diabetes Clinic
Glycemic Control Team:
  NP and CNS Model
Jacqueline Thompson RN, MAS, CDE
   Director Diabetes Service Line
  Sharp HealthCare, San Diego, CA
Health Care Implications
 • There is high variability in the management
     of diabetes in the hospital setting resulting in
     poor glycemic management.
 •   This leads to:
               > increased cost per case
               > complications
               > readmissions
               > prolonged length of stay
    Koproski, et al, Diabetes Care, 1997




53% reduction in
readmission
within 30 days
     P < 0.01
Hospitals Used to Compare
       ANP Models
    CNS Hospital             NP Hospital
• Largest Sharp          • Largest hospital in the
   Hospital                 South Bay
• ~ 450 Acute Care       • ~ 330 Acute Care
   Beds                     Beds
• ~ 90 Critical Care     • ~ 30 Critical Care
   beds                     beds
• ~ 1000 Medical Staff   • ~ 450 Medical Staff
• Trauma center          • Located in an area
                            that is 48% Hispanic
• 26% Diabetics
                         • 36.9% Diabetics
Diabetes Initiative Time Line
 2002        2003         2004          2005    2006   2007
 Planning   Orders       CNS
 Baseline   Metrics      On Watch
 Planning   Orders     Pharmacy     APN
 Baseline   Metrics

            Planning          Orders      NP
                   Baseline   Metrics

              Planning         Orders
                      Baseline Metrics

                          Planning     Orders
                            Baseline Metrics
                        BG-Avg/mo (mg/dl)




            140
                  150
                         160
                               170
                                     180
                                            190
                                                  200


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    t-0
        3
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     - 04
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        4
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  p-0             CNS
        4
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   c-0
        4
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     - 05
Ju
   n-0
        5
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  p-0
        5
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   c-0
        5
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                                             NP




     - 06
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   n-0
        6
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  p-0
        6
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        6
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     - 07
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        7
                                                        Diabetes Initiative – Base Line
Defining the Roles - What is an
APN?
• An advanced practice nurse (APN) is an
  umbrella term that includes nurse practitioners
  (NP), clinical nurse specialists (CNS), certified
  nurse-midwives (CNM), and nurse anesthetists
  (CRNA).

• All are registered nurses with advanced
  training and education, with Master's degrees
  in nursing.
     Primary Differentiation
     between the Roles
     Model 1: CNS- Model
1. Cannot Order tests, prescribe medications or
     implement patient management.
2. Higher Importance placed on Education, Research
     and leadership

     Model 2: NP-Model
1. Order diagnostic tests and procedures
2. Prescribe medications
3. Implement patient management
CNS- Model

      The Role and
      Application of
        the CNS -
          Model
The Role and Application of
the CNS – Direct and
Indirect Care
• Direct Comprehensive Care
• Support of Systems
• Education*
• Research*
• Publication
• Professional leadership*
CNS Application
• Daily review of “On Watch”, patients sorted for priority
    visit based on labs, POC, trends
•   Flag pts with hypo, low fasting or out of target range
•    Daily review of See all Patients with glycemic outliers,
    priority BG<50 or >300
•   Make treatment change recommendations to MD based
    on findings
•   Develop Protocols, Orders Sets, Policies to drive practice
    change throughout the organization.
•   Education – healthcare providers based on identified
    needs
On Watch Monitor
            Hypoglycemia (<50)
            Data Collection Tool
                     Jan               Feb                Mar                   Apr               May               June

                     5     12 19 26 2        9   16   22 2      9   16 23 30 6        13 20 27 3        11 18 25 1         8   15 22 29

Incidents <50        19    15 11 6     12 27 17       19 22 28 19 14 7          17 13 14 5        6     17 29 20 13+ 20 24 16 22

Number of patients   15    10 11 6     9     17 14    14 15 16 12 10 7          10 11 12 5        6     13 25 13 11+ 19 16 14 10

Preventable          7     8   3   1   3     4   1    3   3     12 5    3   3   8     2   4   1   3     5   9   3          2   7   4   10

Orals                      3       1         1   1        1                 1   1         2       1         4                  4

Too much insulin     7     6   5       5     8   5    14 10 14 15 4         2   10 7      4   3   5     8   12 9    7      10 11 7     11

Nutrition            3     1   2             5   7    3   1     8   3   4   2   1     3   2   1         3   6   6   1      2   1       1

Med errors                 2                          1   1     5       1       2         1                 1                  4   2   5

K protocol                                                                                                                 3

Other                5     3   2   2   5     10 3         5         1   3   1   3         2             6   2   1   2      5   1   2   3

Low on admit         3         2   2   2     3   1    1   4     1       2   1         3   2   1             3   4   3          2   5   1

Lab error            2
MD Communication Tool
 Analysis of Patients Seen by Diabetes
 CNS during actual study period
Total Number of Patients Seen
                                            429
     500
     400
     300
                         163      141
     200       125

     100
      0
           September Octobe r Nove mber   Grand
                                          Total
Reasons Patients Were Seen

        Low BGs
          26%




    Labile BGs          High BGs
       7%                 64%
       Follow-up
           3%
Most Frequent
Recommendations
•   dc all/some oral hypoglycemic agents;
•   dc other basal & use Lantus as basal;
•   dc insulin mixes, 70/30
•   use of the Subcutaneous Insulin Order Set
    (SIOS) as appropriate for eating, NPO, or
    tube feeding;
• decrease/change in caloric intake;
• change in IV fluids to non-glucose-containing
    IVs;
• discharge recommendations
Response to Recommendations

    Accepte d
      52%




                      Not
      Partially
                   Accepte d
      Accepte d
                     38%
        10%
Recommendations NOT Accepted
             I mprov ed C ontrol
                   19%




                    N /A
                    9%


                                         N ot I mprov e d
                                              72%




N/A means pt may have been discharged.
Recommendations PARTIALLY
Accepted



      Improve d
       Control      Not
        66%       Improve d
                    34%
  Recommendations ACCEPTED


        Improved                                                                  Not
         Control                                                                Improved
          88%                                                                     6%

                                                                               N/A
                                                                               6%

Not Applicable (N/A) means the pt may have been discharged/transferred out of the hospital, therefore
blood glucose results cannot be evaluated..
   NO Recommendations Made

                                                                        Not Improved
           Improved                                                         34%
            Control
             62%


                                                                   N/A
                                                                   4%

No recommendations are made in certain cases when: (1) pt is 1-2 days new admit & MD adjusting
insulin regimen; (2) based on clinical findings, pt condition is too critically unstable, (3) MD planning
to discharge pt in 1-2 days w/ changes made in tx regimen; (4) other.
… what if …

   … based on the effectiveness rate of accepted
               recommendations,
   if all the recommendations would be accepted
       then the improvement rate would exceed

                     90%
NP- Model

      The Role and
       Application
       of the NP -
          Model
The Role and Application of
the NP -Model
• Higher Importance placed on direct
  comprehensive care
• Conducting H&P’s
• Diagnosing
• Performing Diagnostic Procedures
The Role and Application of the
NP -Model
• Daily review of New Patient Referrals
• “Hot List” Patients already on list and add new
    patients
•   Computer review of Labs, POC, trend
•   Flag pts with hypo, low fasting or out of target
    range
•   Prioritize – SICU patients usually seen first to
    transition pt to SIOS
•   Writes prescriptions for discharge
Advantages of the NP Role

• Timely treatment changes, observation of
  trends and daily review and management
• Has prescriptive ability
• Autonomy
• Appropriate Discharge Needs addressed
Results
 • Physician Practice Patterns
 • Glycemic Control Results at the Two
  Hospitals
Physician Practice: NP Hospital
NP Referrals Grow from 14 – 41%
                                                    Hospital B
                                                 Physician By Specialty
                                         Chula Vista, January 2006 - August 2006

   45%
                                                                                                        41%
   40%


   35%                                                                                                              33%
                                                                             30%                                          Hosp
                                                                                                                          Pulm
   30%
                                                                                                                          Other
                                                                                                                          NP
   25%
                                       22%                                                                                PCP
                                                               19%                                                        PA
   20%                                                                                                                    Oncol
                                                                                   14%                                    Inter Med
         13%      14%
   15%      13%                                         13%                                                               Nephro
              11%                            10%
                        9%                                9%                                       8%
   10%
                                                   7%                                         6%
                                                                                         6%                   6%
                             5%
   5%                                                                4% 4%

                                  1%
   0%
                    Jan 2006                                   May 2006                                 August-06
Physician Practice: CNS- Hospital

 100%
                             Utilization of the Standard
                             Subcutaneous Insulin Orders
 75%


 50%


 25%


  0%
        Nov-03     Mar-04       Sep-04      Nov-04          7-Jun

           New Standard Subcutaneous Insulin Orders
           Traditional/Custom Subcutaneous Insulin Orders
 Glucometrics
Monthly aggregate average


Extreme days                BG <60 or >300 mg/dl


Control days                  BG >65 <200 mg/dl
Well managed days     Measure non monitored DM
AII ICU BG Distribution
BG variability
CII time to target
Well Managed Days
Unit Level Glycemic Control Results
Monthly BG Average and Variability
                        BG-Avg/mo (mg/dl)




            140
                  150
                         160
                               170
                                     180
                                            190
                                                  200


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     - 04
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        4
Se
  p-0             CNS
        4
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        4
M
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     - 05
Ju
   n-0
        5
Se
  p-0
        5
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        5
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                                             NP




     - 06
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        6
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        7
                                                         Glycemic Control: CNS
                                                        Compared to NP Hospitals
       Glycemic Control: CNS
      Compared to NP Hospitals

• Hospital Average BG= Hospital Average BG =
    154mg/dL               164mg/dL
•   ICU Average BG=    •   ICU Average BG =
    133mg/dL               151mg/dL

           CNS                    NP
 Glycemic Control: CNS
Compared to NP Hospitals
                  185
                  180
Avg BG / Period


                  175
                  170
                                     CNS
                  165                NP
                  160
                  155
                  150
                        Base   F/U
 Glycemic Control: CNS
Compared to NP Hospitals
                    6.0%
Hypoglycemia Rate


                    5.0%

                    4.0%

                    3.0%

                    2.0%

                    1.0%

                    0.0%
                           Base   F/U
 Glycemic Control: CNS
Compared to NP Hospitals
Extreme High BG Rate

                       20.0%



                                      CNS
                       10.0%




                       0.0%
                               Base         F/U
Implications and Summary
 • Ability to Implement at each Hospital
 • Cost
 • Impact on the Organization
 • Physician Acceptance
 • Reimbursement
To understand
why different advanced nurse models
were selected … the different “cultures”
at each hospital need to be evaluated
Model Selection
• What does the organization want?
  – Take the Organization in specific direction to improve
    quality
  – Manage a group of patients as a physician extender
• what are you expecting from this role?
• What is the size, culture of the organization?
Factors to Consider in Model
          Selection
          CNS                         NP
• All patients with          • Patients seen only after
   glycemic outliers seen       MD referral to NP
• Depends on physician       • Has management
   acceptance                   authority
• Slower to change           •Affect change more
   practice, but change         quickly for care of
   eventually adopted by        patients managed by NP
   all- MDs, Nursing
                             • Limited effect on the
•Education r/t glucose          bigger picture of the
   control, develops            organization
   tools/resources/data to
   drive improvements
  Factors to Consider in Model
            Selection
          CNS                       NP
• Higher IM involvement   • Higher IM involvement
•Clinical care expert     •No time for staff or
•Patient volume             patient education
   based on priority
•Medical Staff more       • Patient volume based
   accepting of role         on FTE limit
• 40hr work week – no     • On-Call 24/7
   on-call
• Cost minimized          • Cost … related No. NPs
Reimbursement

To Bill or Not to Bill,
 that is the question….
Impact on the Organization
         Questions?




Jacqueline.thompson@sharp.com
sshering@swmedctr.com

				
Lingjuan Ma Lingjuan Ma
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