PowerPoint Presentation

Presented by:

CAPT Christine Chamberlain, PharmD, BCPS, CDE

Multidisciplinary Approach to Inpatient Blood Glucose Management

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NIH Clinical Research Center

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Background about NIH Clinical Research Center, supported by Mark O. Hatfield of Oregon who recently passed away

It was named in honor of Sen. Mark O. Hatfield of Oregon, who supported medical research throughout his congressional career. The facility houses inpatient units, day hospitals, and research labs and connects to the original Warren Grant Magnuson Clinical Center. The 870,000-square-foot Hatfield Building has 240 inpatient beds and 82 day-hospital stations. The highly flexible facility can be easily adapted to allow more inpatient beds and fewer day-hospital

Introduction

1,500 studies currently in progress. Most Phase 1 & 2 trials.

240 inpatient beds, 82 day hospital stations, and outpatient clinics.

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Objectives

List important factors that were considered in the design of blood glucose management service (BGMS)

Explain the design of electronic medical record to support the service

Implement new strategies for managing inpatients requiring insulin efficiently in similar environments

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Introduction

All patients seen at NIH are on a clinical research protocol

Some investigational drugs may affect glucose or insulin action

Some research protocols require steroids

Minimizing serious adverse events of glycemia related to protocol

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Our goal is to minimize serious adverse events related to glycemia control during clinical trial

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Introduction

Patients come from all 50 states and other countries as often we are studying rare diseases

Many foreign languages

Many without insurance

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I am sure your institution faces similar challenges related to native language and no insurance

We have a computerized physician order entry system since the 1970s but most recently upgraded to Allscripts sunrise clinical manager in 2004 (pharmcacy system a few years later) and Scriptpro for outpatient pharmacy in 2010

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Perils of Hyperglycemia

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n engl j med 355;18 www.nejm.org november 2, 2006

Who, What, When, Where, How

Our goal is to not let glycemia control be the cause of a problem for a patient

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Reasons for Formation of Blood Glucose Management Service

No consistency

Changing management guidelines

New drugs to use in controlling blood glucose

Late endocrine consults

Delay in implementing consult recommendations

Discharge planning

Disjointed patient education

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Fellows changed weekly; Attending changed monthly; used regimens familiar with; some more aggressive than others

Literature showing that euglycemia improved outcomes but we were slow to adopt treatment plans

Debate with ICU

Introduction of lantus and detemir, and rapid acting insulins

Patients would come in on byetta

Discharge planning did not occur until day of discharge, communication and consultation not done until day of discharge

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Blood Glucose Management Service

Members

Attending

Fellows

Pharmacist

Dietitian

Nurse Practitioner

Nurse

Social Worker as needed

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The diabetes educators had a dream to not be called at the last minute to counsel a patient on diabetes at discharge to intervene sooner and better BUT we needed a champion!

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BGMS Roles

Attending Physician

Champion

Expert

Training

Liaison

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Organized the service and delineated functions

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BGMS Roles

Fellow

Initial visit and history

Orders

On-call

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Would present new patients and for all patients on service, he/she would devise an insulin plan that would be agreed upon by the entire team

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BGMS Roles

Dietitian

Patient teaching

Participation in daily rounds

Determination of diet/TPN

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BGMS Roles

Nurse

Ambassador

Daily visits with patient

Participate in daily meetings, report

Documentation in electronic record

Discharge teaching with patients

Staff training

Back up on call Fellow

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Clinical nurse specialist Kathy Feigenbaum

We established the term ambassador the person who would glean information about the patient on a daily basis and report to the BGMS staff each ambassador was assigned a patient care unit/or units once we expanded and this person was the point of contact during the day for any issues presented by the patients nurse (change in NPO status etc.). The fellow was contacted if a orders needed to be changed or patient needed to be seen.

What is not on this slide is that she created and managed the call schedule and did most of the staff training

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BGMS Roles

Nurse Practitioner

Ambassador

Daily visits with patient

Participate in daily meetings, report

Documentation in electronic record

Discharge teaching with patients

Staff training

Back up on call Fellow

Facilitate order entry

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She brought many years of experience dealing with severely insulin resistant patients, she was also a Spanish speaking liaison

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BGMS Roles

Pharmacist

Ambassador

Daily visits with patient

Participate in daily meetings, report

Documentation in electronic record

Discharge teaching with patients

Staff training

Back up on call Fellow

Medication Profile review

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Unlike my colleagues, I was not a diabetes educator so, One of my first goals was to become a CDE

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Mission Statement

Multidisciplinary team consult service

Provide around the clock responsibility for blood glucose management for referred patients.

Manage only inpatients receiving insulin

Team will participate in multidisciplinary rounds each working day and a fellow during weekends

Team interdisciplinary notes will be recorded daily in the EMR

Insulin orders will be entered in the EMR rather than a recommendation in a note

Resources: laptops, pager, conference room, supervisor support

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We needed administration support we were not asking for a lot of resources, but relied on many people to devote extra time to this effort and did require support by various supervisors from nursing, pharmacy and dietary

Since evidence-based medicine strongly suggests that near-normal glycemia for hospitalized patients decreases morbidity and mortality, and since proper, modern intensive insulin management requires a multidisciplinary team approach, an NIH Blood Glucose Management Service (BGMS) has been established

Managed insulin orders only, followed patients only on insulin

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BGMS Meeting

Report

Discussion

Orders

Discharge planning

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Ambassador presented patient, endocrine fellow would formulate a plan, the group would discuss the plan and when everyone agreed, orders would be placed in the electronic medical record and reviewed by the entire team and discharge planning discussed

Punctuality and efficiency was continuously stressed as well as quality improvement how can we make it better

PIE - punctuality, improvement, efficiency

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Birth of BGMS

January 8, 2007

Piloted on one unit initially

Medical executive committee endorsement

Hospital wide at 7 months

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We started on one unit and work on smoothing out the wrinkles, the dog and pony show was continued and the concept needed to be sold to the medical executive committee in order to go hospital wide

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Tracking

Census form

Occurrences

Daily Rounds log

Monthly on-call schedule

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Justify your existence:

Track average daily census (how many patients we followed per month)

Medication or documentation occurrences

Record who attended daily rounds

This was used to justify the consult services utility and track a reduction in medication errors or occurrences. We could not use parameters such days in hospital or infection rate as these were dictated by the individual protocol but these are areas that could be measured

Blood glucose values outside of goals is a potential tracking tool at the time this was started, we had no mechanism since most tests were point of care (fingersticks on the individual unit) but this could be a future goals when meter data is incorporated into hospital system and technology such as theradoc could be used.

We could not use traditional metrics

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Selling the Concept

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Initially started on one unit then slowly expanded to other units as we made improvements along the way. Our biggest advocates over time were the nurses they started recommending the service to other teams

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Bumps in the Road

Selling the concept

Finding the data

Primary team physicians changing orders

Communication between BGMS and primary team

Transfers to the ICU (transition of care)

Misinterpretation of insulin order

No resources for diabetes supplies (glucometer, strips)

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About 7 months after our initiation, management did question cost/effectiveness of our service, they even solicited input for other institutions on how they provided this type of care - they were all supportive of this approach

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Documentation

Flowsheet (Eclipsys electronic medical record)

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Ann McNemar was a key figure in development, her a nursing background was a significant asset

We wanted all the information in one place insulin dose, blood glucose level etc.

One issue was double documentation needed by nursing staff (had to record doses on the MAR and on this flow sheet)

Also changing the insulin name (sub heading under basal insulin and insulin standard meal dose)

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Flowsheet continued

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Initially our BGMS plan was written on the flowsheet (separate line at the end of the flowsheet), but the primary team often did not see our notes so we asked our IT expert to devise a BGMS consult note

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Checklist for Expansion

BGMS team pager

Appropriate education for each patient care unit

Sufficient beta-testing of the EMR systems, including:

The BG flowsheet- worklist link and

System for recording daily BGMS progress notes

Stamp for the BGMS fellow to place a note in each patients medical record indicating the service is following that patient, and where progress notes can be found (On service note)

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During team meetings we viewed blood glucose levels in realtime by having to computers connected to the network and electronic medical record and projected on a screen for viewing in a conference room. Orders were entered and all team members reviewed order entry.

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Documentation

Consult Note (structured note)

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The stamp was soon replaced by a consult structured note which Ann McNemar helped create our vision> It stated that the BGMS service would write all insulin orders until one of the parameters listed occurred. It communicated to the primary team that we would take over the responsibility of writing insulin orders thus reducing the time to implementation

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Documentation

Consult Note (structured note)

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Initially a consult was placed under endocrine consult and the provider had to specify BGMS.

We eventually received our own consult order through perserverence

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Bumps in the Road

Selling the concept

Finding the data

Primary team physicians changing orders or putting them in hold status

Communication between BGMS and primary team

Transfers to the ICU

Misinterpretation of insulin order

No meter when discharged

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About 7 months after our initiation, management did question cost/effectiveness of our service, they even solicited input for other institutions on how they provided this type of care

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Documentation

Consult Note (structured note)

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Consult note was devised with the ability to pull in data such as BBGM results, lab values, copy forward option for summary information

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Documentation

Consult Note (structured note)

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Documentation

Consult Note (structured note)

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Documentation

Consult Note (structured note)

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BGMS Meeting - Efficiency

Report

Discussion

Orders

Discharge planning

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Ambassador presented patient, endocrine fellow would formulate a plan, the group would discuss the plan and when everyone agreed, orders would be placed in the electronic medical record and reviewed by the entire team and discharge planning discussed

Punctuality and efficiency was continuously stressed as well as quality improvement how can we make it better

PIE - punctuality, improvement, efficiency

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Standardized Script for Rounds

We are following Mr/Mrs ________ whose primary diagnosis underlying their hospitalization is _______.

Our present blood glucose management orders for him/her are ________.

Issues today that may have influenced the BGs you can see on the flowsheet include _____ (and examples may be infections, alterations in his/her diet, procedures, new medications like glucocorticoids).

Upcoming plans for his/her hospitalization that may effect his/her blood glucose control include ____ (and examples may include alterations in his/her diet, procedures, new medications like glucocorticoids, plans for discharge).

State pertinent lab values for that day

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This became the standardized script for the ambassadors for rounds. Goal was to keep our meetings to 1 hour or less and stay focused

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Quote for the Day

Quoting Lennon and McCartney, I have to admit its getting better, a little better all the time.

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Efficiency, mission, keeping on track, improvements

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Discharge planning

Prepare for home regimen

Prepare for insulin pump or adjust setting if admitted on pump

Transition to outpatient

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We had difficulty with transition of care to outpatient and having a fellow follow the patient

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Discharge planning patient education

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We standardized patient education, one of our goals was group education, however we were never able to achieve that goal but did use the tools we created for the group education to educate individual patients in a consistent manner

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Trials and Tribulations

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And as Dave most eloquently put it seemed at times we were like salmon swimming upstream

Most difficult obstacle was expanding the service

Second was transition to outpatient care who would follow the patient after discharge. We devised a plan to have the endocrine fellow initiating the BGMS consult to follow the patient as an outpatient in our diabetes or endocrine clinics

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Bumps in the Road

Selling the concept

Finding data

Primary team physicians changing orders or putting them in hold status

Communication between BGMS and primary team

Transfers to the ICU

Misinterpretation of insulin order

No meter when discharged

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Initally we saw medication errors including missed doses, wrong dose, unclear orders and lack of communitcation with the BGMS about changes in patient status. Initially some nurses were uncomfortable with the high insulin doses and we provided education and reassurance. We learned how to write better orders and we established rules for insulin dosing

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Medication Occurrences

Feigenbaum et al. The Clinical Center's Blood Glucose Management Service : A Story in Quality Integrated Care Volume 38, Number 2, March/April 2012

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Insulin Basic Concepts

Established rules for initial insulin dosing

Created treatment plans specific to glycemia issue

Created Standard operating procedures

Created insulin ordering templates

Insulin drip

High concentration insulin

Insulin subcutaneous pump

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I will now cover the rules or concepts we established

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Inpatient Glycemia Goals

Pre-meal goal

Critically ill 140-180 mg/dl

Non critically ill pre-meal