Stanford Hospital and Clinics - Solid Organ Transplant

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Diabetes Best Practices Diabetes Best Practices SymposiumSymposiumSponsored by AMGA and Merck & Co., Inc..Sponsored by AMGA and Merck & Co., Inc..

October 21-22, 2009October 21-22, 2009Detroit, MIDetroit, MI

Stanford Hospital and Clinics

Solid Organ Transplant

Transplant Diabetes Program

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Medical Group ProfileMedical Group Profile

The Transplant Diabetes Program started in 1995 2 sites/clinics 29 MDs (30% transplant surgeons; 70% medicine

physicians) + 1 endocrinologist part-time >8 specialties (pre- and post- transplant Hepatology,

Nephrology, Pulmonology, Cardiology) 750 +/- outpt visits/year (includes return/follow-up) EPIC system of Electronic Medical Records being

implemented in phases over the past 18 months Patients are Pre- and Post-solid organ transplant

– Organ failure– Polyimmunosuppressive medications– Disease and ethnicity-associated

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Team CompositionTeam Composition

over 70 members in a multi-disciplinary team including: Transplant Nephrologists Transplant Hepatologists Transplant Cardiologists Transplant Pulmonologists Transplant Surgeons Endocrinologist Transplant Nurse Coordinators Transplant Social Workers Transplant Pharmacists Transplant Dietitians Transplant DM Educator and Program/Research Coordinator.

A core group of 6 taken from the above make up the actual day-to-day working force. 3

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Diabetes Goals & ObjectivesDiabetes Goals & Objectives

Decrease DM-related hospital readmissions of multi-organ post-transplant recipients with pre-existing and post transplant diabetes (PTDM).

Pre-transplant fasting blood glucose of 80-120 mg/dl.

Decrease or prevent DM complications such as cardiovascular disease in a high risk population.

Prolong transplant graft survival.

Diabetes Intervention & Population Diabetes Intervention & Population BaselineBaseline

Percent of total who develop PTDM or have DM prior to transplant:

by organ:

• 40% kidney

• 37% liver

• 30% heart

• 32% lung and heart/lung

by sex:• 57% male

• 43% female

by ethnicity:

• 47% Caucasian

• 24% Hispanic

• 11% Asian

• 6% Pacific Islander

• 4% Indian sub-continent

• 2% Black

• 1% Middle Eastern

• 1% Native American

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Diabetes Intervention & Diabetes Intervention & Population BaselinePopulation Baseline

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Overall Population Composition:•8% type 1 DM •65% type 2 DM•27% PTDM

•For the type 1 mean duration of disease: •kidney and liver group= 17.8 years•Heart, heart/lung group= 24.3 years

•For the type 2 mean duration of pre-existing DM •kidney and liver group= 12.4 years•Heart, heart/lung group= 7.4 years


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•Registry equivalent: •“TransChart”•Integrated Solid OrganTransplant database•Coordinates data collection & communication •Contains a Txp/DM registry•Accessed by the Transplant RN Coordinator (pre and post), Transplant Social Worker, Transplant Physician and Surgeon, Transplant RD (pre and post), Transplant PharmD, Transplant CDE, and Transplant Insurance Coordinators


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Behind-the-scenes work:•Interested party analysis and satisfaction surveys done to identify common needs•Secure multi-departmental support and buy-in through mutual gain

•Staffing, support, revenue•Solid Organ Transplant•Clinical Nutrition•Pharmacy•Endocrinology

•Directors of departments support key to champion Program development


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Work flow changes:•RD and Program/Research Coordinator set aside time to:

•Provide routine duties for inpatient care•Develop Program materials•Designate established outpt clinic times•Coordinate space allocation•Secure initial grant funding•Meet with department Directors to secure support•Inservice Solid Organ Transplant Team to services/benefits provided


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Information Technology•TransChart (Solid Organ Txp Database and communication mode)•Down-loadable glucose meters•CGMS (selectively through Endocrinology)•Website http://stanfordhospital.org/clinicsmedServices/COE/transplant/diabetes/•Email, telephone, and fax


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Changing MD Practice:•Inservices

•Developing usable tools and resources•Txp/DM Reference Tool

•Research studies involving glycemic control•Close attention to transplant protocols•Visibility

•Attending and participating in rounds•Attending and participating in transplant team meetings

•One-on-one meetings•Identifying common goals•Learning to speak toward MD’s goals

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Improvement InterventionsImprovement Interventions

Transplant Diabetes Reference Tool– For outpatient use– Pocket-sized format– Quick reference regarding treatment modality options

• Transplant-specific considerations

– Standards referenced• Diagnostic criteria

– Contact information– Guidelines for ordering consults

Pre-printed diabetes supplies order form– For discharge and outpatient use– Quick, standardized for transplant needs

Establish and reinforce Program standardsConvenient and perceived as time-saver

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Measures UsedMeasures Used

As no universally accepted definition of Post-Transplant/New Onset DM, identification based on:– Standard diagnostic criteria from the Expert Committee on

the Diagnosis and Classification of Diabetes Mellitus

And one of the following:– Fasting Blood Glucose (FBG) > 126 mg/dL on two or more occasions – Random glucose of >200 mg/dL with symptoms on two or more occasions

Efficacy determined by utilizing pre-established, evidence-based standards from:

– American Diabetes Association (ADA) – American Association of Diabetes Educator (AADE)– American Transplant Congress (ATC) Clinical Practice Guidelines

Measures UsedMeasures Used

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•quarterly laboratory values•medical record review•compilation of patient satisfaction survey•pre- and post-transplant DM knowledge assessment test•tracking of hospital readmissions•measurements of lipids•quarterly HbA1c•Creatinine•pre- and post-transplant body mass index (BMI)•neuropathy screening•annual eye and foot exam monitoring•continued smoking cessation•monthly review of home blood glucose logs•hospital readmission for DM-related complication tracking•patient and provider satisfaction surveyed•transplant rejection reviewed.

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Challenges or ObstaclesChallenges or Obstacles

Funding– Advocate for less expensive health care professionals

rather than MD– Develop protocols to support increased use of allied

health professionals.– Look for JCAHO standards to support increased staffing

Space– Flexibility

Outcomes and SuccessesOutcomes and Successes

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•Improved lipid levels

•Improved average initial HbA1c of 8.8%, with an average value of 7.2% following a minimum of three months of management

•stable creatinine and BMI

•95% average compliance for annual neuropathy, eye, and foot exams

•mandatory compliance to smoking cessation criteria for organ transplantation

•home blood glucose logs showed a 80% compliance to pre-transplant blood glucose of 80-140 mg/dl and post-transplant to 80-200 mg/dl

•40% reduction of DM-related re-admissions one year post-transplant

• 95% patient satisfaction rating

•94% provider satisfaction rating

•26% decrease in the incidence of rejection


% patients in control (A1c<7%):– 21% improvement (statistical significance=12, p>.05)

Diabetes-related hospital readmissions:– 37% improvement (statistical significance=6.96, p>.05)

One year patient survival rates by organ:– Kidney 98% (highest nationally)– Liver 90%– Heart 83%– Lung 86%– Heart/Lung 92%

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Patient outcome/process-centered Transplant-specific, unique within the transplant community Designed to empower the txp patient Pro-active intervention and education Consistently reliable follow up Strong communication

– Aware of txp protocols and effect on glycemic control– Shaped SHC MOTC—steroid-free kidney txp protocol

Enhance the overall Multi-Organ Transplant Program as a “client” of Txp/DM Program

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Future StepsFuture Steps

Develop protocol for Transplant Pharmacists to adjust DM medications

Secure funding for inpatient/outpatient Cystic Fibrosis Dietitian

Support staff development for Physician Assistant or Nurse Practitioner for Transplant Diabetes Program

Lessons LearnedLessons Learned

Find a champion(s)– tell your Administrator what you are doing, show your

Boss what you are accomplishing

Collaborate, define common goals– Learn to define goals in “meaningful” language

Rather than sing louder, teach the song to more people

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Stanford Hospital and Clinics - Solid Organ Transplant