Inpatient Glycemic Control How many professionals does it take to - - PowerPoint PPT Presentation

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Inpatient Glycemic Control

Rachel Brewster, BA, CMSRN, ME-SAFE-A Judy Curry, BPA, RDMS, CPHQ Ruth Littlefield, CNA

How many professionals does it take to steer the sugar ship away from the rocks?

Objectives

S The Need to Steer a Sugar Ship

S The importance of glycemic control for hospitalized patients

S Establishing the Crew of the Ship

S Finding the right people to be at the table and to lead the

initiative S Jumping on Board or Jumping Over Board (Walking

the Plank)

S Leading through change, moving the project forward, and

staying focused S Knowing the Crew is Accomplishing It’s Mission

S Tracking progress and identifying success JC

The Need

S Increased risk of infections –sepsis, pneumonia, wound infection in

postop patients with one blood glucose level >220 on post-op day one

S Decreased neurologic recovery – observational studies show an

association between hyperglycemia and worsened outcomes in patients with acute stroke

S Higher mortality with acute MI– 1 year mortality rate 19.3% with

admission blood glucose <101 compared to 44% with an admission blood glucose >200

S Longer hospitalization S Delayed procedures

Potential Harms of Uncontrolled Blood Glucose Levels in Hospitalized Patients with Type 2 Diabetes

RB

The Target

S Literature review for leading practices for

glycemic control in hospitalized patients

S Non DKA Patients S Decrease episodes of hyperglycemia S Avoid episodes of hypoglycemia S Have majority (80%) of blood sugars be within

the range of 70-180

S January 2016 S <70

2%

S 70-180 49% S >180

49%

RL/JC

The Crew

S Subject matter experts S Currently doing the work

Finding The Right People to Participate and Lead

S Excited and optimistic S Willing to share ideas S Open minded S Committed to the team S Willing to trial change S Uses critical thinking S Active listener S Committed to the work JC

All Aboard!

Jumping on Board or Walking the Plank

RB

“The” Captain

ALL

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Ship Mates

CMO

Kent Clark, MD

Discharge Planner

Catherine Gelsinger

Quality

Judy Curry

Hospitalists

Tim Canham, PA Curt Smith, MD

Nutritioni sts

Brooke Reed Ally Sherman

Diabetes Educator

Sue Maxwell

Nurses -MSU

Rachel Brewster Lindsay Moore

CNAs

Ruth Littlefield Taylor Varnum

Nurse Managers

Nicole Kenney Pam Sprague Lisa Sirois Leaders

Inpatient Care Comm

Heather Ward, MD - Chair

Nurse Educator

Natalie Trombley

Nurses -ICU

Sonya Conary Becky Osborne RL/JC

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How To Avoid The Rocks

Insulin Engage d Patients Providers Staff Data Hypoglycemia Hyperglycemia

JC

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Embrace the Fish

Insulin Correction Basal Fast Acting Pre Meal Patient s Outisde Food Steroids Illness New Dx Education Providers Education Real Time Review Consistency Basal Calculation Feedback Staff Data Hypo- and Hyper- glycemia Education Documentation Insulin Timing Orders Used Documentation Real Time Review Education Symptoms Blood Sugars Correction Rule of 15 Feedback Steroids Basal Optimizatio n JC

Steering the Ship

JC

Gemba Board

Anchors Aweigh

Any

The Voyage

Just Some of the Many Changes Tried!

S Hospitalist chart review process S CHO meal menu in grams S CHO in the MAR S Real time chart review S Sliding scale and basal insulin orders S New calculation for basal insulin dose S Red tray delivery of meals S Signs in patient rooms re: guest food S Insulin drip for non DKA ICU patient

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The Voyage

RL

The Voyage

Timely Administration of Prandial Coverage Plan Do Study Act

Educatio n About New Standard Meals on Red Trays MSU Nutrition ICU Gemba Board KPI

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The Voyage

Simultaneous BS and Insulin Administration Plan Do Study Act

Move to CNA Approach Nurse Does All Tasks Trial By Nurse BS at Meal Time

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The Voyage

Delivery of Meals Plan Do Study Act

Educatio n About New Standard CNA Support Take BS and Deliver Tray Gemba Board KPI

RL

Fleet Collaboration

Nutrition Services: Red Trays Nurse Educator: Skills/Knowledge Providers: Order Consistency

RL/RB

Beyond the Rocks

Overall - Blood Glucose Samples 70-180

JC Goal

Beyond the Rocks

Overall - Blood Glucose Samples < 70

JC

Beyond the Rocks

0% 20% 40% 60% 80% 100%

Of the Blood Sugars Greater >180

JC No Steroids Steroids

Beyond the Rocks

Total Times Correction Insulin Given in the Month Divided by the Total Number of Patients in the Month

2 4 6 8 10 12 14 16 18 20

JC

Beyond the Rocks

0.5 0.6 0.7 0.8 0.9 1

CHO Coverage Insulin Given Within 30 Minutes

JC

Beyond the Rocks

0.2 0.4 0.6 0.8 1

Goal

Correction Insulin Given Within 30 minutes

JC

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So….How Many?

RL

166 People / 1178 Days

Workgroup (19)

S Nutritionists (2) S Hospitalists (2) S Nurse Managers (3) S Diabetes Educator (1) S Nurse Educator (1) S Quality (1) S CMO (1) S Bedside Nurse (4)

In Addition to Workgroup (147)

S Providers (17) S Bedside Nurse (60) S Bedside CNA (39) S House Supervisors (6) S Nutrition Services (25) S Inpatient Care Committee (4) S Discharge Planners (2) S aICU Providers (?) RB

Finding the Treasure

Knowing That the Crew Has Accomplished It’s Mission

RB

Questions/Comments

ALL

References

S Glucose Management in Hospitalized Patients, Charles

Kodnet, MD; Laurie Anderson, MD; and Katherine Pohlgeers, MD; University of Louisville School of Medicine, Louisville, Kentucky; American Family Physician, Volume 96, Number 10, November 15, 2017

S Diabetes Care; Standards of Medical Care in Diabetes, 2019 S Inpatient Management of Diabetes and Hyperglycemia:

Implications for Nutrition Practice and The Food and Nutrition Professional; Journal of the American Dietetic Association, 2007

JC