Inpatient Glycemic Management: How We Get Others To Follow Our Lead

Size: px

Start display at page:

Download "Inpatient Glycemic Management: How We Get Others To Follow Our Lead"

Norah Foster
6 years ago
Views:

and Metabolism University of California, San Francisco San Francisco, CA 94115 robert.rushakoff@ucsf.

Glycemic Management: How We Get Others To Follow Our Lead August 5 th, 2015 New Orleans, LA

insulin safety 3) Describe several ways to decrease clinical inertia in acute care 4) State

1 Robert J. Rushakoff, MD Medical Director, Inpatient Diabetes Professor of Medicine Division of Endocrinology and Metabolism University of California, San Francisco San Francisco, CA Disclosures Conflict of Interest (COI) and Financial Relationship Disclosures: none Inpatient Glycemic Management: How We Get Others To Follow Our Lead August 5 th, 2015 New Orleans, LA Objectives 1) State current inpatient glycemic control goals 2) Discuss several strategies to improve insulin safety 3) Describe several ways to decrease clinical inertia in acute care 4) State innovative ways to educate health care professionals in the hospital setting using technology "Each blind man perceived the elephant as something different: a rope, a wall, tree trunks, a fan, a snake, a spear..." 1

2 /5/2015 Patient Assessment of Skills, Education Transitions Coordination Diabetes Assessment of Form Outpatient Outpatient Education Medical Data Care Management Secondary Jargon Patient Inpatient Inpatient Nurses Collection Inpatient ICU Diagnosis Errors Inpatient Protocols Periop Order to Physicians Outpatient Home Medical Education care Students Entry services Errors Management CQI Smart Orders Outpatient Glucometrics Dosing JCAHO diabetes Calculators classes Page 1 of 6 Insulin Administration Order Written Order Sent to Pharmacy Order Entry by Pharmacist Drug Preparation by pharmacy Insulin delivery to unit Medication Administration Documentation Inpatient Diabetes Goals Inpatient Diabetes Goals Target Glucose Levels Who Cares Just get patient home Sliding Scales are fine Avoid that scary hypoglycemia Inpatient Diabetes Goals Appropriate Glucose Control Based on physiology and outcome studies Normal glucoses for everyone A high glucose means failure Sliding Scales are banned Some hypoglycemia is acceptable Alive Target Glucose Levels No DKA or Hyperosmolar Coma Target Glucose Levels No hypo- or hyperglycemia Prevent fluid and electrolyte Decreased abnormalities post-mi secondary mortality to Decreased osmotic diuresis post-cabg morbidity Improve and WBC mortality function Improve gastric emptying Decrease surgical complications Earlier hospital dischange 2

3 Target Glucose Levels Normal Glucoses Problems With High Glucoses Decreased Morbidity and Mortality Glucose and Post-CABG: Morbidity and Mortality Diabetes and Coronary Artery Bypass Surgery An examination of perioperative glycemic control and outcomes Retrospective review of 291 patients surviving 24 h post-op 40% with retinopathy, nephropathy, or neuropathy Inpatient complications: For each 1 mmol/l (18 mg/dl) increase in post-op day 1 over 6.1 mmol/l (110 mg/dl), a 17% increased risk of complications McAlister FA et al. Diabetes Care. 2003; 26: High Blood Glucose Levels Associated With Increased Mortality in ICU Retrospective review of 259,040 critically ill patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati Hyperglycemia A significant but was weaker an effect independent was seen predictor in patients of mortality with sepsis, starting pneumonia, at 111 and mg/dl pulmonary embolism Effect Hyperglycemia was greatest was not with found acute to be myocardial associated with infarction, mortality unstable diseases such angina, as COPD and stroke and hepatic failure, hip fractures Raised MI risk from 1.7 to 6 times In diabetes Raised patients, stroke risk the from increase 1.8 to in mortality 29 times risk was not seen until mean glucose was >146 mg/dl Raised unstable angina from 1.4 to 3 times Falciglia M et al. Crit Care Med. 2009; 37: Hyperglycemia related mortality in critically ill patients varies with admission diagnosis Intervention Studies Falciglia M et al. Crit Care Med. 2009; 37:

4 Decreased Infections Insulin infusion improves neutrophil function in diabetic cardiac surgery patients Perioperative IV insulin infusion Neutrophil phagocytic activity % baseline Control 47 Insulin 75 Decreased Infections Glucose control lowers the risk of wound infection in diabetics after open-heart operations Perioperative IV insulin infusion Protocol to maintain glucoses <200 mg/dl Incidence of Deep Wound Infections (%) Routine Control Tight Control Rassias AJ et al. Anesth Analg. 1999; 88: Zerr KJ et al. Ann Thorac Surg. 1997;63: Furnary AP et al. Ann Thorac Surg. 1999;67: Furnary AP et al. J Thorac Cardiovasc Surg. 2003;125: Decreased Morbidity and Mortality Intensive Insulin Therapy in Critically Ill Patients Patients (all) on mechanical ventilation in ICU Randomly assigned to IV insulin maintaining glucoses between mg/dl or conventional treatment (IV insulin if glucose >215 mg/dl then maintain glucose between ) 12 month mortality % given insulin 24-hour dose AM glucose Main effect on patients Intensive Intensive 4.6% units 103 in ICU >5 days Conventional 8.6% units 153 NICE-SUGAR 6104 adults who were expected to require treatment in the ICU on 3 or more consecutive days randomized to intensive blood glucose control (target range, 81 to 108 mg/dl) or conventional blood glucose control (<180 mg/dl) Primary endpoint death from any cause within 90 days after randomization Baseline characteristics similar Van den Berghe G et al. N Engl J Med. 2001;345: The NICE-SUGAR Study Investigators. N Engl J Med. 2009;360: Data on Blood Glucose Level, According to Treatment Group Probability of Survival and Odds Ratios for Death, According to Treatment Group Problems With Low Glucoses The NICE-SUGAR Study Investigators. N Engl J Med. 2009;360:

Hypoglycemia and Mortality in Insulin-treated vs on Insulin-treated AMI Patients Mortality, % 20 10 18.4 P<.001 9.2 P=.92 10.4 10.

5 Hypoglycemia and Mortality in Insulin-treated vs on Insulin-treated AMI Patients Mortality, % P< P= Hypoglycemia No hypoglycemia Hypoglycemia was a predictor of higher mortality in patients not treated with insulin, but not in patients treated with insulin Hazard Ratio for Death According to the Occurrence of Hypoglycemia on 1 Day or More Than 1 Day and Receipt or Nonreceipt of Insulin Therapy at the Time of the First Hypoglycemic Episode. 0 No Insulin Treatment Insulin Treatment Kosiborod M, et al. JAMA. 2009;301(15): The NICE-SUGAR Study Investigators. N EnglJ Med 2012;367: Inpatient Glucose Goals Organization ICU Non-ICU Pre-prandial Non-ICU Maximum AACE/ACE mg/dl <140 mg/dl 180 mg/dl ADA mg/dl <140 mg/dl 180 mg/dl ACP mg/dl Avoid <140 mg/dl Endocrine Society <140 mg/dl 180 mg/dl Society of Critical Care Medicine mg/dl UCSF mg/dl mg/dl Mean Blood Glucose Levels During Blood Glucose Insulin Levels During Therapy Isulin Treatment Blood glucose (mg/dl) * * * 180 SSRI Lantus + glulisine A dm it Days of Therapy * p<0.01 p<0.05 Day 3: P=0.06 Umpierrez GE Et al. Diabetes Care. 2007;30: How to Obtain Tight Control Bedside glucose monitoring IV insulin drips Diabetes Flow sheets Discourage the use of traditional Sliding Scale insulin INSULIN SLIDING SCALE 5

INSULIN SLIDING SCALE Roller Coaster Effect of

XXXXX are admitted for Giants fever. Mr.

XXXXX also has Type 2 diabetes but she has

coverage: FSBG Action < 50 1 amp D50 iv and

5-1 hr 81-150 no coverage 151-200 2U regular

251-300 6U regular insulin SQ 301-350 8U

6 INSULIN SLIDING SCALE Roller Coaster Effect of Insulin Sliding Scale Mr. And Mrs. XXXXX are admitted for Giants fever. Mr. XXXXX has Type 2 diabetes and takes a total of 75 Units insulin per day (2 shots). Glucoses at home are poorly controlled. Mrs. XXXXX also has Type 2 diabetes but she has good control taking about 25 units of Lispro premeal and 40 Units glargine at night. Fingerstick qid with regular insulin SQ coverage: FSBG Action < 50 1 amp D50 iv and call HO give juice and repeat in hr no coverage U regular insulin SQ U regular insulin SQ U regular insulin SQ U regular insulin SQ U regular insulin SQ >400 12U regular insulin SQ, call HO INSULIN SLIDING SCALE 6

8/5/2015 Jane Jeffrie Seley Disclosures DNP, MPH, GNP, BC-ADM, CDE, CDTC Presenter: Jane Jeffrie Seley Diabetes Nurse Practitioner Inpatient

Nordisk March 2015 -Bayer Diabetes Care April 2015 -Sanofi Diabetes April 2015 diabetesdiva@gmail.com Why Computerized Order Sets?

Simplifies & promotes weight based dosing: Auto-populates weight into dosing algorithm Reduces insulin TYPE errors: basal, prandial and

Reduces clinical inertia: Takes fear out of dosing insulin by automating process Secret to Success With Comprehensive Pre-Selected Matters

7 8/5/2015 Jane Jeffrie Seley Disclosures DNP, MPH, GNP, BC-ADM, CDE, CDTC Presenter: Jane Jeffrie Seley Diabetes Nurse Practitioner Inpatient Glycemic Control Team New York Presbyterian Hospital Weill Cornell Medical College New York, New York Attended Advisory Board Meeting: -Novo Nordisk March Bayer Diabetes Care April Sanofi Diabetes April 2015 Why Computerized Order Sets? Improving Insulin Safety Creating and Implementing Comprehensive Insulin Order Sets Reduces insulin dosing errors: Autocalculates safe dose Simplifies & promotes weight based dosing: Auto-populates weight into dosing algorithm Reduces insulin TYPE errors: basal, prandial and correction insulins are separated 40 Why Computerized Order Sets (Cont.)? Reduces clinical inertia: Takes fear out of dosing insulin by automating process Secret to Success With Comprehensive Pre-Selected Matters Reduces omission of doses and improper timing of BGM & insulin: e.g. RN gets medication due reminder, Prescriber & RN get reminder of need for basal insulin for Type 1 patients 41 Secret to Success: Pre-Checked Orders 7

8 Step One Which Order Set Do I Choose? Descriptions Next To Each Order Set Why wasn t poor PO intake ordered? Very Low Dose Aspart-Glargine Order Set NPO Aspart Only Order Set for short-term NPO Reduced Fear of Hypos: Correction Starts at >150 mg/dl A1c* Type of Diabetes Just check box *A1c can be used to diagnose diabetes, evaluate glycemic control PTA Diabetes Meal Plan** Bedside BGM Defaults to 4 servings (60gm Carb) per meal **All diabetes and/or hyperglycemia pts placed on Diabetes Meal Plan 47 Defaults to ac & bedtime for prandial & q6 hrs for NPO 48 8

Hypoglycemia Treatment NPO: no auto-basal for type 2 Very Low Dose.10 u/kg Low Dose.

30 u/kg Diabetes Education 49 50 Pt Education: Focus on Survival Skills Diabetes Survival Skills

Crackers (3 crackers)........ 17. Plain Rice Cake (1 cake)............. 7.

.... 1½ Rice Pudding (½ cup).............. 24 1½ Ice Cream: Vanilla (½ cup).................... 27.

. 2 0 1 ½ Step1 Step2 SampleFoodLabel Beverages Skim, 2% or whole milk (8 oz).

..... 1. Regular or Decaf Coffee/Tea (8 oz)...... 0..... 0.. Diet Ginger Ale (8 oz).

............. 4...... 0.. Sugar Free Jelly (1 Tbsp)............. 6 ½ Sugar Free Syrup (2 Tbsp)............ 3.

. 0 Fat-Free Mayo (1 Tbsp).............. 1... 0 Mustard (1 packet).................. 0.. 0 Fat-Free Italian (1 Tbsp).

9 Hypoglycemia Treatment NPO: no auto-basal for type 2 Very Low Dose.10 u/kg Low Dose.15 u/kg Med Dose.20 u/kg High Dose.30 u/kg Diabetes Education Pt Education: Focus on Survival Skills Diabetes Survival Skills Diabetes Teaching Resources Consistent Carbohydrate Menu Lists Serving Sizes & Grams Graham Crackers (3 crackers) Plain Rice Cake (1 cake) Pudding: Vanilla (½ cup) ½. Chocolate (½ cup) ½ Rice Pudding (½ cup) ½ Ice Cream: Vanilla (½ cup) Chocolate (½ cup) Jello/Gelatin: Sugar Free Strawberry (~½ cup) ½ Step1 Step2 SampleFoodLabel Beverages Skim, 2% or whole milk (8 oz) Lactose Free milk (8 oz) Vanilla Soy milk (8 oz) Regular or Decaf Coffee/Tea (8 oz) Diet Ginger Ale (8 oz) Condiments/Salad Dressing: Smart Balance Butter Spread (1 tsp) Peanut Butter (1½ Tbsp) Sugar Free Jelly (1 Tbsp) ½ Sugar Free Syrup (2 Tbsp) Lemon Juice (1 packet) Ketchup (1 Tbsp) Fat-Free Mayo (1 Tbsp) Mustard (1 packet) Fat-Free Italian (1 Tbsp) Creamy French (1 Tbsp) Step 3 Carbohydrate Carbohydrate Grams Servings 5 10 ½ ½ ½ ½

8/5/2015 Teaching Patients to Use Insulin Pen Diabetes Champions Meets

RDs Created TEAM WEB with educational resources for pts & professionals

Diabetes Education Documentation Developing & Implementing Glycemic

ADJUSTMENT: If AM fasting BG is too high or low: If pre-lunch,

HOW TO ADJUST: If BG is less than 50: If BG is less than 70: If BG is

10 8/5/2015 Teaching Patients to Use Insulin Pen Diabetes Champions Meets Monthly (1 hr) & Annually (8 hr) reminders sent to all RNs, NPs, RDs Created TEAM WEB with educational resources for pts & professionals Adult Inpatient Glycemic Management Guideline Pocket Card Page 1 Diabetes Education Documentation Developing & Implementing Glycemic Control Guidelines Insulin Titration Algorithm WHICH INSULIN NEEDS ADJUSTMENT: If AM fasting BG is too high or low: If pre-lunch, pre-dinner or bedtime is too high or low: Adjust Glargine Adjust Aspart HOW TO ADJUST: If BG is less than 50: If BG is less than 70: If BG is : If BG is : If BG is >250: Deduct 50% Deduct 20% Deduct 10% Add 10% Add 20% 60 10

Inpatient Guideline Pocket Card (P2) Inpatient Guideline Pocket Card (P3) Inpatient Guideline Pocket Card (P4)

Prescribers (NPs, PAs) References American Diabetes Association (2015).

Pathways to quality inpatient management of hyperglycemia and diabetes: A call to action.

Basal Insulin Use in the Non-Critical Care Setting: Is Fasting Hypoglycemia Inevitable or Preventable? J.

Best Practices for Interdisciplinary Care Management by Hospital Glycemic Teams: Results of a Society of Hospital

11 Inpatient Guideline Pocket Card (P2) Inpatient Guideline Pocket Card (P3) Inpatient Guideline Pocket Card (P4) Data VIS Pattern Management Tool Online Mandatory Education by Discipline: Dietitians Nurses Pharmacists Prescribers (NPs, PAs) References American Diabetes Association (2015). Standards of Medical Care In Diabetes Diabetes Care: 38(1):1-86. Draznin, B., Gilden, J., et al (2013). Pathways to quality inpatient management of hyperglycemia and diabetes: A call to action. Diabetes Care; 36(7): Flory, J.H., Aleman, J.O., Furst, J., & Seley, J.J. (2014). Basal Insulin Use in the Non-Critical Care Setting: Is Fasting Hypoglycemia Inevitable or Preventable? J. Diabetes Sci. Technology, J Diabetes Sci Technol; 8(2): Rodriguez, A., Magee, M. et al (2014). Best Practices for Interdisciplinary Care Management by Hospital Glycemic Teams: Results of a Society of Hospital Medicine Survey Among 19 US Hospitals. Diabetes Spectrum; 27(3), Rushakoff, R., et al (2014). Using a Mentoring Approach to implement an Inpatient Glycemic Control Program in Unites States Hospitals. Healthcare; 2 (2014). Pp

12 References (Cont.) Ryan, D., Swift, C., (2014). The Mealtime Challenge: Nutrition and Glycemic Control In the Hospital. Diabetes Spectrum; 27 (3). Pp Mendez, C. Umpierrez, G.E. (2014). Pharmacotherapy for hyperglycemia in Noncritically Ill Hospitalized Patients. Diabetes Spectrum; 27 (3). Pp Seley, J.J. (2015, In Press). Diabetes Care in the Inpatient Setting, in Complete Nurse's Guide to Diabetes Care (3 rd ed.), Childs, B.P., Cypress, M., & Spollett, G. (Eds): American Diabetes Association, Alexandria, VA. Umpierrez GE, Hellman R et al (2012). Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. Endocrine Society. J Clin Enddocrinol Metab. Jan;97(1): UCSF Inpatient Diabetes Infrastructure 1989: Bedside Glucose Monitoring 1990: IV insulin order set Mid 1990s SQ Insulin Order sets 1999: intranet education 2004: Mandatory use of New insulin order sets 2004: New mandatory nursing (online) and Physician education (online and small group case based) 2012: Inpatient EMR for orders (EPIC) Insulin Order Forms Adult DKA Adult SQ Insulin Patient eating Adult SQ Insulin NPO, TPN, Tube Feeding IV insulin ICU protocol IV insulin Med-Surgical Unit protocol Adult Insulin pump Patient waver form Adult SQ insulin algorithm for NPO patients** CV Surgery Specific orders PREO-OP Pathway** OB-GYN SQ Insulin Patient eating IV Insulin form - delivery Pump Form Pump waiver form Pediatrics SQ Insulin Patient eating Pump Form Pump waiver DKA IV insulin Therapeutic Inertia Glucoses Better Low rate of hypoglycemia Nevertheless, our audits continued to show inappropriate initial insulin orders and therapeutic inertia for both attending staff and housestaff, with required insulin order changes not being made on a daily basis. Therapeutic Inertia Physician Education Daily High Glucose Report Nurse to check in on patients with very high glucoses Diabetes team for patients with high glucoses Physician Nurse Pharmacist Diabetes Team for All Patients Physician Nurse Pharmacist General Resident Education residents may gain confidence about their knowledge and feel more at ease with inpatient glucose management, but significant improvements in management have generally not occurred. 12

Education by Example David Baldwin, et al showed that having an endocrinologist round with a member of the medical team improved both insulin order-writing and glucose levels UCSF Intervention

13 Education by Example David Baldwin, et al showed that having an endocrinologist round with a member of the medical team improved both insulin order-writing and glucose levels UCSF Intervention limitations Physician Education Still not all residents get training Residents not taking care of patients Hospitalists (turnover) Nursing NPs managing patients Order set Adult SQ Insulin Patient eating: set premeal dose Adult SQ Insulin Patient eating: CHO Counting Adult SQ Insulin NPO, TPN Adult SQ Insulin Tube Feeding Adult Insulin Pump IV Insulin protocol: ICU IV insulin protocol: Medical/surgical units Premeal Dosing Postmeal Dosing (based on amount consumed) Premeal Dosing CHO dependent Postmeal Dosing (based on CHO consumed) Q4h nutrition and correction Nutrition dose timed to cycle TPN, correction q4h Q4h nutrition and correction Nutrition dose timed to cycle feedings, correction q4h Specific initial rate for CVS/DKA/other Specific initial rate for CVS/DKA/other Big Brother Daily Reports: 2 or more glucoses>225 Glucose <60 On insulin pump Dx type 1 DM DKA How to communicate with teams Impossible to figure out who is actually taking care of patient Pager to tell them to read (but which pager) no one actually reads s Sticky notes Endocrine notes (people don t actually read other notes) 13

14 Inpatient Hyperglycemia The virtual Inpatient Glucose Management Service 14

15 10 Day Audits of Patients Per Day with 2 or More Glucoses 225 mg/dl (for specific units) Before vgms After vgms % of Patient in Each Glucose Range Among Patients on SQ Insulin Premeal Protocol 15

% of Patient in Each Glucose Range By Days on SQ Insulin Premeal Protocol Changes in number of Days patients on high glucose list Date # Months vgms Total # individual % of patients % of patients on

0 (baseline) 272 20 80 4.06 3.45 5/2013 1 month 257 21 79 3.62 3.07 10/2013 5 months 242 17 83 3.39 2.8 5/2014 1 year 248 31 69 3.25 2.55 4/2015 2 years 220 38 62 3.01 2.

16 % of Patient in Each Glucose Range By Days on SQ Insulin Premeal Protocol Changes in number of Days patients on high glucose list Date # Months vgms Total # individual % of patients % of patients on # consecutive # consecutive active patients on list on list for list for > 1 day days on list (for days on list (for during month only 1 day patients on list all patients on for >1day) list) 10/ (baseline) / month / months / year / years Criteria Used for No Note I know that for my interns, the feedback really drives their own improvements because they want to avoid getting a "Rushakoff note" in the chart the next morning. And it works as a perfect "just-in-time" teaching mechanism to inform appropriate responses to high blood sugars for inpatients. Followed by endocrinology consult team Random High: Glucoses were fine before No new meds (eg glucocorticoids) No pattern Would be dangerous to change orders based on the two higher numbers Criteria Used for No Note New Orders Already Written Appear appropriate Shows understanding how to adjust On IV insulin infusion Change of Medications Single glucocorticoid pulse Glucocorticoid discontinued Criteria Used for No Note One time issue Received Dextrose with medication (though may put in note to avoid the dextrose) Procedure Glucoses before fine and would expect ok after New orders written (often day of admit) Cannot yet assess effect 16

The numbers Number of vgms notes in past 2 years: 3400 Time to complete task: 30-45 minutes Change in number of Formal Endocrinology Consults: none Physicians Robert Rushakoff Umesh Masharani Melissa

17 The numbers Number of vgms notes in past 2 years: 3400 Time to complete task: minutes Change in number of Formal Endocrinology Consults: none Physicians Robert Rushakoff Umesh Masharani Melissa Weinberg Sarah Kim Aaron Neinstein Bonnie Kimmel Saleh Adi Stephen Gitelman Jan Hirsch Kathryn Rouine- Rapp David Robinowitz Michael Hwa Heather Nye Steve Pantilat PEOPLE CHANGING INPATIENT DM MANAGEMENT AT UCSF Nurses Mary Sullivan Pauline Chin Marlene Bedrich Craig Johnson Molly Killion Jeanne Buchanan Noraliza Salazar Lynn Dow Dietary Byanqa Robinson Marian Devereaux Ami Bhow Pharmacists Heidemarie Windham Lisa Kroon Kethen So Thomas Bookwalter Anna Seto Yali Brennan Administration Rosanne Rappazini Jennifer Pacholuk Joy Pao Janice Hull Physicians Community Hospital Training Annenberg Project Rushakoff RJ, Sullivan MM, Seley JJ, Sadhu A, O'Malley CW, Manchester C, Peterson E, Rogers KM. Using a Mentoring Approach to Implement an Inpatient Glycemic Control Program in United States Hospitals. Health Care: The Journal of Delivery Science and Innovation Volume 2, Issue 3, September 2014, Pages Robert J. Rushakoff, MD Director Inpatient Diabetes, UCSF Cheryl W. O Malley, MD Program Director, Internal Medicine Banner Good Samaritan Medical, Phoenix, Arizona Kendall M. Rogers, MD Chief, Hospital Medicine University of New Mexico Health Sciences Center Albuquerque, New Mexico Archana Sadhu, MD Director, Inpatient Diabetes Program, The Methodist Hospital System Houston, Texas Diabetes Educators Carol Manchester, MSN, ACNS, BC-ADM, CDE University of Minnesota Medical Center, Minneapolis, Minnesota Jane Jeffrie Seley, DNP, MPH, BC-ADM, CDE New York Presbyterian/Weill Cornell Medical Center Mary M. Sullivan, RN, DNP, ANP-BC, CDE University of California, San Francisco Eric D. Peterson, EdM, FACME Annenberg Center for Health Sciences at Eisenhower 17

18 Site Visit Faculty team visits each site 1 physician (inpatient endocrinologist or hospitalist) 1 nurse with inpatient glycemic control experience Team Meeting Review experience, goals, barriers Refine the team project who they need to involve Data collection to characterize their current performance Common barriers that they are likely to face and strategies that have been used by other institutions to overcome them Implementation and measurement that they may want to consider to evaluate both process and outcome Presentation to other stakeholder groups Physician or nursing staff forums Web Conferences 3 Web conferences planned #1 Sites share their project plans #2 Sites present interim progress and challenges #3 Sites present data generated from their project Primarily intended as a tactic to keep sites on task and to facilitate interaction between sites Annenberg Center Diabetes Project -Hospital B- Community, non-teaching; No Endocrinology Lots of forms main was self adjusting SS Many MD groups, hospitalist group No education, Meal timing Annenberg Center Diabetes Project -Hospital B- Lots of forms main was self adjusting SS SS form gone; BB mainly used (CHO based postmeal for meals on demand) Many MD groups, hospitalist group Hospitalist contract dispute No education Case studies CDs, in person for specific populations Meals Refreshment centers closed Still get meals on demand CDE Involvement Assist with insulin orders Call MDs for consistently high numbers Annenberg Center Diabetes Project Annenberg Center Diabetes Project 18

19 19

Meeting the Challenge of Inpatient Glycemic Management in the Non-Critical Care Setting

Meeting the Challenge of Inpatient Glycemic Management in the Non-Critical Care Setting Jane Jeffrie Seley, DNP, MPH, GNP, BC-ADM, CDE, CDTC, FAAN, FAADE Diabetes Nurse Practitioner, Inpatient Diabetes