Implementation of an Interprofessional Team to Prevent Inpatient Hypoglycemic Events. November 12, 2016

Transcription

1 Implementation of an Interprofessional Team to Prevent Inpatient Hypoglycemic Events November 12, 2016

2 St Joseph s Health Fast Facts Founded 1869 by Sisters of St. Francis Patient Volumes (2014) Inpatient discharges: 27,635 Primary Care Visits: 66,554 Emergency Department Visits: 66,835 Psychiatric Emergency Program: 13,464 Outpatient Surgeries: 9,791 Home Healthcare Admissions: 6,332 Employees FTEs: 3,636 Volunteers: 500 Medical Staff Physicians and Dentists: 870

3 Diabetic Glycemic Control High proportion of diabetes in Onondaga County. Onondaga: 13.9% National: 10.4% & New York: 9.4% Insulin administered 23% Hospital Days at St Joseph s

4 Morbidity and Mortality associated with Severe Hypoglycemia Current Medical Research & Opinion 29: , Increased in inpatient mortality risk: <70 mg/dl adjusted odds ratio (OR) 1.66 <50 mg/dl adjusted odds ratio (OR) Increase LOS: 8.2 vs. 5.2 days. Diabet. Med. 12:e445-8, Increase in inpatient mortality risk: mg/dl adjusted odds ratio (OR) 1.62 <40 mg/dl adjusted odds ratio (OR) Increase LOS cw >70mg/dL group: mg/dl 1.51 fold <40 mg/dl 2.33 fold

5 Hypoglycemia 5.19% vs NYSPFP 6.99% (Inpatients with at least one glucose <50mg/dL/100 prescribed insulin) vs Current Medical Research & Opinion 29: , %

6 Hypoglycemia Initiatives 1. Interprofessional Hypoglycemia Response Team. 2. Revised Sub Q insulin protocol. 3. House-wide education: insulin regimens. 4. Leverage new EHR to create actionable and analytical reports

7 Hypoglycemia Response Team Interprofessional Team: Endocrinology Pharmacy Dietary Nursing Patients with severe hypoglycemia <50mg/dL identified. Daily EPIC EHR report Plan formulated and attending provider contacted.

8 Daily Severe Hypoglycemia Report No Patients!

9 Lantus Insulin Protocol Proactively identify patients at risk for severe hypoglycemia. Patients with a fasting glucose 100 mg/dl identified. Daily EPIC EHR report. Pharmacy provides Lantus to floors. Glucose mg/dl: pharmacy decreases Lantus by 20%. Glucose <70 mg/dl: hypoglycemia protocol started and provider contacted.

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11 Rate per 1000 Pt-Ins days Severe Hypoglycemic Episodes (<50mg/dL) Initiation Hypoglycemia Response Team and Pharmacy Lantus Protocol

12 Percent Patients treated with Insulin with Hypoglycemic Episode Severe Hypoglycemic Episodes (<50mg/dL) Initiation Hypoglycemia Response Team and Pharmacy Lantus Protocol

13 Patients treated with Insulin with Hypoglycemic Episode Severe Hypoglycemic Episodes (<50mg/dL) Initiation Hypoglycemia Response Team and Pharmacy Lantus Protocol

14 Percent Pt-Insulin Days Avg Glc > 200 mg/dl Inpatient Hyperglycemia Initiation Hypoglycemia Response Team and Pharmacy Lantus Protocol

15 Rate per 1000 Pt-Ins days 4 Repeat Severe Hypoglycemic Episodes (<50mg/dL) Initiation Hypoglycemia Response Team and Pharmacy Lantus Protocol

16 Rate per 1000 Pt-Ins days Severe Hypoglycemic Episodes (<50mg/dL) and Hyperkalemia Initiation Hypoglycemia Response Team and Pharmacy Lantus Protocol Hyperkalemia OS Final K+ guidelines 50g bolus D10

17 Percent Insulin Administrations 25% Severe Hypoglycemia and Insulin Adminstration for Hyperkalemia Treatment 20% Hyperkalemia OS Final K+ guidelines 50g bolus D10 15% 10% 5% 0%

18 Hyperkalemia Treatment Order Set Medications

19 Timing POC Glc and Insulin Administration

20 Percent POC Glc to Insulin Admin <=30min POC Glc to Insulin Admin Initiative to decrease variability in glucose testing to insulin administration time: unit and clinician metrics.

21 Percent Change Last Mos:2015 POC Glc to Insulin Admin <=30min POC Glc to Insulin Admin

22 Percent Change Last Mos:2015 POC Glc to Insulin Admin <=30min POC Glc to Insulin Admin

23 Summary Reduction of hypoglycemic episodes <50mg/dL by 44% Reduction of repeat episodes by 78% Treatment of Hyperkalemia: 16% episodes 5.6% after Order Set Optimization Timing POC Glc-Insulin Admin <30min 60% to 75% administrations No initial but gradual increase in hyperglycemia

24 Lessons Learned Interprofessional team is a powerful resource. A team of key stake-holders critical Amplified knowledge Amplifies manpower Identify and make system changes All levels of patient care

25 Daily patient reviews identify areas for focused improvement: Timing of insulin dosing Stacking A la carte meals Lessons Learned Frequency POC glucose IV insulin Creative community insulin regimens Hypoglycemia associated with hyperkalemia treatment Order set incorporating insulin, glucose, monitoring

26 Lessons Learned Ripple effect of principles from Core Group. Key insulin regimen principles knowledge Permeate throughout community to improve diabetes care

27 Acknowledgements Dr. Marya Gendzielewski, Endocrinology Dr. Grant Kelley, Endocrinology Bernie Delello, Pharmacy Director Alecia Hehfoster, Pharmacy Sarah Linnertz, Pharmacy Kristen Bradshaw, Pharmacy Susan Branning, Clinical Dietician Sue Rioux, Diabetes Educator Christopher Jordan, Director of Quality