Introduction. Methods

Transcription

1 A New Perspective On A Difficult Discharge: Ensuring the newly diagnosed diabetic patient gets the proper prescriptions when it s time to go home. Ashley Carter, PGY 3 Introduction A hospitalized patient with new onset diabetes mellitus is often a complicated one for the resident who is providing his care. There have been multiple protocols set into place to help with determining when to check blood glucose, how to treat high and low blood glucose levels with insulin or fluids, and when to follow urinary ketone levels which are all very helpful in making the hospital course run more smoothly. Diabetic educators and nutritionists are instrumental in preparing the patient and his family for discharge, but when it is time for him to go home the resident is responsible for providing the necessary prescriptions. On average, these patients will leave the hospital with eight new prescriptions. These prescriptions include everything from various forms of insulin to an emergency glucagon kit to all necessary supplies to check blood glucose, monitor urinary ketone levels, and administer the insulin. For example, whether a patient is using insulin pens and pen needles or insulin vials and syringes needs to be determined. If the patient is using an insulin pen, then whether it is appropriate for him to be on a regular pen that only administers insulin in full unit increment or a Junior pen that will administer half unit increments needs to be decided. The patient s insurance is another factor that significantly plays into which prescriptions will need to be written as insurance companies often cover only certain brands of blood glucose test strips, blood glucose meters, insulin, etc. All of these challenges factor into making this discharge a particularly difficult and somewhat confusing one for most residents. In the past, a onepage prescription form provided by the pediatric endocrinology clinic was available to the residents that included all medications and supplies that would be needed at time of discharge (Figure 1). Unfortunately pharmaceutical board is no longer allowing this form to be utilized, and with the use of electronic medical record (EMR), our method of prescribing the proper medications/supplies was in need of change. We therefore developed an order set in the EMR that included the typical prescriptions that a diabetic patient would need at hospital discharge and educated the residents on exactly how to use this order set. There were two major aims of this project. The first was to improve comfort level among the prescribers (the residents) with this new order set. The second was to improve knowledge base pertaining to the medications and supplies every patient with newly diagnosed diabetes will need at hospital discharge. Methods A 16 question survey, Figure 2, was distributed to all of the residents and filled out anonymously. The first question evaluated the comfort level of the provider on a scale of 1 to 10 (1 meaning not comfortable at all and 10 meaning very comfortable). The other 15 questions evaluated knowledge base. An intervention was performed after the initial survey was collected. This intervention was a 45 minute powerpoint lecture reviewing types of insulin, methods of administration, and the proper way to complete the template prescriptions in the EMR. The lecture was also distributed to the residents via

2 for review if needed. The same 16 question survey was completed a second time after the lecture was given. Results A total of 34 surveys were collected, 14 pre-intervention and 20 post-intervention. The survey was scored broken down into comfort level and overall score. Table 1 shows the results of the comfort level in residents. The scores were averaged and there was a 2.14 average comfort level prior to the lecture and a 4.65 average afterwards which are displayed in Figure 3. A 46% increase was noted. Table 2 shows the overall scores for questions The averages were found to be 5 and 11.7 in the pre- and post-intervention groups respectively and are shown in Figure 4. A 43% increase occurred. Discussion Out of the 35 pediatric residents in our program, a total of 14 completed the pre-intervention survey and 20 completed the post-intervention survey. Of the surveys completed, both comfort level and knowledge base scores increased after the intervention was provided. The two areas missed most on the surveys included the difference between insulin pens and insulin cartridges and the amount (units) of insulin in an insulin vial and pen. The powerpoint presented a brief review of different types of insulin; rapid, short, intermediate, and long acting. For each type, we discussed the onset, peak, and duration as well as typical trade names and how each is packaged. For example, we discussed that Novolog is a rapid-acting insulin with an onset of 5-10 minutes, peak at 1-3 hours, and duration of 3-5 hours that is available in vials, disposable pens, and cartridges/penfills and Lantus is a long-acting insulin that has an onset in hours, no peak, and duration of 24 hours and is available in vials and disposable pens. Next there was a detailed review of insulin pens, cartridges, and vials. Prescribers were reminded to provide pen needles when writing for pens and appropriately sized syringes when writing for vials. Most types of Medicaid insurance refuse to provide coverage for insulin pens unless there are extenuating circumstances (ie the patient is blind). This was not known to many as we often use insulin pens in the hospital due to convenience and then discharge the patient home on them as well since that was what they were using for insulin administration during the hospital stay. The importance, mechanism, and appropriate weight-based dosing of glucagon was covered. Lastly, we reviewed each prescription template in the new EMR order set to teach about what needed to be filled in for insurance to appropriately cover the medications and supplies. One common misconception was that when writing a rapid-acting insulin prescription, one could just put the patient s correction factor and insulin to carbohydrate ratio in the directions without specifying an absolute number of units of insulin the patient should use each day. The appropriate way of writing the rapid-acting insulin was reviewed. Overall the participating residents appeared to have a better understanding and comfort level after the powerpoint was given. Unfortunately the new EMR order set has not fully become accessible at this time, but the residents who have done discharges since the intervention occurred have been able to use the last slides that reviewed each medication to put appropriate ones in at time of

3 discharge. As a next step, we may be able to look to see that the EMR order set is beneficial and also we are trying to have the diabetic educators leave information on what is covered by the insurance including pens vs vials and type of glucometer. Figures and Tables Figure 1: One page all inclusive prescription form from the endocrine clinic.

4 Figure 2: Diabetic Discharge Prescription Questionnaire 1. What is your comfort level with writing discharge prescriptions for a new onset diabetic without using the endocrinology prescription form? (Circle one number below) Not comfortable at all Very comfortable What is the difference between an insulin pen and an insulin cartridge? A. The insulin cartridge has the needle already attached and the insulin pen does not B. The insulin pen comes pre-filled with insulin and the insulin cartridge has to be filled manually with insulin before use C. The insulin cartridge is for use in an insulin pump and the insulin pen is to be used for subcutaneous injections D. None of the above E. Both A and B F. I have no clue G. I thought an insulin pen and an insulin cartridge were the same thing 3. a) What is the minimum number of insulin pens that can be dispensed to a patient at one time because that is how many come in one box? b) What is the minimum number of insulin cartridges that can be dispensed to a patient at one time because that is how many come in one box? 4. a) What is the concentration of insulin (Units/mL) in the standard insulin vial or insulin pen used in the treatment of pediatric diabetes? units of insulin per ml b) How many units of insulin are in one standard insulin vial? c) How many units of insulin are in one standard insulin pen? 5. Are pen needles included with the box of insulin pens? (Check one) Yes No 6. When discharging a child home on insulin therapy: a) What other medication should you also provide a prescription for? b) What is the standard dose of this medication if the child weighs > 20kg? mg c) What is the standard dose of this medication if the child weighs < 20kg? mg 7. Most forms of Medicaid insurance will cover insulin pens.(check one) True False 8. Most forms of Medicaid will cover any type of glucometer as long as the patient has a prescription that specifies exactly which glucometer is being prescribed.(check one) True False 9. How do you write a standard prescription for a Novolog FlexPen for a 16yo boy with type 2 diabetes that weighs 80 kg? Medication Name: Sig: Disp: Or check this box if you don t know how to write such a Rx 10. How do you write a standard prescription for a Novolog FlexPen Junior for a 16yo boy with type 2 diabetes that weighs 80kg? Medication Name: Sig: Disp: Or check this box if you don t know how to write such a Rx 11. In general, children with type 1 diabetes should check urine ketone levels when their BG level is above which minimum level? A. >400 mg/dl B. >200 mg/dl C. >240 mg/dl D. When there glucometer reads HI E. > 300 mg/dl

5 Table 1: Comfort level in the pre and post-intervention survey Comfort Level Pre-intervention Post-intervention Figure 3: Comfort level averages compared between the two groups Comfort Level Pre-intervention Post-intervention

6 Table 2: Overall scores in the pre and post-intervention survey. Overall Score Pre-intervention Post-intervention Figure 4: Overall score averages between the two groups.