How a Written Back-Up Plan Saves Money and Lives. Jill Emerick, MD

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1 DKA, Quality, ad Costs: How a Writte Back-Up Pla Saves Moey ad Lives Traci Carter, MA, RN, CDE Aa Isfort, MD Kare Vogt, MD Jill Emerick, MD 18 // AADE I Practice // March 2017

2 Early last summer, we, the staff of a pediatric edocriology cliic, foud ourselves earig extra steps o our pedometer apps by walkig more frequetly to the Pediatric Itesive Care Uit (PICU) from our Pediatric Edocriology Cliic. We oticed a icrease i these trips to see our pediatric patiets with type 1 diabetes (T1D) admitted for diabetic ketoacidosis (DKA), defied as the presece of ketoes i blood or urie ad serum bicarboate less tha or equal to 15 mmol/l or ph less tha 7.3. At first the icrease was subtle, ad each idividual case was maaged with extra family educatio ad a short stay. However, whe we started compilig the PICU admissio data, we realized several families were sharig the same reaso for the tumble ito DKA. It souded somethig like this: I guess the pump was t workig ad we did t realize he/she was gettig sick. From Jauary 2011 to Jue 2015, about 30% ( = 35) of our DKA admissios were caused by isuli pump malfuctio or lack of actio by patiets ad families i respose to sigs of iterrupted isuli delivery. Diggig Ito Our DKA Admissios As providers ad educators, we wated to optimize DKA prevetio for our patiets ad help miimize the eed for costly comorbidity treatmet with the potetial for sigificat morbidity ad mortality. A outpatiet chart review showed provider-patiet educatio o safe pumpig practices was give ad documeted. However, the patiet/family perceived a lack of kowledge about a pump backup pla (as stated durig the admissio). We asked patiets what led up to their admissio how did it all start? Usually the patiet respoded that he or she oticed a rise i blood glucose (BG) ad used the isuli pump correctio factor bolus with o success. Here are the commo steps o the jourey to DKA: Step 1: BG is above 300 mg/dl. Use the pump to give a correctio factor bolus. Step 2: Do t recheck the BG... or check ad see a high BG ad give aother correctio. Step 3: Do t check ketoes. Do t do a site chage. Step 4: Thik it s a flu bug causig stomachache ad vomitig. Go back to bed. Step 5: Ca t keep fluids dow ad get dehydrated. Step 6: Do t call the cliic for advice. Step 7: Hopefully, go to the Emergecy Room for care ad admissio to PICU. A Commitmet to Quality Improvemet As a result of these observatios, a quality improvemet project was bor. We leared that most of our DKA admissios were related to ew oset diabetes. These were patiets we had ot yet met, ad we likely had little chace of prevetig PICU admissios i these patiets. However, 30% of our DKA admissios occurred i patiets kow to us, receivig isuli via isuli pump, ad ot correctly recogizig iterruptios i isuli delivery ad/or ot takig appropriate actios to address the iterruptios. Kowig that DKA due to isuli pump malfuctio ca be preveted, the icreasig expese of ipatiet ICU care, ad the risks to the child, our staff moved forward. The team icluded a certified diabetes educator (CDE), pediatric edocriologists, pediatric edocriology fellows, ad ursig support staff. A literature review did ot idetify ay existig educatioal itervetio data, but several articles poited out this problem ad suggested the eed for itervetio (see referece list). Accordig to research led by Tieder, a cost aalysis of ipatiet admissios varied widely. Usig mea data from multiple orgaizatios, it was reasoed that if PICU admissio days decreased, the cost avoidace could be over $3074 per admissio. Also, elimiatig additioal follow-o costs i o-picu rooms might add cost savigs of over $2500 per admissio. The project started with pediatric patiets 2 to 23 years of age i the outpatiet cliic. All patiets had T1D diagosed at least 6 moths prior to startig o the pump. After reviewig Bolderma s book o isuli pumps, we developed a writte back-up pla to provide istructios o moitorig for sigs of impedig DKA, givig isuli by ijectio at specific doses, ad trouble-shootig the pump (Figure 1). We leared that most of our DKA admissios were related to ew oset diabetes. Elimiatig additioal follow-o costs i o-picu rooms might add cost savigs of over $2500 per admissio. AADE I Practice // March 2017 // 19

3 Diabetes Educatio Pump Back Up Pla Name: DOB: I the evet of a isuli pump malfuctio, please follow these istructios. Pump Set Chage Precautios: Always be aware of your Blood Glucose (BG) treds. Whe placig a ew caula, pick a time early i the day so you ca moitor your BG. This will reassure you that the tubig ad/or the isertio set is ot kiked, leakig or blocked. If there was a problem with the flow of isuli, it may take several hours for the pump to alarm or it may ot alarm at all. Check your BG at regular itervals i the hours after a chage. Do ot go to bed right after a set chage. Watch your BG ad/or CGM device throughout the day to make sure there are o treds caused by lack of isuli. What Next?: If you otice BG readigs above 300mg/dL twice i 2 hours after a bolus isuli (correctio) ad it cotiues to rise, suspect a pump set failure. Check ketoes. Commo causes are listed o side 2. Whe do we suspect pump set or pump failure?: You have symptoms of high BG. Examples: thirsty, frequet uriatio, tired, fruity breath, stomach aches. If the ketoes are positive If high BG results cotiue eve after correctio Act fast: Stop the pump, ad give the Novolog correctio factor by usig your isuli pe or syrige/vial. Chage the isuli pump caula, tubig ad resume your basal rate. Cotiue to check your BG at 30 miutes ad the hourly util you are sure the ifusio set is workig properly ad the BG results stay uder 300mg/dL. Pump Back Up Pla: I case you are ot certai the pump or tubig is workig correctly, use this pla. Cotact the isuli pump compay represetative to troubleshoot the problems. (Help umbers are o the back of the pump device) Stop the pump ad discoect the tubig ad isertio set. If you will be off the pump for more tha 1-2 hours without a basal rate, you must correct with Novolog or switch to a log actig isuli pla. Optio 1: Correct usig Novolog pe or syrige/vial with the isuli sesitivity factor (correctio) every 3 hours. Use Novolog ijectios for your carbohydrate ratio with meals. Optio 2: Use log-actig isuli pla (Latus) after pump stops. Your Dose: uits Latus oce per day. Use Novolog ijectios for your correctio factor ad carb coverage at meals. Whe usig Latus, do t restart your usual pump basal rate o that day. This will cause low BG. Ask us for help trasitioig back to the pump whe ready. Be careful about high or low BG results durig these chages i isuli therapy. Recheck ketoes. Follow the sick day ketoe pla ad icrease drikig of u-sweeteed fluids. Carry fast-actig carb choices like glucose tabs. Cotact the Diabetes Educator or the Pediatric Edocrie Doctor O-Call Ask about updatig your isuli back up pla at every routie visit. Check your Latus expiratio dates ad keep refills refrigerated. Replace a opeed vial/pe every 28 days. Staff Sigature: Date: Patiet/Paret Sigature: Diabetes Educatio Cotact Iformatio: Figure 1. Diabetes educatio back-up pla. (cotiues) Dowload this resource to use i your practice at diabeteseducator.org/aipresources. 20 // AADE I Practice // March 2017

4 Pump Back Up Pla Side Two Commo Causes of Isuli Pump Malfuctio: Loose coectios Kiked or clogged caula Air bubbles i tubig. Tubig that was ot correctly primed. Cracked tubig Dislodged ifusio set or caula came out of ski Ieffective ifusio site. Scarred ski or lipohypertrophy (fatty scars uder the ski wo t absorb well). Site irritatio or ifectio Empty isuli reservoir Expired isuli or isuli that wet bad due to heat or freezig Icorrect bolus doses or settigs Missed bolus doses (check pump memory) Icorrect basal rate settigs Pump was left i susped mode for more tha 2 hours Old batteries Pump malfuctio (specific pump compay techicia ca troubleshoot if replacemet is eeded) Referece: Bolderma, Kare. Puttig Your Patiets o the Pump. 2d Ed Cosider purchasig: Chase, Peter, MD & Laurel Messer, RN. Uderstadig Isuli Pumps & Cotiuous Glucose Moitors. Childre s Diabetes Foudatio at Dever, CO. Keep track of your curret Novolog settigs. Write i Pecil. Take a picture. Dosig Time Segmets Uits Target BG Carb Ratios: Correctio Factors: Documets eclosed are subject to the Privacy Act of Cotets shall ot be disclosed, discussed or shared with idividuals uless they have a direct eed-to-kow i the performace of their official duties. Figure 1. Diabetes educatio back-up pla. AADE I Practice // March 2017 // 21

The itervetio icluded a pretest that aalyzed the kowledge base of isuli pump patiets or parets/guardias, a itervetio i the form of the writte isuli pump back-up pla, ad a posttest at a follow-up

5 The itervetio icluded a pretest that aalyzed the kowledge base of isuli pump patiets or parets/guardias, a itervetio i the form of the writte isuli pump back-up pla, ad a posttest at a follow-up visit (Figure 2). Idividualized couselig was provided with the writte pla, ad it was documeted i the medical record. These stadardized steps were followed whe teachig DKA prevetio. Step 1: Write it dow. Prepare a isuli pump back-up pla whe well. Take a smartphoe picture of the pla to use aywhere. Step 2: If BG is >300 mg/dl, check urie or blood ketoes. Step 3: Use correctio factor, drik water, set alarm to recheck BG i 1 to 2 hours. Follow the writte pla. Step 4: If highs cotiue, have ay symptoms, or positive ketoes, the dose isuli with a eedle (pe or syrige) ad chage the pump site. Step 5: Report fidigs from Steps 2 through 4. Keep commuicatig with the health care team. Repeat. Reducig Admissios With Back-Up Plas After implemetig writte isuli pump backup plas i Jue 2015, a decrease i ipatiet admissios ad a icrease i the kowledge of Isuli Pump Back-Up Pla Questios Purpose: If the isuli pump fails or eeds to be stopped, please tell us about your back up pla. 1. Do you have a writte isuli pump back up pla? Yes / No 2. What is your back up basal isuli dose (usually Latus isuli)? uits 3. Sice startig o the pump, have you bee i the hospital for DKA (Diabetic Ketoacidosis)? Yes / No 4. If the pump stopped, how cofidet are you kowig how much ijectable isuli to give? Circle oe: Very Cofidet Cofidet Somewhat Cofidet Little Cofidet Not Cofidet Figure 2. Pre/posttest Dowload this resource to use i your practice at diabeteseducator.org/aipresources. 22 // AADE I Practice // March 2017

6 100 p = p = p = Pre-test % Post-test % 20 0 Q1: Have a pla? Q2: Correct dose? Q4: Cofidet? Figure 3. Pre/posttest compariso. DKA prevetio was observed. Admissio data show oly 1 DKA admissio related to pump use sice the project implemetatio. This patiet, however, had ot received the itervetio. Icludig the oitervetio admissio, there was a 75% reductio i admissios for pumprelated DKA. A total of 42 pretests ad 30 posttests were completed ad aalyzed durig the 6-moth data gatherig timeframe. Patiets recallig havig a isuli pump back-up pla icreased from 43% to 90% at the follow-up visit (P =.001), ad correctly listig the proper back-up log-actig isuli dosage icreased from 37% to 70% (P =.008) (Figure 3). As part of the quality improvemet project, ogoig suggestios ad feedback were utilized to evaluate the outcomes. Patiet ad professioal feedback of the isuli pump back-up pla has bee positive. Families are glad for the defied actio pla. The health care system is takig ote of the quality ad fiacial beefits. Cost avoidace as compared to the previous 6 moths would be estimated at $ based o 4 fewer admissios to the PICU (ot icludig o-picu bed days). Coclusio While the staff may ot be accumulatig so may steps o pedometer apps ow, they are pleased with the ability to catch kowledge deficits ad prevet admissios. After successful use of a writte pla ad educatioal itervetio as a quality improvemet project, the iformatio ad tools will be shared i hopes of improvig the outcomes of all T1D childre. Traci Carter, MA, RN, CDE; Aa Isfort, MD; Kare Vogt, MD; ad Jill Emerick, MD, are with Walter Reed Natioal Military Medical Ceter i Bethesda, MD. The views expressed i this article are those of the authors ad do ot reflect the official policy of the Departmet of the Army, Departmet of the Navy, Departmet of the Air Force, Departmet of Defese, or U.S. Govermet. Refereces Bolderma K. Puttig Your Patiets o the Pump. 2d ed. Alexadria, VA: America Diabetes Associatio; Haas R, Ludvigsso J. Hypoglycemia ad ketoacidosis with isuli pump therapy i childre ad adolescets. Pediatr Diabetes. 2006;7(suppl 4): Realse J, Goettle H, Chase HP. Morbidity ad mortality of diabetic ketoacidosis with ad without isuli pump care. Diabetes Techol Ther. 2012;14(12): Scaramuzza AE, Dell Acqua M, Macedoi M, Zuccotti GV. Isuli pump therapy i childre with type 1 diabetes: the dark side of the moo. J Diabetes Sci Techol. 2013;7(4): Tieder JS, McLeod L, Kere R, et al. Pediatric research i ipatiet settigs etwork. Variatio i resource use ad readmissio for diabetic ketoacidosis i childre s hospitals. Pediatrics. 2013;132(2): Icludig the oitervetio admissio, there was a 75% reductio i admissios for pump-related DKA. AADE I Practice // March 2017 // 23

Modified Early Warning Score Effect in the ICU Patient Population

Modified Early Warning Score Effect in the ICU Patient Population Lehigh Valley Health Network LVHN Scholarly Works Patiet Care Services / Nursig Modified Early Warig Score Effect i the ICU Patiet Populatio Ae Rabert RN, DHA, CCRN, NE-BC Lehigh Valley Health Network,