HEN 2.0 ADVERSE DRUG EVENTS WEBINAR #2: PREVENTING HYPOGLYCEMIA. March 15, :00 a.m. 12:30 p.m. CT

Transcription

1 HEN 2.0 ADVERSE DRUG EVENTS WEBINAR #2: PREVENTING HYPOGLYCEMIA March 15, :00 a.m. 12:30 p.m. CT 1

2 WELCOME AND INTRODUCTIONS Natalie Erb, Program Manager, HRET 11:00 11:05 2

3 AGENDA FOR TODAY 11:00-11:05 AM Welcome and Introductions Opening and housekeeping information, including review of relevant HRET HEN resources, change packages and Listserv. 11:05-11:10 AM HEN Data Update Review of ADE measures and national progress toward our 40/20 HEN goals. 11:10-11:25 AM 2016 Hypoglycemia Prevention Strategies Review of 2016 American Diabetes Association recommendations for treatment of hypoglycemia in hospitalized patients. 11:25-11:45 AM Case Study from Rexburg, ID Sharing from a rural HEN hospital about their approach to glycemic management and ADE prevention. 11:45 AM-12:05 PM Case Study from Tucson, AZ Sharing from an urban HEN hospital about their approach to glycemic management and ADE prevention. 12:05-12:20 PM Finding the Data in Manual and Electronic Systems Discussion of where to find data, from simple manual systems to mining of electronic systems. 12:20-12:25 PM Bring It Home Action items from today s webinar and suggestions for next steps in your ADE prevention work. 12:25-12:30 PM Q&A All Natalie Erb MPH Program Manager, HRET Annette Urganus MPH Data Analyst, HRET Steve Tremain MD Improvement Advisor, Cynosure Health Mikel Barr RN Misty Gordon RN Madison Memorial Hospital Claudia L. Koreny PharmD Linda Pelger PharmD, BC-ADM, CDE Tucson Medical Center Kathleen CarrothersMPH, MS Improvement Advisor, Cynosure Health Natalie Erb MPH Program Manager, HRET 3

4 AVAILABLE NOW: ADE CHANGE PACKAGE Download It Here 4

5 SIGN UP TODAY: ADE LISTSERV ADE Listserv is available for: Sharing of: HRET Resources Publically Available Resources Best Practices Learnings from Subject Matter Experts Troubleshooting for Data Reporting and Analysis Sign Up Here 5

6 HEN DATA UPDATE Annette Urganus, Data Analyst, HRET 11:05 11:10 6

7 HEN DATA UPDATE Core Harm Topics / Measures Cohort 1 Baseline Submission Rate Baseline Rate Excessive Anticoagulation with Warfarin - Inpatients 55% 3.10 Hypoglycemia in Inpatients Receiving Insulin 50% 5.16 ADE due to Opioids 49%

8 ADE The definition of an adverse drug event is any injury resulting from medication use, including physical harm, mental harm or loss of function. Data can be collected through incident reporting, trigger tools, pharmacists intervention data or administrative data. 8

9 ADE: EXCESSIVE ANTICOAGULATION 9

10 ADE: HYPOGLYCEMIA IN INPATIENTS RECEIVING INSULIN 10

11 ADE: OPIOIDS 11

12 PROCESS MEASURES Adverse Drug Event (ADE) Venous Thromboembolism (VTE) Warfarin Therapy Discharge Instructions Reconciled medication list received by discharged patients Percentage of patients on insulin whose blood sugars registered <80 mg/dl at least once Percentage of patients receiving opioids who receive an opioid risk assessment prior to first opioid dose Percentage of patients receiving opioids who regularly receive a formal assessment (e.g., POSS or RASS) during therapy CoreProcess.pdf 12

13 ADE FACT SHEETS On the HEN homepage ( ), click on topics, then Adverse Drug Events 13

14 ADE FACT SHEETS 14

15 Preventing Hypoglycemia Steven Tremain, MD, FACPE Improvement Advisor, Cynosure Health 11:10 11:25 15

16 HYPOGLYCEMIA: THE KEY CAUSES Normo-glycemic targets Labile blood glucose during illness Illness Failure to report symptoms Emesis Decreased oral intake 16

17 HYPOGLYCEMIA: THE KEY CAUSES New NPO status Inappropriate timing of short acting insulin in relation to meals Unexpected interruption of parenteral, enteral or oral feedings Reduction of IV dextrose infusion rate Abrupt decrease in corticosteroid dose 17

18 COORDINATION OF INSULIN AND MEALS? WHY IS IT SO DIFFICULT? 18

19 2016 ADA STANDARDS OF CARE: MANAGING GLUCOSE LABILITY All Patients Avoid hypoglycemia (< 70 mg/dl) If one episode of hypoglycemia, the anti-hyperglycemic regimen MUST be changed* A second episode of hypoglycemia MUST be avoided. *Unless it can be certain that it will not happen again without a regimen change! 19

20 INPATIENT HYPOGLYCEMIA First inpatient episode of glucose < 70 SHAME ON DIABETES Any subsequent episode of glucose < 70 SHAME ON THE HOSPITAL 20

21 2016 ADA STANDARDS OF CARE: TARGET Proper Inpatient Glucose Target mg/dl in certain cardiac surgery patients acute ischemic cardiac and neurologic events only if hypoglycemia is avoided 21

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23 2016 ADA STANDARDS OF CARE: MANAGING GLUCOSE LABILITY Outside of Critical Care Scheduled insulin therapy Aligned with meals and bedtime or Q 4-6H if No meals are consumed Continuous enteral nutrition Continuous parenteral nutrition 23

24 2016 ADA STANDARDS OF CARE: INSULIN Outside of Critical Care: Preferred Care for Patients with Good Nutritional Intake Point of Care Glucose should be tested immediately before meals Consistent carbohydrate meal plans Basal-Bolus Basal + nutritional + correction components 24

25 2016 ADA STANDARDS OF CARE: INSULIN Outside of Critical Care: Preferred Care for Patients with Poor Nutritional Intake or NPO Basal + correction (no bolus at meal time) 25

26 2016 ADA STANDARDS OF CARE: INSULIN Do not use Sliding Scale as the sole method of managing glucose levels. Schafer, Weinberg, Rushakoff, USCF 26

27 2016 ADA STANDARDS OF CARE: ORAL AGENTS? Not expressly prohibited Insulin is preferred Insulin allows for more nimble management of glucose levels Insulin helps avoid hypoglycemia associated with oral agents in ill patients who May eat erratically May be NPO for a procedure without notice 27

28 COORDINATION OF INSULIN AND MEALS? WHY IS IT SO HARD? Unit routines More labor intense Meals delayed Poor appetite Pharmacokinetics not understood Patient doesn t control timing as done at home 28

29 CAN WE LET THE PATIENT SELF-MANAGE DIABETES IN THE HOSPITAL? Patient Criteria: Must be doing it successfully at home Must have necessary cognitive and physical skills Adequate oral intake Able to count carbohydrates Use multiple daily injections or continuous pump Understand sick day management 29

30 CAN WE LET THE PATIENT SELF-MANAGE DIABETES IN THE HOSPITAL? Organization Criteria: Approval by patient, nursing and physician Appropriate protocols and procedures in place 30

31 HYPOGLYCEMIA FACT SHEET ADEGuidanceHypoglycemiaininpatientsReceivingInsulin.pdf 31

32 CASE STUDY: Madison Memorial Hospital Mikel Barr RN, Director of Quality & Misty Gordon RN Quality Improvement 11:25 11:45 32

33 ABOUT US Madison Memorial Hospital is a first-class regional health care provider that instills pride in the community, medical staff and employees. Provide professional and compassionate healthcare to those we serve. We do this through QUALITY, creating the EXCEPTIONAL EXPERIENCE, and ENSURING OUR FUTURE. 33

34 TESTS OF CHANGE & WHAT WE LEARNED Collecting data draws attention to areas of focus and this added awareness helped our focus on reducing hypoglycemic events. We added a new diabetic educator to our hospital staff. We were awarded a grant to focus on improving diabetic education. There was a focus on bringing awareness of glycemic control to limit SSI s. Our surgery team has this as a focus. Patient education offered before elective orthopedic surgeries addresses the importance of glycemic control. Protocols for insulin administration. Hard stops in the medication administration module that prompts a blood sugar reading prior to administration. Sliding scale documentation improvements. 34

35 BARRIERS AND HOW WE RESOLVED We were surprised at how well we have been doing despite the fact glycemic control has not been one of our top initiatives of focus. Some barriers that we faced: Staff turn over and re-educating team members to our protocols We keep focused and continue educating and tracking our data. We have implemented a learning session during new nurse orientation. Our Diabetic Educator reviews tips that can be used while caring for a diabetic patient. Diabetic educator located off site. We improved our communication with our educator Physician engagement on quality and safety initiatives. We resolved this by sharing data, increasing our transparency and letting the data drive our improvement efforts. 35

36 MEASURES WHAT & HOW How did you measure the improvement? Through our ADE/ Patient Safety score/ Total Harm score What measure did you use? Patients receiving more than one dose of insulin with a glucose level of <50 mg/dl Where did you find the data? Our Quality team data expert runs data reports and reviews to exclude patients. Did you share data with your team? We are very transparent with our data and share it to all staff, clinical and non-clinical, and it is available to our patient population on our department data boards 36

37 RESULTS 37

38 ADVICE FOR OTHERS Never stop fighting for patient safety Start with small quick wins Make sure to get the staff doing the work aware and involved in improvement efforts. Improvement work is never finished 38

39 WRAP UP AND NEXT STEPS We will continue being obsessed with improvement work - decreasing patient harm and improving quality. Questions? Mikel Barr Mikel.barr@mmhnet.org Misty Gordon Misty.gordon@mmhnet.org 39

40 CASE STUDY: Tucson Medical Center Claudia L. Koreny, PharmD & Linda Pelger, PharmD, BC-ADM, CDE 11:45 12:05 40

41 ABOUT US 600-bed community hospital Located in Tucson, Arizona 41

42 IDENTIFICATION OF OPPORTUNITY In 2010, Medication Safety Oversight Committee (MSOC) made glycemic management a major focus. The subcommittee tasked with this focus was the Adverse Drug Event (ADE) team led by Pharmacy. Adult Critical Care units demonstrated a higher usage of Dextrose 50% compared to other adult medical units. The ADE team conducted an in-depth review to assess the high use of D50W in critical care units. 42

43 HOW WE STARTED How did we find the problem? Ran quarterly rescue drugs reports from the automated drug cabinet D50W administrations were included in this review What happened when we discovered our numbers? Presented data to MSOC ADE team was tasked to review indications for D50W use in Critical Care. Critical Care Nursing Director felt that hyperkalemia treatment was primary cause for D50W use. Reviewed 54 charts looking for patterns Shared results with administration, nursing & pharmacy Chief Nursing Officer became executive sponsor chartering the Glycemic Management Oversight Committee (GMOC) 43

44 WHAT WE FOUND The ADE team conducted an in-depth review to assess the high use of D50W in critical care units. Several inconsistencies in the treatment of hypoglycemia were found. Discrepancies of when Laboratory Services were calling critically low blood sugars Hypoglycemic protocol was not followed Rescue medications not ordered NPO status and start of Dextrose containing IVF Poor documentation of intervention 44

45 TESTS OF CHANGE & WHAT WE LEARNED Standardization of Communication Hypoglycemic treatment badge cards for staff (nursing and patient care technicians) SBAR (situation, background, assessment, reporting) reporting tool for nursing to use when contacting provider in regards to hypoglycemic event Doorway signs created as reminder to staff for POCT 45

46 TESTS OF CHANGE & WHAT WE LEARNED Availability of correct product for intervention Pre-made snack packs available on all adult nursing units Standardization of DM supplies on unit carts Addition of Dextrose 50% to all unit code carts Glucometers stocked in ancillary units 46

47 TESTS OF CHANGE & WHAT WE LEARNED Support in Electronic Record Information Services added EMAR hard stop requiring 24 hour review of blood glucose prior administration of long-acting insulins Automatic order entry of rescue medications for insulin and sulfonylurea agents approved by Pharmacy & Therapeutics Committee 5/8/

48 TESTS OF CHANGE & WHAT WE LEARNED Pharmacy and Therapeutics Committee approved the Treatment of Hypoglycemia in Adult Patients as a Standing Order on 2/23/15 Entry of all severe hypoglycemic events into quality alert system to obtain baseline data and improve tracking of interventions Development of a Glycemic Care Team 48

49 GLYCEMIC CARE TEAM Interdisciplinary glycemic care team managed by the pharmacy department and piloted in post critical care unit in January Team consists of Glycemic Care Pharmacists, Certified Diabetes Educators, Nurse educator, Registered Dietitian, Case Management and Diabetes Nurse Practitioner Team works together to: Focus on high-risk patients Employ evidence-based approaches Daily huddles to review inpatient care/education needs Support providers (PTA med review, current BG control, etc.) Support bedside nursing staff Review patient s discharge plan and needs 49

50 9.00% Tucson Medical Center - Rate of BG<50mg/dL Events in Adult Inpatients on Insulin and/or Oral Hypoglycemic Agents 8.00% 7.00% 6.00% 5.00% 4.00% HEN 2.0 begins 3.00% 2.00% 1.00% 2013: 1-Insulin order set review 2-HEN participation LEAN Kaizen 7/ % Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 % Events (HEN 2.0 rate) Trendline 50

51 WHAT ABOUT Coordinating meals and insulin Review cause and effect when issues arise Dietary and Nursing staff communication regarding timing of meal delivery and insulin administration Enteral feedings and insulin therapy Preventing recurrence of glucoses < 70mg/dL Evaluating use of automatic reduction in basal insulin Monitoring renal function changes, steroid taper, BG monitoring post hyperkalemia treatment Review of outpatient insulin therapy, A1c and patient status for inpatient adjustment of insulin therapy 51

52 MOVING FORWARD Cause/effect analysis showed several areas that need focused improvement efforts. Team has decided to focus on three areas: Patient nutritional status (NPO, not eating, changes in diet) Prior to admission medication history is not accurate Hypoglycemia as a result of mixed insulin products (70/30) and sulfonylureas Glycemic Control Oversight Committee work is communicated internally to Patient Safety Committee & Medication Safety Oversight 52

53 ADVICE FOR OTHERS Glycemic care team has been instrumental in educating staff and patients about diabetes management. Using one universal insulin order set has made ordering insulin, POCT, ancillary consults and pertinent labs more consistent. Consistent nursing staff support has increased awareness for earlier interventions to prevent hypoglycemic event. Greatest surprise lack of knowledge about diabetes and inpatient glycemic management in general. 53

54 WRAP UP Questions? Contact Us: Claudia L. Koreny, PharmD Linda Pelger, PharmD, BC-ADM, CDE, 54

55 IMPROVEMENT SCIENCE Kathleen M. Carrothers, MS, MPH, CPHQ Improvement Advisor, Cynosure Health 12:05 12:20 55

56 IT S TOUGH TO BE SMALL Manual data collection Time consuming 56

57 IT S TOUGH TO BE BIG System defines metrics Measure specifications may be different from existing report Long queue for report requests Too much data 57

58 BIG OR SMALL, DATA COLLECTION MAY BE A BURDEN 58

59 ADE DATA COLLECTION WITHOUT EMR Just find patients with blood sugars < 50 Only requires lab reports Identify D50 use through automated drug cabinet reports 59

60 ADE DATA COLLECTION WITH EMR Run lab report Patients with BS < 50 Run pharmacy report Patients with insulin orders Merge files Use account number to retrieve patients in both reports For example, where lab.accountnumber = rx.accountnumber -OR- Use Excel to find patients receiving insulin that also had BS < 50 VLOOKUP function 60

61 VLOOKUP Lab report (BS < 50) Pharmacy Report (Patients on insulin) Add column, find patients in both 61

62 GOAL Find where hypoglycemia is occurring Specific units? Specific patient types? Determine why hypoglycemia is occurring Chart review ~20 charts 62

63 TIPS AND TRICKS If small: Include BS<50 in safety huddles Report to charge nurse, who reports it to Quality If big: Use existing reports (e.g., BS<70) and filter data Add fields to an existing report 63

64 AIM FOR USEFUL, NOT PERFECT 64

65 BRING IT HOME Natalie Erb, Program Manager, HRET 12:20 12:25 65

66 PHYSICIAN LEADER ACTION ITEMS What are you going to do by next Tuesday? Review the glucose targets Review your use basal bolus and sliding scale insulin What are you going to do in the next month? Assess and revise basal-bolus protocols Assess and revise insulin drip protocols 66

67 UNIT-BASED TEAM ACTION ITEMS What are you going to do by next Tuesday? Assess coordination of insulin and meals Assess physician receptivity to calls for insulin regimen changes when hypoglycemia occurs What are you going to do in the next month? Test strategies to coordinate insulin and meals Test scripts for nurses to use to contact physicians when hypoglycemia occurs; test with early adopter nurses and physicians 67

68 HOSPITAL LEADERS ACTION ITEMS What are you going to do by next Tuesday? Examine your data collection methods: Is there an easier way? Meet with multi-disciplinary staff to learn how meals and insulin are delivered to patients What are you going to do in the next month? Using simpler data collection tools, find and report rates of severe hypoglycemia to clinical and administrative leaders Work with the medical staff to review, modernize, and implement glucose targets, and insulin regimens, including insulin infusions in critical care area and basal-bolus-correction in non critical care patients Develop and sponsor a multi-disciplinary team to perform rapid cycle tests of change to achieve 100% coordination of meals and insulin 68

69 PFE LEADS ACTION ITEMS What are you going to do by next Tuesday? Talk to staff and understand how patients and families are currently involved in diabetes care Engage current PFE groups regarding the patients and families involvement in inpatient diabetes management What are you going to do in the next month? Formally commission a multi-disciplinary group that includes PFE representatives regarding the coordination of food and insulin Working with physicians, nurses and patients/family members, develop the basis for trialing and testing self-management of diabetes for appropriate candidates, especially those with Type 1 DM on pumps and continuous glucose monitors 69

70 QUESTIONS? 70

71 THANK YOU! Find more information on our website: Questions/Comments: 71