Lessons Learned: Interdisciplinary collaboration to reduce hypoglycemic events

Transcription

1 Lessons Learned: Interdisciplinary collaboration to reduce hypoglycemic events Ryan ull, Pharm.., BCPS ssistant Professor of Pharmacy Practice Creighton niversity School of Pharmacy legent Health Lakeside Hospital maha, NE bjectives List recommended strategies to optimize glycemic control escribe interventions to minimize hypoglycemic events 1

2 Inpatient iabetes and Glycemic Control Morbidity Infection Length of stay Mortality Cardiac surgery Surgical IC Economic 22% inpatient days $87 billion S CE/ Consensus Statement on Inpatient Glycemic Control Endoc Pract 2009;25(4):1-17. Negative utcomes ssociated with Inpatient Hyperglycemia Longer hospital stays Infection isability after discharge eath Table 1. ssociation between mean blood glucose concentrations and risk of mortality in hospitalized patients Mean BG (mg/dl) djusted dds Ratio ( ) ( ) ( ) > ( ) Moghissi EG. m J Health-Syst Pharm 2010;67(Suppl 8):S3-8 2

3 Therapeutic Response Therapeutic Response 6/1/2012 Balancing Efficacy and Safety Hyperglycemia Infection, illness, stress Poor or worsening diabetes control Holding diabetic medications Fluids/nutrition: 5W, TPN Medications: glucocorticoids Newly diagnosed diabetes (K, HHS) Hypoglycemia Change in nutritional status: NP, TF Change in clinical status: medications Failure of clinician to make appropriate adjustments Poor coordination of BG testing and administration of insulin with meals Poor communication upon transfer Errors in order writing and transcription Poor Patient utcomes Poor Patient utcomes ose/response: rug Therapeutic Index ose/response: Insulin Toxicity 1 Hypoglycemia Efficacy Euglycemia ose ose 3

4 Systematic Barriers to Improved Management of Hyperglycemia Fear of hypoglycemia Skepticism about benefits of adequate glycemic control Inadequate knowledge and understanding Lack of integrated information systems Time and resources CE/ Consensus Statement on Inpatient Glycemic Control Endoc Pract 2006;29(8): Components of n Effective Strategy to ptimize Glycemia ppropriate level of administrative support Multidisciplinary steering committee to promote development of initiatives ssessment of processes, quality, and barriers evelopment and implementation of interventions Metrics for evaluation CE/ Consensus Statement on Inpatient Glycemic Control iabetes Care 2006;

5 legent Health Lakeside Hospital 16 IC beds 104 acute care beds 650 physicians on staff 126 full-time registered nurses 494 Full-time Employees Hypoglycemia at Lakeside Increasing trend in Q No clear reason identified Initial solution: Education Insulin pharmacokinetics Insulin subcutaneous protocol Mealtime administration prandial & correctional Hypoglycemia management 5

6 F C S P S Find a process to improve Clarify current knowledge of the process Select the process improvement Plan the improvement o the improvement Study the effectiveness of the change ct to hold the gain Morning blood glucose monitoring, meal consumption, and prandial insulin administration o the improvement ct to hold the gain Nursing department Pharmacy department Quality: Patient safety officer iabetes educators Food and nutrition Clinical informatics 6

7 o the improvement ct to hold the gain PCT, insulin administration, and meal time were not coordinated o the improvement ct to hold the gain Issues identified: Shift change Culture Knowledge and competency System administration times Med work list view for each shift ining on-call verride tracking 7

8 o the improvement ct to hold the gain bjective: ecrease the interval of time from PCT to meal and insulin administration to 30 minutes or less for breakfast meal. o the improvement ct to hold the gain Plan: Table tent cards Insulin nursing in-service Notify RN when meal ordered 8

9 o the improvement ct to hold the gain ction: CN shift report CN tells RN once meal ordered ietary instructs patient to push the call light when the order CN/RN staffing coordination o the improvement ct to hold the gain Chart review: Baseline Post-intervention 9

10 Percentage 6/1/2012 o the improvement ct to hold the gain Random chart audits Blood glucose monitoring and insulin administration with morning meal PCT* 30 minutes within meal Insulin administration within 30 minutes Baseline Post intervention Random audit *Point-of-care testing 10

11 Number of insulin doses Number of insulin doses 6/1/2012 Morning mealtime and insulin aspart administration Target 20 Poor coordination Minutes from meal Baseline Post-intervention Random audit Time between PCT * and morning meal Target Poor coordination Minutes from PCT Baseline Post-intervention Random audit *Point-of-care testing 11

12 oes improved prandial insulin administration yield fewer hypoglycemic events? extrose 50% Syringe se Limited data 10 nable to conclude cause and effect 5 4 Plausible association 0 Baseline Random audit 50W is a surrogate for glucometrics Glucometrics: Measuring inpatient glycemic control efinitions Target population Hypoglycemia Hyperglycemia Euglycemia nits of nalysis Glucose value Patient Monitored-patient day Measures of Control Rate of hypoglycemia Rate of hyperglycemia Mean glucose value Percent patient days within target Hyperglycemic index Schnipper JL et al. Hospital Medicine;3(5):S66-S75 12

13 Lessons Learned Poor glucose control is associated with adverse outcomes Inpatient blood glucose is influenced by many factors and requires a multidisciplinary approach to effectively manage. team approach to coordinating patient care can improve insulin administration and may minimize hypoglycemic events. Resources merican iabetes ssociation (): merican Society of Health-System Pharmacists (SHP): Society of Hospital Medicine (SHM): lines.cfm Institute for Healthcare Improvement (IHI): Yale glucometrics: 13

14 References 1. CE/ Task Force on Inpatient iabetes. merican College of Endocrinology and merican iabetes ssociation consensus statement on inpatient diabetes and glycemic control. Endoc Pract 2006;29(8): CE/ Task Force on Inpatient iabetes. merican College of Endocrinology and merican iabetes ssociation consensus statement on inpatient diabetes and glycemic control. Endoc Pract 2009;25(4): Schnipper JL, Magee M, Larsen K, Inzucchi SE, Maynard G. Society of Hospital Medicine Glycemic Control Task Force Summary: Practical recommendations for assessing the impact of glycemic control efforts. Hospital Medicine;3(5):S66-S75 4. Moghissi ES. Reexamining the evidence for inpatient glucose control: New recommendations for glycemic targets. m J Health-Syst Pharm 2010;67(Suppl 8):S3-8 Questions? 14