8/15/2018. Promoting Education, Referral and Treatment for Patients Presenting with Metabolic Syndrome. Metabolic Syndrome.

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1 Promoting Education, Referral and Treatment for Patients Presenting with Metabolic Syndrome Diagnostic Criteria (3/5) Metabolic Syndrome Key Facts JAN BRIONES DNP, APRN, CNP FAMILY NURSE PRACTITIONER Abdominal obesity High triglycerides Low HDL cholesterol High blood pressure High blood sugar Affects 23% of Americans Under-diagnosed Under-treated Leads to Diabetes Mellitus and Atherosclerotic Cardiovascular Disease Needs Assessment Literature Review Identify and educate patients with metabolic syndrome on admit to: ED Urgent Care Hospital Clinic Provide patient education regarding aggressive lifestyle modification through: Dietary therapy Exercise therapy Pharmacologic therapy Psychological therapy Surgical therapy ATP III: The Metabolic Syndrome Diagnosis is established when >3 of these risk factors are present Prevalence of Metabolic Syndrome (men) Risk Factor Defining Level Abdominal obesity (Waist circumference ) Men Women TG HDL-C Men Women Blood Pressure Fasting glucose >102 cm (>40 in) >88 cm (>35 in) >150 mg/dl <40 mg/dl <50 mg/dl >130/>85 mm Hg >110 (>100)**mg/dL ** 2003 New ADA IFG criteria (Expert Panel,Diabetes Care 26: , 2003) * The Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285: **The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 26: ,2003 1

2 Prevalence of Metabolic Syndrome (women) Prevalence of Metabolic Syndrome (men & women, by age) Prevalence of Metabolic Syndrome (men & women, by age) Prevalence of Metabolic Syndrome (men & women, by age) Prevalence of Metabolic Syndrome (men & women, by age) Treatment of the Metabolic Syndrome in Obese or Overweight Patients Weight loss induced by diet and increased physical activity is the cornerstone of therapy Weight loss induced by drug therapy can also improve specific features of the metabolic syndrome Bariatric surgery is the most effective weight loss therapy for extremely obese subjects and improves all features of the metabolic syndrome Psychological counseling effectively augments each of the other services, improving outcomes and long-term success 2

3 Treatment of the Metabolic Syndrome in Patients with Cardiovascular Risk Factors Management of hypertension through lifestyle modification and antihypertensive medication, if necessary Counsel smoking cessation ATP III recommends lipid lowering for patients with diabetes mellitus; statins often shown to be effective Prophylactic daily aspirin to lower risk of occlusive cardiovascular disease Project Overview/Scope: Educate nursing staff Calculate BMI on admit Provide education to patients with BMI >30 Patient self-referral to PCP Additional patient education at PCP visit Patient referral to one or more therapy options Stakeholders Internal Board of Directors CCMMC Chief Executive Officer (community partner) Power to move things forward Primary Care Providers Nurse managers (hospital and clinic) Nursing staff IT staff Lab staff Dietician Physical therapy Surgeons Surgery Staff Patient Stakeholders External Community members with metabolic syndrome Local pharmacies Local health clubs/gyms Insurance companies, Medicare and Minnesota Care Tax payers in Chippewa County Local resturants Metabolic Syndrome Patient Education Project Core Teamwork Breakdown Process Objectives Jan Briones DNP Project Development Project Implementation Project Evaluation CEO Budget oversight Media oversight Family Medicine Chief of Staff Quality Assurance (Standing Orders, Pt. Ed. Oversight) Medical Staff Liaison Registered Dietician Dietary Therapy Program Chief of Surgery, MD Surgical Therapy Program Medical Staff Resource Physical Therapy Director Exercise Therapy Program Family Medicine MD Pharmacologic Therapy Program Medical Staff Resource Director of Nursing Hospital Nursing Education Hospital Nursing Implementation Psychiatrist Psychological Counseling Program (Surg & Non-Surg) December 30, 2008 Core team members approved an education program and work structure breakdown February 1, % of the medical staff participated in an educational session conducted at the medical staff meeting 100% of the clinic nursing staff participated in education April 1, % of the hospital nursing staff participated in educational 3

4 Impact Objectives: Outcome Objectives: June 1, % of patient charts with will be flagged for telephone followup post-education August 1, % of patients will be referred for aggressive lifestyle management by PCP January 1, % of patients identified with metabolic syndrome will be actively enrolled in a lifestyle management program January 1, % of patients identified with metabolic syndrome will demonstrate a 5% weight loss July 1, % of patients identified with metabolic syndrome will demonstrate a decrease in blood pressure, abdominal girth, fasting blood sugar and LDL cholesterol Healthcare costs related to metabolic syndrome will decline in this service area Risk Management/Damage Control Milestones Medical Model Mindset EMR delay Distraction/move to new facility Lack of staff participation Medical Lack Model of provider Mindset/Resistance participation to prevention EMR delay Lack Distraction/move of patient interest to new facility Lack of staff participation Lack of provider participation Lack of patient interest September 2008 Community partner agreement Core team selection October 2008 Preliminary literature search Core team input regarding education materials March 2009 IRB approval Staff education complete April 2009 Project Implementation August 2009 Project Evaluation Change Theory Implementation Nurse Education Metabolic Syndrome Patient Education Project Change Theory Urgency/Epidemic: Untreated Metabolic Syndrome PowerPoint presentation The Law of the Few Core team members committed to project: Mavens/Connectors/Salesmen Multiple departments committed to change Pre-test Tic-tac-toe Metabolic Syndrome Game Post-test The Stickiness Factor Nursing staff education regarding undiagnosed/untreated metabolic syndrome Role play Power of Context 4

5 Implementation Patient Education Pre-test and Post-test Education Scores Clinic Urgent Care ED Height Weight BMI BMI >30 Nurse educates re: metabolic syndrome Patient follows up with PCP Diet Exercise Psych Counseling Pharmaco Treatment Statistical differences were found between pretest (M=4.27, SD=1.35) and posttest scores (M=8.88, SD=0.97), t (63) = , p <.001 Hospital Inpatient Surgery Percent of Total Sample Participating Frequency and Percent of Sample by Gender Frequency and Percent of Sample by Age Frequency and Percent of Sample by Exercise Mean Age = SD =

6 Frequency and Percent of Sample by Diet Frequency and Percent of Sample by Counseling Frequency and Percent of Sample by Surgery Frequency and Percent of Sample by Drugs Frequency of Exercise Endorsements by Age Group Frequency of Diet Endorsements by Age Group 6

7 Frequency of Counseling Endorsements by Age Group Frequency of Surgery Endorsements by Age Group Frequency of Drugs Endorsements by Age Group Frequency of Exercise Endorsements/gender Frequency of Diet Endorsements/Gender Frequency of Counseling Endorsements by Sex 7

8 Frequency of Surgery Endorsements by Sex Frequency of Drugs Endorsements/Gender Expanding Influence and Audience The Big Picture Looking to the future in the organization Expanding awareness in the larger community Incorporating in graduate curriculum Great spirits have always encountered violent opposition from mediocre minds Albert Einstein References References (cont.) Bray, G.A., (2007). Screening for and clinical evaluation of obesity in adults. Retrieved December 30, 2007 from Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 26: ,2003 Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA 2002;287: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285: Gladwell, M., (2000). The tipping point: How little things make a big difference. Little Brown and Company: New York. Grundy SM, Brewer HB, Cleeman JI, Smith SC, Lenfant D, for the Conference Participants. Definition of metabolic syndrome: report of the National, Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation. 2004;109: Grundy, S.M., Cleeman, J.I., Daniels, S.R., Donato, K.A., Eckel, R.H., Franklin, B.A., Gordon, D.J., Krauss, R.M, Savage, P.J., Smith, S.C., Spertus, J.A. & Costa, F. (2005). Diagnosis and management of the metabolic syndrome: an american heart association/national heart, lung and blood institute scientific statement. Circulation, Managing Projects Large and Small: the fundamental skills for delivering on budget and on time. 8

9 References (cont.) References (cont.) Miller, E.L. & Mitchell, A. (2006). Metabolic syndrome: Screening, diagnosis, and management. Journal of Midwifery & Women s Health, 51, Rosenson, R.S. (2005). New approaches in the intensive management of cardiovascular risk in the metabolic syndrome. Current Problems in Cardiology, Sarti, C. & Gallagher, J. (2006). The metabolic syndrome prevalence, CHD risk and treatment. Journal of Diabetes and its Complications, 20, Beltrán-Sánchez H, Harhay MO, Harhay MM, McElligott S. Prevalence and trends of metabolic syndrome in the adult U.S. population, J Am Coll Cardiol Aug 20;62(8): Moore JX, Chaudhary N, Akinyemiju T. Metabolic Syndrome Prevalence by Race/Ethnicity and Sex in the United States, National Health and Nutrition Examination Survey, Prev Chronic Dis Mar 16;14:E24. Pearson TA, Blair SN, Daniels SR, et al. AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases. American Heart Association Science Advisory and Coordinating Committee. Circulation 2002; 106:388. 9