CLOSING THE QUALITY GAP Key Elements to Improve Care of the Inpatient with DM

1. CLOSING THE QUALITY GAPKey Elements to Improve Care of the Inpatient with DM / HyperglycemiaGarnering Institutional Support Greg Maynard MD, MS Professor of Clinical Medicine and Chief, Division of Hospital Medicine University of California, San Diego

2. Tale of Identical TwinsTom and Harry 65 year old twins Diabetes: on NPH 20 units and OHGs with poor control, neither sees MD regularly Smokers At a �Gentleman�s Club� when both developed chest pain. After 6 hours�.. Tom: goes to Hospital �A� Harry: Hospital �A� full, so Harry goes crosstown to Hospital �B�

3. Tom at Hospital �A� Admitted to CCU, MI confirmed Glucose 230 mg/dL No infusion started for 18 hours Infusion control poor, glycemic excursions when Tom eats. Recurrent hypoglycemia, treated inconsistently, especially with trips to Radiology Finally controlled on infusion day 4.

4. Tom at Hospital �A� cont�d Transition to ward: Tom on sliding scale Recurrent hyperglycemia to 300 Brief return to unit for CRBSI Confusion with various insulin regimens as Tom goes from eating to NPO several times. No mention of hyperglycemia in discharge summary Tom discharged on same meds as admit LOS 6 days, EF 35% at 1 month

5. Tom: 3 years later Follows up with Cardiology only (no PCP) Glycemic control remains poor Recurrent CV events Recurrent hospitalizations

6. Harry at Hospital �B� Admit CCU, MI confirmed, glu 230 mg / dL Infusion started by protocol when glucose > 140 mg/dL x 2. Glycemic excursions with meals covered w/ subcutaneous RAA-I per protocol. Minor hypoglycemia covered routinely Transitioned to ward on basal / bolus regimen, TDD of 80 units. A1C obtained: 10

7. Harry at Hospital �B� cont�d When Harry goes NPO for test, nurses continue basal insulin, hold nutritional insulin (as per MAR instructions) Education on smoking cessation and DM Information about DM / glucose control included in DC summary. Hospitalist arranges for PCP, discharge regimen of Glargine 35 units, 10 units RAA-I w/ meals prescribed. LOS 5 days, EF at 1 month 45%

8. Harry: 3 years later Quits smoking A1c = 6.2 Not re-hospitalized What can you do to make sure all patients with hyperglycemia are treated like Harry�every time?

9. Focus on the Wards:Implementation Gap One-third with mean glucose > 200 mg/dL 60%-70% of insulin regimens sliding scale only (even if horrible control) >10% with hypoglycemic episodes. Uneven training amongst staff Poor coordination of tray delivery, monitoring, and insulin Inconsistent transitions Patients often confused or angry

10. Barriers Fear of hypoglycemia Time Workflow change Information / reporting Multiple teams and hand-offs Ongoing Education needs Steroids, etc Skepticism of benefits Pre-existing orders Habits Coordination Staff turnover Competing priorities Unpredictable / varied caloric intake Varied insulin requirements

12. My Own Journey Interest in Inpatient DM / Glycemic Control Past failures Opportunity to lead efforts at UCSD Slow painful improvement�. then some breakthroughs with PI techniques Writing panel: AACE / ADA Call to Action Society of Hospital Medicine Glycemic Control Task Force

13. Components of a Glycemic Control Program Administrative support Multidisciplinary steering committee to promote the development of initiatives Assessment of current processes, quality of care, and barriers to change Development and implementation of interventions Standardized order sets, protocols, policies. Educational programs, Special teams Metrics for evaluation

14. Society of Hospital Medicine Glycemic Control Taskforce Greg Maynard-UCSD David Wesorick � Univ of Michigan Kevin Larsen-HCMC Jeff Schnipper-Brigham and Women�s Cheryl O�Malley-Banner Good Sam Case Management, Pharmacy and Nursing representatives Great feedback / examples: Jacqui Thompson, Chris Hogness, others This includes questions like Who, what specific doses and how to safely implement this in the hospital.. About 1 and a half years later, an workgroup from the society of hospital medicine was formed and met to begin working on sharing knowledge of the effective strategies for improving diabetes management in hospitalized patients. I was one of several Internal Medicine physicians mainly practicing in the hospital brought together with a list of well known endocrinologist who have worked on this topic as well as representatives from case management, nursing and pharmacists. An on-line resource room focused on this topic. This includes questions like Who, what specific doses and how to safely implement this in the hospital.. About 1 and a half years later, an workgroup from the society of hospital medicine was formed and met to begin working on sharing knowledge of the effective strategies for improving diabetes management in hospitalized patients. I was one of several Internal Medicine physicians mainly practicing in the hospital brought together with a list of well known endocrinologist who have worked on this topic as well as representatives from case management, nursing and pharmacists. An on-line resource room focused on this topic.

15. Endocrinologists on SHM Task Force Representing the ADA Andrew J. Ahmann, MDMichelle F. Magee, MD Representing AACE Richard Hellman, MD, FACP, FACE Expert Panel Susan Shapiro Braithwaite, MD, FACP, FACEMary Ann Emanuele, MD, FACPIrl B. Hirsch, MDRobert Rushakoff, MD Other Experts Providing Feedback Guillermo Umpierrez Stephen Clement MD Silvio Inzucchi MD

17. How Do We Close the Gap? Essential Elements Institutional support and multidisciplinary teams Standardized order sets Infusion Subcutaneous which promote basal / bolus regimens Algorithms / protocols / policies Address dosing Nutritional intake Special situations: TPN, enteral tube feedings, perioperative insulin, steroids Safety issues Transitions in care and discharge planning Metrics: How will you know you�ve made a difference? Comprehensive educational program

18. The Multidisciplinary Team Team Leader Critical Care Wards Endocrinologist Hospitalist Senior Administrator Nurse supervisor Nurse Ward ICU Pharmacist CPOE expert Information/data pull QI staff representative Diabetes Educator Health Unit Secretary Case manager PRN Anesthesia Surgeon ED personnel Patient re Nutrition/dietary Laboratory Efforts are often initiated by just a few thoughtful leaders who see a big gap between the current practice and the best-known practice and who then recruit others to their cause. Members of each glycemic control team for each major area of focus should include a team leader, content expert, and process owners. We did not start out with this team. We had some of the necessary people but realized over time who we were missing (ED personnel, QI staff, HUS)Efforts are often initiated by just a few thoughtful leaders who see a big gap between the current practice and the best-known practice and who then recruit others to their cause. Members of each glycemic control team for each major area of focus should include a team leader, content expert, and process owners. We did not start out with this team. We had some of the necessary people but realized over time who we were missing (ED personnel, QI staff, HUS)

19. Why Glycemic Control?(It�s about more than infusion insulin glycemic targets!) DM / Hyperglycemia Very Common Opportunity to identify and intervene poorly controlled DM, previously undiagnosed DM, stress hyperglycemia (pre-diabetes) Hypoglycemia and extreme hyperglycemia Safety problem and a Quality problem Inpatient Care - Complex w/ unique challenges Education alone insufficient, need systems change Talking points can be used to champion glycemic control projectsTalking points can be used to champion glycemic control projects

20. Hyperglycemia*: A Common Comorbidity in Medical-Surgical Patients in a Community Hospital In a more recent study that involved 2020 consecutive patients admitted to a community hospital in Atlanta, we found that 64% of patients had normal glucose values, 26% had a prior history of diabetes, and that 12% of patients with hyperglycemia, as determined by 2 or more FBG > 126 or RBG > 200, did not had a know history of diabetes prior to admission.In a more recent study that involved 2020 consecutive patients admitted to a community hospital in Atlanta, we found that 64% of patients had normal glucose values, 26% had a prior history of diabetes, and that 12% of patients with hyperglycemia, as determined by 2 or more FBG > 126 or RBG > 200, did not had a know history of diabetes prior to admission.

22. Insulin Requirements in Health and Illness Insulin Requirements in Health and Illness Components of insulin requirements are defined physiologically and are divided into basal, prandial (mealtime) or nutritional, and correction insulin. Insulin required to cover �nutritional� needs may include insulin needed to cover intravenous dextrose, total parenteral nutrition, enteral feedings, and nutritional supplements. The basal and prandial/nutritional orders as written as scheduled insulin while correction dose insulin tends to be written as an algorithm to supplement scheduled insulin. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in the hospital. Diabetes Care. 2004;27:553�591. Insulin Requirements in Health and Illness Components of insulin requirements are defined physiologically and are divided into basal, prandial (mealtime) or nutritional, and correction insulin. Insulin required to cover �nutritional� needs may include insulin needed to cover intravenous dextrose, total parenteral nutrition, enteral feedings, and nutritional supplements. The basal and prandial/nutritional orders as written as scheduled insulin while correction dose insulin tends to be written as an algorithm to supplement scheduled insulin. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in the hospital. Diabetes Care. 2004;27:553�591.

23. Drugs Promoting Hyperglycemia COMMONLY ASSOCIATED Steroids Catecholamines Tacrolimus Cyclosporine Gatifloxacin TPN SIGNIFICANT but LESS PROMINENT Oral contraceptive pills Thiazides Atypical antipsychotics Calcium-channel blocking agents Protease inhibitors

24. The Other Reason Rational Use of Insulin and Other Agents Is Important in Hospitals: Iatrogenic Hypoglycemia JCAHO considers insulin to be one of the 5 highest-risk medicines in the inpatient setting Catastrophic damage can occur Frequent source of adverse drug effects; usually #1 or #2 at UCSD

25. Why Glycemic Control? (continued) Huge Implementation Gap Public reporting, regulatory guidelines etc. Can be cost effective Inpatient hyperglycemia is very strongly associated with poor outcomes Improved glycemic control is associated with improved outcomes

26. JCAHO�s Certificate of Distinction for�Inpatient Diabetes Care Specific staff education requirements Written blood glucose monitoring protocols Plans for the treatment of hypoglycemia and hyperglycemia Data collection of incidence of hypoglycemia Patient education on self-management of diabetes An identified program champion or program champion team.

27. Business Case Improved coding = better reimbursement Diagnosis: ? Uncontrolled �or� ? Controlled (? with complications);Diabetes type: ? 1 ? 2 ? Gestational �or� ? Secondary to another cause;Specify �or� ? Stress/situational hyperglycemia Incremental Billing Improved outcomes = Improved bottom line

28. The Multidisciplinary Team Asks� What? Is the right thing to do? Will make the system more effective? Where? Are the processes to improve? Do we start? (dissect and understand the processes) How? You cannot destroy productivity You must devote as much attention to fitting changes into clinical work flow as you do to the evidence-based guideline What will be the general aims Where will be the process flow map How is the interventions Finally, they will ask, did it work? This is where our metrics come in.What will be the general aims Where will be the process flow map How is the interventions Finally, they will ask, did it work? This is where our metrics come in.

29. Institutional Assessment Institutional Support Multidisciplinary team Reliable data flow / metrics Standardized order sets, protocols and algorithms for subcutaneous insulin Intensive insulin infusion order set/ protocol Nutritional dietary system Diabetes self-management Hypoglycemia, insulin safety and safety culture issues Transitions in care Educational issues What is happening at your medical center now? Where is your current level of patient care in these areas and how far is it from the place that evidence or guidelines support. You should ask yourself these questions as you start planning your work. Do you have institutional support? Is there an existing multidisciplinary team? Perhaps you have those and some standardized order sets but no metrics. The needs are so vast in caring for patients with diabetes in the hospital, chances are that some institutional policies or procedures exist to address some of these areas�what is missing? You need to begin the process by looking at what is currently happening. This will tell you, the team, administration where you need to go.What is happening at your medical center now? Where is your current level of patient care in these areas and how far is it from the place that evidence or guidelines support. You should ask yourself these questions as you start planning your work. Do you have institutional support? Is there an existing multidisciplinary team? Perhaps you have those and some standardized order sets but no metrics. The needs are so vast in caring for patients with diabetes in the hospital, chances are that some institutional policies or procedures exist to address some of these areas�what is missing? You need to begin the process by looking at what is currently happening. This will tell you, the team, administration where you need to go.

30. Looking into the gap: Early Evidence Iatrogenic hypoglycemia Glycemic control: Extreme hyperglycemia Insulin use patterns frequency of sliding scale only number of different order sets Anecdotes about insulin use Sample active inpatients Keep ICU and ward separate Define your exclusion criteria Build a data collection tool Besides looking at the existing processes within the institution you want to know how those are working (or not). Important metrics that you can look at include instances of iatrogenic hypoglycemia, assessing glucose control and extreme hyperglycemia will be an easier measure to look at. You may also look at the frequency with which the sliding scale only is being used knowing that it has been proven to NOT work and current guidelines state that it should not be used as the sole method for glucose control. Finally, just pulling out the drawer at the unit secretary�s desk revealed to me that we had 4 different order sheets for sliding scales which indicates that the process isn�t standardized and leaves the potential for errors. Collecting data can seem overwhelming even when you have a full team behind your efforts, however, this early data can be on a small scale and take the form of anecdotes or a small sample of active inpatients. You will want to keep the ICU and ward patients separate, define who to exclude (for example DKA, HHS, pregnancy, TPN, etc) and then create a tool to collect the data and finally summarize your findings.Besides looking at the existing processes within the institution you want to know how those are working (or not). Important metrics that you can look at include instances of iatrogenic hypoglycemia, assessing glucose control and extreme hyperglycemia will be an easier measure to look at. You may also look at the frequency with which the sliding scale only is being used knowing that it has been proven to NOT work and current guidelines state that it should not be used as the sole method for glucose control. Finally, just pulling out the drawer at the unit secretary�s desk revealed to me that we had 4 different order sheets for sliding scales which indicates that the process isn�t standardized and leaves the potential for errors. Collecting data can seem overwhelming even when you have a full team behind your efforts, however, this early data can be on a small scale and take the form of anecdotes or a small sample of active inpatients. You will want to keep the ICU and ward patients separate, define who to exclude (for example DKA, HHS, pregnancy, TPN, etc) and then create a tool to collect the data and finally summarize your findings.

31. Small Sample Data Example:Use to gain institutional support �Basal insulin is being used in insulin regimens less than half the time. A third of our monitored patient-days have a mean glucose of more than 180 mg/dL. One of the 5 days we monitor patients includes at least one hypoglycemic event, and almost 1 of 3 days incorporates either a hypoglycemic event or an unsafe extreme hyperglycemic event of more than 300 mg/dL.�