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Becker's Healthcare Clinical Leadership + Pharmacy Virtual Forum
Collaborate to Innovate: How Clinical Leadership Drives Practice Change to Optimize Patient Safety Outcomes
Catherine Rolih, MD | Novant Health
Jordan Messler, MD, SFHM, FACP | Glytec
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Transcript of Presentation
CARLY XAGAS: Welcome to Becker’s Clinical Leadership and Pharmacy virtual forum and the featured session, Collaborate to Innovate: How Clinical Leadership Drives Practice Change to Optimize Patient Safety Outcomes. On behalf of Becker’s Healthcare, thank you for joining us today.
Before I introduce today’s speakers, I’d like to go over some quick housekeeping details. You can submit any questions throughout today’s session in the Q&A box on your dashboard. Today’s session is being recorded and will be available after the event. You can use the same link you used to log in to today’s session to access that recording. If at any time, you don’t see your slides moving or have trouble with your audio, try refreshing your browser. You can also submit any technical questions into the Q&A box. We are here to help. You’ll also find a few other engagement tools on your dashboard. Be sure to check out our resources section.
With that, I am pleased to introduce our speakers today, Dr. Cathy Rolih, clinical physician executive of the Diabetes Center of Excellence and co-chair of the Diabetes Best Practice Exchange Team at Novant Health, and Dr. Jordan Messler, executive director, clinical practice, at Glytec.
Dr. Rolih is an endocrinologist with more than 25 years of experience in caring for people with diabetes. In her role as director of the Diabetes Center of Excellence, she leads a system-wide focus on quality, safety, access, and equity in diabetes care across a 15-hospital integrated health system.
Dr. Messler is trained in internal medicine at Emory University in Atlanta and subsequently served as an academic hospitalist at Emory University for several years after residency. He is the former medical director for the Morton Plant Hospitalist Group in Clearwater, Florida, serving BayCare Health, where he continues to work as a hospitalist. He is the current physician editor for the Society of Hospital Medicine’s blog, the Hospital Leader. In addition, he previously chaired the Society of Hospital Medicine’s quality and patient safety committee and has been active in several of their national mentoring programs, including Project BOOST and Glycemic Control.
Dr. Rolih, Dr. Messler, thank you so much for being here. I’ll turn the floor over to you.
JORDAN MESSLER: Great, thank you. Thanks, everyone there, for joining us today. We’re excited to share this topic with you. Glytec is a proud sponsor of this presentation. Glytec has Glucommander, which is insulin-management software, and we offer a suite of solutions to help optimize the care of the hospitalized patient with diabetes and hyperglycemia. We’re on a mission to improve the lives of patients with glycemic issues and those who administer their care by optimizing insulin therapy.
We know that diabetes management in the hospital is common, it’s costly, and in many ways, preventable outcomes. One in three Americans have glycemic-control issues, diabetes or prediabetes. We know that insulin is involved, in some studies, up to 16.3% of medication error. Insulin is a high-alert medication. And in the hospital setting, we’re seeing up to 30-40% – and some hospitals that we work with, up to 50% – of patients with diabetes and/or hyperglycemia during their hospital stay.
And during this pandemic, since June, when we’ve introduced steroids as a treatment strategy for COVID-19, 80% of patients in the hospital with COVID-19 are meeting indications for steroids, and we know steroid use contributes to hyperglycemia.
And there are a variety of challenges to achieving safe glycemic management. The challenges we’re going to lay out here are challenges for other areas of care we’re trying to improve in the hospital setting. Challenges with collaboration – glycemic management teams are often siloed. People are working on glycemic-management issues independently – and often not working on it, because the data is not there to recognize what to improve. Data around glycemic management is often minimal, many sites only reporting one or two metrics and not having a compendium of glucometrics, glucose data to report and then, hence, take action on. And we know that 90% of US hospitals still treat glycemic issues with confusing, ineffective, outdated protocols to manage insulin – both IV and sub-Q management of insulin in the hospital.
So I’m excited to introduce Dr. Rolih, who comes from Novant Health System. We can advance to the next slide. Novant is a patient safety-focused organization. They show that innovative healthcare systems are leading the way in realizing the possibilities for glycemic management by leveraging technology, collaboration as key strategies for innovation – and particularly in this past year, doing work in a year that’s been fraught with challenges, where some places have been stifled in their ability to innovate, and others, as we’re going to lay out with Novant and Dr. Rolih’s work, have been able to excel.
As we heard earlier, Dr. Rolih is an endocrinologist – more than 25 years of experience in caring for people with diabetes. She’s been the champion for patient safety and quality in her organization. And the work she’ll share today around diabetes and glycemic management serves as an excellent template of ideas for improving quality via collaboration, innovation in this and other areas in your hospital setting. So I’ll pass it off to you, Dr. Rolih.
CATHERINE ROLIH: Thanks, Jordan, for that introduction, and thank you to Becker’s for the opportunity to share our journey with COVID and diabetes.
In the past year, like everyone else in healthcare, we’ve faced the dual challenges of responding to a pandemic which has upended almost everything we do, while maintaining a focus on delivering our promise of clinical excellence. A key to our survival and success during this last year really has been both collaboration and innovation – collaboration with partners within our organization, with teams new and established, and with external experts and technology partners, such as those at Glytec.
So let me give you a little bit of an overview about Novant Health. Novant is a large integrated healthcare system located in the Carolinas and Virginia. We now have 18 hospitals, over 600 physician practices, and are growing as we speak. We have around 3,500 licensed inpatient beds. And last year, in 2020, during this challenging year, we had over 162,000 inpatient admissions. As is true for most healthcare systems, about 25% of our inpatients have diabetes, so that poses a significant challenge for a system in caring for that many people with a complex management scheme.
Fortunately, we had a platform already in place, and that was the Diabetes Best Practice Exchange Team, or what we call the BPET. This is our platform for managing the complexity of diabetes care across a large hospital system such as ours. The BPET was created in 2016 in response to concerns about glycemic management and lack of uniform processes. It’s a multidisciplinary team composed of physicians, nurses, pharmacists, nutritionists, diabetes educators, IT specialists, administrators, and data analysts. It exists to promote safety and quality in diabetes care delivery, promote adoption of best practices, reduce clinical variation, and remove silos between our facilities.
A secondary focus of the BPET is the collection and analysis of data and sharing that at a system and facility level. The data that we currently gather has to do mostly with hypo- and hyperglycemia rates. But we also track the utilization of our Glucommander Insulin eGlycemic Management tool as well as length of stay and readmission rates.
The Diabetes BPET meets monthly for two hours – or more, if necessary – to identify opportunities, provide advice when requested, and drive change. Currently, we have a major role in the oversight of our inpatient eGlycemic Management tool, including providing guidance on optimal management, hypoglycemia risk reduction, and investigation of these adverse glycemic events.
We also have worked over the years on development of standardized protocols for managing hypoglycemia that are nurse-driven as well as developing our policies and procedures regarding inpatient use of insulin pumps and continuous glucose monitors. Fortunately, this team has been very fluid and dynamic and has been able to adapt as our needs evolve.
COVID reached Novant Health, as it did in much of the country, in March of 2020, with our first patient admission. Fortunately, we had a fairly small first wave. We reached our first 1,000 case mark by late June but were at that time already into our second wave, which peaked in mid-July. Our third wave or major surge of COVID admissions began in late November and peaked in January, with a system-wide daily census of close to 6,000 (sic) patients. Fortunately, now we’re on the downswing, with caseloads decreasing very dramatically, but we still will reach about our 12,000th COVID discharge shortly.
We began by cohorting our COVID-positive patients at five of our hospitals, but during this most recent surge, as caseloads increased, these patients spilled over into our community hospitals as well. This posed some new challenges, since our resources, as Jordan mentioned – resources for glycemic management differed between our smaller community hospitals and our larger tertiary-care centers.
So as with others around the country and around the world, we have spent the last year learning about coronavirus. COVID poses a particular challenge for people with diabetes. As you probably all are aware, diabetes is a primary risk factor for COVID-19 infection, and patients with diabetes who do contract COVID tend to have more complications and a prolonged hospital stay.
In addition, caring for the COVID patient with diabetes has its own challenges. COVID typically induces a fairly significant stress hyperglycemia and may independently affect the function of the pancreatic beta cells. And use of high-dose steroids, which is now – as we will discuss a little further later – as is part of standard care for the COVID patient, complicates glycemic control for all COVID patients and particularly those with diabetes. Finally, hyperglycemia may be associated with an increased risk of mortality in the COVID patient, and thus aggressive glycemic management is probably very important.
Fortunately, we had an existing team to deploy and count on when caring for this high-risk population with a new and complicated disease, and that’s our diabetes education specialist team. This is a group of eight specialists who before the onset of the pandemic spent their time rounding in the hospitals, focusing on providing just-in-time diabetes education to our inpatients with diabetes and providing nursing support. However, in April, they became a virtual team literally overnight. Our team then of eight specialists were able to cover all 12 of our hospitals in North Carolina, and they have maintained that virtual ability even during redeployment of several of our team members during our most recent surge to bedside clinical work.
In addition to now being available to provide support and education at all of our hospitals, they assumed a second new role, that of glucose surveillance. So our specialists are able to track hyper- and hypoglycemia events on a daily basis using a custom workbench report generated in Epic, and our DES specialists call the nurses and providers involved in care of these patients to offer real-time guidance.
In addition to utilizing our existing teams, we recognized the need to set up a multidisciplinary team of experts in order to crowdsource or figure out what the COVID and diabetes challenge was looking like within our own walls. This team was launched in April of 2020 and met every two weeks for a period of four months. When it was eventually rolled into the Diabetes BPET, the team membership included hospitalists, critical-care specialists, pharmacists, dieticians, nurses, adult and pediatric endocrinologists, again our diabetes education specialists, data analysts, administrator, and partners from Glytec.
Our goal for this team was to help us identify challenges in glycemic management and other points of care in managing our patients with diabetes who are admitted with COVID. It allowed them to share their experiences and key learnings so we can accelerate change across the system.
We were also able to leverage an existing data analytics team and quickly created a dashboard which allowed us to track the number and distribution of our COVID patients with diabetes across the, at that time, 15 hospitals of our system.
This slide here illustrates an example of data that we were able to gather from our second peak in July. This actually is a snippet of a dashboard involving our discharged patients with coronavirus. And as you see, diabetes was the largest or most greatly represented comorbidity, with 30% of our patients with COVID having diabetes. This has continued to be true up to this point in the pandemic. So our diabetes patients or people with diabetes are overrepresented in our COVID inpatient population. They’re also overrepresented in our patients who expire from COVID. Whereas about 25% of our hospitalized patients have diabetes, 47% of our patients who have expired from COVID have diabetes.
So given the prevalence of people with diabetes in the COVID inpatient population and the challenges associated with their management, we identified some areas of opportunity, one of which I’ll cover in the next slides.
As Jordan mentioned, high-dose dexamethasone became standard of care in the COVID-positive patient in July and was adopted widely across Novant Health. So dexamethasone improves survival. But it adds complexity to an already sick patient population and certainly exacerbates hyperglycemia in all patients. It’s particularly difficult for patients with diabetes who already have poor glucose control, and this was being validated by our DES team noting increasing rates of severe hyperglycemia during the course of this pandemic.
We recognized that our inpatient care teams needed guidance in how best to manage glucose in the COVID patient treated with dexamethasone, so the BPET responded. Our solution was to stand up a small workgroup to address these evolving needs. This again was a multidisciplinary team, with pharmacists, hospitalists, critical-care nurse specialists, endocrinologists, and again, collaboration with our Glytec clinicians. The team searched the literature and contacted experts around the country for best practices in this patient population and really found nothing consistent, so we had to build something ourselves.
We realized that we needed something that was effective and could be quickly implemented, so we realized we couldn’t build something from scratch, and we need to design some guidelines using our existing glycemic management tool, Glucommander. So we provided – after some head-scratching and study, provided some guidelines for direction on when to initiate insulin, optimal doses to start at, how to monitor dose titration, and how to monitor the patient during and at the conclusion or after cessation of dexamethasone treatment.
However, before rolling these guidelines out more widely, we needed to do a test run, so we designed a pilot study. We piloted our guidelines at a community hospital for 10 days in early February. A hospitalist superuser was tasked with instructing his team in implementation of the protocol. We had an on-site PharmD who was available to provide real-time support for our nurses and providers. And we had an off-site PharmD who is a clinical pharmacy specialist. He monitored the application of the protocol, advised the care teams on dose titration. He collected reams of data and performed data analysis.
Here’s the summary. So we applied our guidelines to 51 consecutive COVID inpatients – eight in an intensive care unit, 36 in med/surg beds, seven in intermediate care, all at a single community hospital. 22 of the patients in whom we deployed our protocol or our guidelines had diabetes, and 29 had no history of diabetes. Our outcomes were fairly impressive. The majority of the glucose values in the patients treated with our guidelines were less than 250 by the third day of treatment, and we had only one episode of significant hyperglycemia and no inpatient mortality.
So here’s an example from a real patient who’s managed with Glucommander and the guidelines that we developed. This was a 63-year-old patient with type 2 diabetes managed on oral medications, with a fairly good baseline glycemic control. This blue panel on the bottom shows us glycemic trends over the first three days of his hospitalization. So his admission blood glucose was 344 and trended downward nicely, reaching less than 250 by the end of day two. He had a little blip there, which we think was related to inadequate counting of the carbohydrates he consumed, and that was quickly corrected, and he recovered and reached this glycemic target of 140 to 180 by the end of the third day.
So we were very satisfied with this, and this is actually fairly characteristic of the glycemic control in patients in this small study. And it’s a significant contrast to what we had been encountering otherwise, with most glucose values being over 250 and frequently into the 300 range in our diabetic patients in particular who were being treated with the dexamethasone. So our goal is to refine and tweak our protocol so that we can roll this out for more general use across our now 18-hospital system.
So where do we go from here, and what’s on the horizon? Nobody knows, of course, but we do have now some experience to draw from.
First, we plan on expanding our DES presence, both in person and virtually, as we have found them to be crucial in their new role of glucose surveillance.
We’re also continuing to refine other order sets and protocols important for our COVID patients. Currently, we’re working on insulin management for continuous and bolus tube feeds as well as standardizing our approach to insulin delivery in patients on TPN, since a high proportion of our critically ill – or the majority of our critically ill patients with COVID are being fed in this way.
As I mentioned, we are refining our glycemic-management guidelines and will share these best practices as part of our system-wide COVID management cookbook.
We’re also exploring new opportunities to stand up new teams and utilize new tools. The success of our virtual pharmacist in our COVID and dexamethasone glycemic-management trial was really very impressive. And his virtual oversight was so well received by the team that we hope to find other ways to use our pharmacists in this sort of support.
So 2020 was certainly a year of learning, and here are some of our key learnings. First of all, culture is important, and we were fortunate to begin this journey and this challenge with a culture that’s very patient-centric, quality- and safety-focused, collaborative, and interested in problem-solving. That culture was a key feature of our ability to successfully manage in a complex problem and evolving situation.
Second is teamwork. Teams of people are important, as is our ability to capitalize on, expand, and optimize our existing teams. Also important is our ability to deploy teams differently and to create new teams of experts in order to meet our evolving needs.
Finally is passion, and passion is the key ingredient. Having a group of highly passionate individuals who are willing to work above and beyond their previous and traditional job roles, going from what we are to what we can become, has been critical for our ability to adapt and respond to this crisis, and I think will be critical for our success in the future.
Now, I’ll hand this back to Dr. Messler.
MESSLER: Great. Thanks, Dr. Rolih. Really a terrific story about your health systems journey and your leadership through this, showing collaboration, teamwork, locally, nationally developing dashboards, real-time tools, testing out of new ideas – all are incredible examples of innovation and collaboration, with the constant vision of improving the care for your patients with diabetes and hyperglycemia.
I just want to take a few minutes as we wrap up here to share our eGlycemic Management System, eGMS, talk about Glucommander just briefly – how Glytec’s eGMS system, our eGlycemic Management System, enables that collaboration through our software that integrates with the EMR, the EHR.
I want to start in the center, which really is our passion, our focus – as you heard from Dr. Rolih, the importance of teamwork and collaboration – essential for us to be part of the team when we can and having that team of leaders, educators, pharmacy, quality, and all various disciplines represented as you’re trying to move the needle and improve the care of your patients with diabetes and hyperglycemia. So we certainly start at that center.
Glucommander is our software, on the top left. I’ll just highlight briefly – we don’t have an opportunity for a demonstration today, but Glucommander is the name of our software, which provides personalized insulin-dosing decisions at the point of care, both IV Glucommander, we have a transition module from IV to subcutaneous insulin management, and then our sub-Q Glucommander module.
If we go to the top center, we operate in the GlyCloud. Our software is a cloud-hosted platform which enables us to implement and upgrade remotely, enables that layer of security as well, operating in the cloud.
On the top right, I think you’ve heard from me earlier and Dr. Rolih the importance of getting data out there and metrics out there. Our dashboard example at Novant is a great example of using real-time data. We have a suite of tools and metrics that we provide back to our sites so they can see how they’re doing and continue to improve.
The bottom right – GlucoSurveillance – our tool to get some real-time identification of patients that are not on Glucommander but that would benefit from being on Glucommander because of persistent hyperglycemia.
On the bottom are our solution works. We have the SmartClick solution to enable Glucommander to seamlessly integrate with your electronic medical record. We have a lab integration as well. So for the end user, the nurse, the provider, they have this really seamless integration with your EMR, whatever EMR you have.
And then going around the circle to GlucoView, the solution that we have to allow for alerts to make sure that end users, nurses, are getting those alerts for a subsequent blood sugar check, so that they’re timely. And we have other monitoring features to continue to safely manage insulin for your patient.
That’s just a quick snapshot of who we are and what Glucommander – and it’s been a joy to collaborate with places like Novant and Dr. Rolih that really are able to take just a piece of what we have and continue to improve and really improve the safety of their patients.
So with that, that ends our portion. We really appreciate you sticking around and listening to us today, and I’ll pass it back along to Becker’s.
XAGAS: Thank you, Dr. Rolih and Dr. Messler, for that fantastic presentation. We also want to thank today’s featured session sponsor, Glytec. Thank you for joining us at Becker’s Clinical Leadership and Pharmacy Virtual Forum, and enjoy the rest of your day.