Thank You! | How a pharmacy-led initiative helped AdventHealth manage practice change in the ICU

In by Alexa Driscoll

Thank you!

 

How a pharmacy-led initiative helped AdventHealth manage practice change in the ICU

Angela Hodges, PharmD, LSSYB, BC-ADM | Texas Health Huguley Hospital, AdventHealth

Jordan Messler, MD, SFHM, FACP | Glytec

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F: Hi, everyone, and welcome to today’s webinar, “How a Pharmacy-Led Initiative Helped AdventHealth Manage Practice Change in the ICU.”  On behalf of Becker’s Healthcare, thank you for joining us today.

Before we begin, I’m going to walk through a few quick housekeeping instructions.  We’ll begin today’s webinar with a presentation and have time at the end for a question-and-answer session.  You can submit any questions you have throughout the session by typing them into the Q&A box you see on your screen.  Today’s session is being recorded and will be available after the event.  You can use the same link you used to log into today’s webinar to access the recording.  If at any time, you don’t see your slides moving or have trouble with the audio, try refreshing your browser.  You can also submit any technical questions into the Q&A box.  We are here to help.

With that, I am pleased to welcome today’s speakers – Angela Hodges, diabetes center of excellence manager at Texas Health Huguley Hospital, and Dr. Jordan Messler, chief medical officer at Glytec.  Thank you for being here today.  Dr. Messler, I’ll turn the floor over to you.

JORDAN MESSLER:  Great.  Thanks so much.  Thanks, everyone, for joining us this afternoon.  I’m excited to be here and talk to you about Angela’s exciting case review talking about a pharmacy-led initiative at her health system, and really diving in to the concept of a best-in-class glycemic management program.

A brief introduction about myself.  I’m a hospital medicine physician in Florida.  I work at Morton Plant Hospital in Clearwater.  I’ve been in the quality improvement/patient safety space for many years.  I was running a hospitalist group, and that work really got me into quality improvement.  And a lot of diabetes work over the years locally and nationally with our Society of Hospital Medicine organization and that work helped bring me to Glytec a few years ago.  I’ve been at Glytec now for almost three years and really working closely with sites to help them achieve their glycemic management goals.

Just to introduce a little bit of the topic of what we’re going to talk about today, what Angela’s going to discuss is the idea of creating a best-in-class glycemic management program.  Here at Glytec, we have our Glucommander insulin management software.  Our mission since 2006 is to improve the lives of patients by managing their glycemic issues and those who administer the care, optimizing insulin therapy.  We work with over 300 healthcare facilities across the United States.

And we have our insulin management software, Glucommander, but we’re not just a technology provider.  We know that success in a glycemic management space requires the right people, the right process, and the technology all working together, and we’ve focused on providing this domain expertise.  We’ve noticed that the best-in-class glycemic management programs have many similarities, but execute differently.  They successfully manage practice change, the best-in-class programs.  They foster continuous improvement.  And all this contributes to ongoing excellence.  You won’t be able to find a place that has a perfect process that you just set and forget, so practice change, continuous improvement, or organizational skills continually need to be put in place and built upon.

Before I hand over to Dr. Hodges, I did want to touch briefly about our insulin management software, Glucommander, and our suite of solutions here at Glytec.  You might have heard of Glucommander, our eGMS – eGlycemic Management System – which provides personalized insulin dosing, decision support at the point of care, our FDA-cleared solution. 

But it’s not just, again, the technology really trying to operate with a suite of solutions.  Our solution – you can move to the top of this diagram – operates in the cloud, the GlyCloud.  We’re able to implement and upgrade our solution remotely. 

Move over to the top right, and you’ll hear from Angela about their data, but any improvement project, you have to have the data.  So we have a suite of metrics – GlucoMetrics – to get real-time data to our sites about their patients in real time as well as feedback to understand their improvements over time.

Move down to the bottom right of this picture – GlucoSurveillance – again, some more real-time data to be able to see who would benefit from being placed on insulin, patients who have multiple readings above 180.

Move down in this diagram in the bottom, the SmartClick.  So our solution integrates within EMR systems.  We have a variety of integrations – ADT, lab results, orders, charting systems with a single sign-on, so it’s a seamless experience for end users, as our solution integrates with the EMR.

Moving around this diagram to GlucoView, another part of our suite of solutions, with workflow alerts for blood sugar checks and patient monitoring.

All this operating around what we have in the center of this diagram is your glycemic management team.  Implementing the technology is what we do, but also over time, being able to optimize and working with a multidisciplinary team to fully optimize the solution.

So I want to give an introduction to Dr. Hodges, really go through her experience at Texas Health Huguley.  Let me provide a short bio about Dr. Hodges.  She received a doctor of pharmacy degree from Texas Southern University in Houston, Texas, completed a pharmacy practice residency with Owen Healthcare.  She holds a board certification in advanced diabetes management and a Lean Six Sigma yellow belt, serves as the manager of the diabetes center of excellence for Texas Health Huguley Hospital, and is an adjunct professor for the University of North Texas Health Science Center College of Pharmacy.  She’s the lead author of the case study entitled “Implementing a Pharmacy Consult Model for Multimodal Basal-Bolus Insulin Therapy,” which was published in The American Journal of Health-System Pharmacy.  And she and her husband have two beautiful daughters who love all things dance.  Thank you, Angela, for joining us, and I will hand it over to you.

ANGELA HODGES:  OK.  Thank you for that introduction, and thank you all for joining us today for this webinar on change management.  Texas Health Huguley is a CMS five-star facility as of 2021, so we’re really proud of that accomplishment.  It’s a 291-bed acute care hospital located on the edge of Fort Worth, Texas.  We serve a mixed rural and urban population.

Our facility is a joint venture between Texas Health Resources and AdventHealth, with AdventHealth managing our clinical functions.  We are the only acute care hospital in Tarrant County with a Joint Commission Advanced Inpatient Diabetes certification, and we also have a certified outpatient diabetes education center.

One thing that makes our program unique is that we have an automatic pharmacy insulin dosing consult model, our basal-bolus insulin dosing that we’ve had for a while.  Currently, pharmacists manage about 90% of inpatient insulin dosing.

Today, I’m here to talk about change – what motivates us to change a process, what are our desired outcomes, the solutions that we derive along the way, and what major challenges we encounter.  Our facility changed our insulin dosing software, and I will tell you how a pharmacy-led initiative helped manage that practice change in the ICU.

The great philosopher Heraclitus is credited with saying, “change is the only constant in life.”  Then, there’s the musical genius Donny Hathaway, who told us, “everything must change, nothing stays the same.”

So first, allow me to explain our standard process before our conversion to Glucommander IV.  The American Diabetes Association and AACE, or the American Association of Clinical Endocrinologists, even the Society of Thoracic Surgeons, they all agree that hyperglycemia in the ICU should be managed with an insulin infusion that also prevents that also prevents hypoglycemia.  We had a system in place to initiate an insulin infusion in patients that had glucose values greater than 180 times two within 6 hours in one of our ICUs.  It came in the form of an automatic, nurse-driven protocol.  The ICU nurses initiated the insulin drip order set, called powerplans in Cerner, which is our EMR, and we utilized EndoTool at the time.  So it was our electronic glycemic management system.

This protocol was approved by the medical executive committee, and physicians admitting patients to one of our ICUs could not opt out of this process.  The ICU nurses were extremely consistent, and the process was expanded to allow emergency department nurses to start EndoTool on patients meeting criteria who were being admitted to one of our ICU critical care units.

For years, both ED and ICU nurses were trained on this process, and they did a great job.  Pharmacy, physicians, administration – everybody knew it.  When criteria was met, nurses started patients on an insulin drip using this software.

One big kink in this process, in the previous process, was that the physicians enter a separate order set for patients in diabetic ketoacidosis or a hyperosmolar hyperglycemic state.  So when patients were in hyperglycemic crisis, the labs, the IV fluids to correct the big fluid deficit – all of those orders were ordered separately from the insulin infusion.

Another area for improvement involved mealtime coverage of patients receiving insulin infusions.  This process wasn’t really clear-cut, and it wasn’t really consistent.

I also want to tell you about our non-critical care units.  We had a similar evidence-based practice in the non-critical care areas, but it was pharmacist-led.  So hyperglycemia in non-ICU areas should be treated with long-acting basal insulin and rapid-acting mealtime insulin coverage.  This is known as basal-bolus insulin therapy.

I want to add that sliding-scale insulin is not recommended for inpatients – sliding-scale alone is not recommended for inpatients.  But the criteria for non-ICU was two blood glucose values greater than 180 within a 12-hour timeframe.  So we had a little bit more of an expanded timeframe for you to meet criteria. 

And another difference is physicians opted into this automatic protocol by signing an agreement with the pharmacy department to manage their patients once criteria was met.  A large number of our physicians utilize this service, including all of our hospitalists, our cardiothoracic surgeons to transition those patients from IV to subQ after open-heart surgery, our orthopedic surgeons, and most of our other internal medicine physicians utilize this service.  So the insulin dosing consult model requires that all pharmacists competently evaluate the patient’s risk for hypoglycemia or hyperglycemia and that those pharmacists are able to make dosing adjustments accordingly.

Now that you have some context, let’s dig back into those tenets of practice change highlighted earlier.  First, for motivation, the tech was falling a little behind, and we weren’t getting enough support from that.  So there was a little frustration that the previous decision-support software was not making changes that seemed to improve the product.  We wanted to make sure that patients had insulin coverage when they wanted insulin infusion and also receiving a meal – to cover those postprandial glucose levels.  And our desired outcome was to optimize DKA and HHS care for our patients in hyperglycemic crisis.

As a glycemic manager, I noticed that physicians did not always initiate the needed order set to treat patients with DKA and HHS.  This was most likely because of the separation in that clinical (audio cuts out; inaudible) task that was built into our process.  The nurses would order the insulin drip, and then the physicians would order everything else.  So then they had an opportunity to order those as separate line items.  And we wanted to make sure that was all ordered in an evidence-based powerplan.

We also wanted our patients to transition safely to subQ insulin without excursions, and we knew that that might help our non-ICU reach their glucometric goals.  Of course, our top priority was patient safety and a whole care patient experience.  So in the ICU, when patients meet criteria for an insulin infusion, we really liked to see them continue on that insulin infusion until they’re ready for their next level of care.  That was usually when the pharmacist gets involved.  The pharmacist will put the basal insulin on the MAR for the nurse to give to the patient, and then once the basal insulin is given, they cover with an insulin infusion for a couple of hours, and then the patient goes to their next level of care, whether that’s a progressive care unit or a med surge unit or something like that.

Also, we wanted to look at our solutions.  So what solution did we come to?  We needed to transition from EndoTool to Glucommander IV decision-support software in the ICU.  We also switched from a nurse-driven process to a pharmacist-led insulin infusion initiation process.  And we had to define some roles.  Our hospitalists were identified as a physician group to dose insulin on critical care of patients.  So in short, we made changes to our people, we made changes to our process, and we made changes to the technology.

You may be asking yourself, why didn’t you just continue to use the nurse-driven process and allow them to put the Glucommander plan in, since they were getting good results?  So I’ll let you know, Glucommander requires a clinical evaluation and decision.  The provider has to assess the patient’s risk of hypoglycemia and hyperglycemia.  From that information, a multiplier has to be selected, and a target range is determined.  The higher the patient’s risk for hypoglycemia, for example, the lower the multiplier to be selected, and the higher your target range would be.  This type of clinical evaluation is outside of our ICU nurses’ scope of practice, and it wasn’t previously required.  Those weren’t previously required inputs for EndoTool.

So going back up to major challenges, our ICU nurses had a little bit of an identity crisis.  They were AdventHealth leaders in glycemic management.  They were recognized as such.  They were the insulin dosing experts in the ICU, and it was their baby.  They took ownership of that ask.  They were reluctant to trust new software and also the new process that we were putting in place.  We also had to, for that reason, define new roles and responsibilities for the pharmacists, physicians, and the nurses.  So at the end, it became a total culture change.  And let’s not forget, we were learning new software – software that we had to trust.

AdventHealth and Texas Health Huguley have always supported empowered leadership.  I sometimes joke that no one ever really leaves Huguley Hospital.  They just go PRN.  For example, we have a pharmacist who took a great position.  It was really a promotion at a big teaching facility in Ohio.  She chooses to fly into Texas and work a few shifts at Huguley to remain a part of our team.  Empowered leadership creates family, and you will do anything for your family.  It all comes down to our service standards – keep me safe, love me, own it, and make it easy.  They are self-explanatory and beyond reproof.

Next, our strategic teams – I am the queen of pocket card creation, which I am.  And then health is the king of the collaborative.  Interprofessional teams are greatly encouraged.  These teams help create the training and procedures that make the organization dynamic in the face of change.  None of that would mean anything without proof that what you’re doing is effective.  Key process indicators and metrics bring that information to the table.

In my area of glycemic management, I am so thankful for our monthly dashboard, which reveals how many patient days had blood glucose values less than 70, less than 40, which is critical hypoglycemia, and greater than 300.  We also have a chance to see how many patient days were within range, meaning blood glucose values between 70 and 180.

We’re challenged to determine key process indicators locally.  So over the years, we’ve had a few at Texas Health Huguley.  We’ve looked at the A1c documentation rate.  We’ve looked at the follow-up appointment documentation rate and also the initiation of a diabetes-related plan of care.  In short, our toolbox was filled with our culture, our strategic teams, and our honest data.  Now, I’d like to delve into each of these a little deeper. 

As a true daughter of AdventHealth, Texas Health Huguley operates with a focus on collaboration.  Tammy Ellis, our CNO, Sharon Washburn, our quality admin, Dr. Laue, our CMO and diabetes champion at the time, along with Barbara Willis, our ICU admin, and James Hall, our pharmacy director, all believed in the pharmacy department’s ability to help decrease the chances of clinical inertia and continue great glycemic results in our critical care area after this conversion.  The same team had always supported my efforts to hardwire our glycemic management process prior to Glucommander implementation. 

So the take-home message here is to look within your organization for untapped talent that might be able to help in your next change initiative.  In this example, the interprofessional team saw potential in the pharmacists expanding their role into the ICU.  Having clear ownership is important.  Not wanting to back down from a challenge and not wanting to lose ground on all the nurses had built, pharmacy leadership took ownership of the new process.  I’ll talk more about what that entailed.

When Glucommander IV was implemented at Texas Health Huguley, it actually came as a corporate decision.  Though everyone was ready for new software, no one really wanted to change their practice.  But the only constant in life is change, so what we were going to do about it?  We had to leverage our strengths to make the new process mimic the nurse-driven process as much as possible.  That was the first no-brainer.

As I said previously, Huguley leadership felt that they could tap pharmacy to make this happen.  But the pharmacists were embarking on new territory.  Would we fail and let the nurse team down?  Would we make a big clinical mistake and let the patient down?  Would we shrink back and take an MIA stance and provide no real assistance to the physicians?  These were all important questions.  Success would take training.

It was determined that the pharmacists should understand what the nurses would see, even though the pharmacists wouldn’t actually touch the software in practice.  So every pharmacist at Huguley completed Glucommander nurse training, and every pharmacist completed Glucommander physician training.  There were additional sessions within the department to help them understand critical care glycemic management and how it differed from non-critical care areas.  So they had the non-critical care process hardwired with our pharmacy consult model.  This is where they attained competency on how to easily recognize DKA and HHS, because those disease states would now require orders from physicians only.

As I said, I’m the queen of the pocket card.  But with Glucommander IV, I became the queen of the schematic.  So I created schematics on our pharmacy consult model workflow, schematics on ordering the Glucommander powerplan.  And to my surprise, the physicians even found these schematics helpful and useful and asked for them to be posted in their area. 

So as we tried to define this new process, we said that nurses would remain the primary caregivers who identify patients meeting criteria for an insulin drip.  Now, instead of entering that powerplan, they would notify pharmacy the criteria was met.  Pharmacy would evaluate the patient and enter the Glucommander IV order set.  Or if there were any signs of DKA or HHS, they would call and notify the physician to enter that powerplan.

Now that we have all of the framework in place, let’s explore interprofessional collaboration.  In the Lean Six Sigma DMAIC process, which stands for define, measure, analyze, improve, and control, collaboration is a winning tool to decrease waste, errors, and variation in order to provide sustained positive results.  I was blessed to be a part of two collaboratives at the time of the transition.  I facilitate our local hyperglycemia collaborative, and I co-chair the AdventHealth corporate glycemia monthly collaborative. 

So we invited facilities to present at the corporate collaborative.  Glytec representatives attended the corporate collaborative meetings to help troubleshoot issues at the time.  We were able to quickly work through reasons for hypoglycemia and hyperglycemia that were occurring with the new software when we started to use Glucommander.

My co-chair and I knew that it’s going to be really important to get members involved with the collaborative, especially at this time.  So we reached out to facilities and asked their leads to present.  The entire team learned from these presentations.  Sometimes, a win was presented, and other times, a challenge was presented.  But no matter where it fell on the spectrum, we worked together to bring solutions that could be used at other facilities as well.  Leads didn’t always recognize that what we were asking was worth sharing.  When we asked them, they stepped up and they presented their process.  And having Glytec there to walk through those events really shortened the learning curve.

For me personally, many times issues were discussed at the corporate collaborative before they occurred locally at Texas Health Huguley.  But when they did occur at our facility, I had an idea of why the issue was occurring, possible solutions, and also a colleague to turn to.  So we have to get creative and figure out how to engage people in different units, departments, or even regions to share wins and challenges or promote growth.

Just recently, Jason Hoffman shared with the collaborative how AdventHealth Kissimmee completed a pilot program for a pharmacist-led glycemic management model after learning of Texas Health Huguley’s success.  So creating that culture of collaboration brings opportunities and relationships that would not occur otherwise.  It lets you know where your untapped talent is in your organization.  Sometimes, all it takes is an invitation to bring that talent to the light.  

Over time, everyone will know who to reach out for help, which equals increased efficiency.  If I have a peripartum or OB question, I’m going to call Shawnee Mission.  If I have a question about Glucommander subQ, I’m going to reach out to Waterman.  And my first stop for diabetes center questions is Tampa.  So it is literally how one person can be in two places at one time.

Let’s remember I’m a pharmacist talking in spaces usually reserved for nurses.  So this is transdisciplinary work in action.  If you have the insight to bring about a solution, you’re free to speak up.  Build professional relationships.  You might not get a chance to if you don’t have a culture of collaboration. 

Pharmacy and nursing get along very well at Huguley.  As pharmacists, we try to make their job easier, and I think they know that.  One example from years ago is when I first started, we added the hypoglycemia treatment meds on the MAR.  As a glycemic manager, I saw how difficult it was for the nurses to get to the hypoglycemia protocol in Cerner, let alone to pull the meds and enter those orders later.  It was just too much work, and it slowed down the process.  So pharmacy created an order set, and we entered those hypoglycemia treatment meds in all patients receiving insulin.

I spoke at a national pharmacy conference once, and I suggested that everyone make this big improvement.  I got the impression that some pharmacy departments believed it would take an act of Congress to implement.  I knew how special how pharmacists at Huguley were at that point, because they were on board from day one – absolutely no pushback.

So the meds for hypoglycemia treatment are on the MAR.  The nurses don’t have to go the extra step of putting them in later.  They can just scan and give.  Plus, best practice is reinforced, because daily, the nurses see the hypoglycemia protocol criteria right there on the MAR, and that makes the nurse much more likely to remember the process when an event occurs.  If I had not stood in their shoes for a moment, I wouldn’t know that this little change could help, so I wouldn’t have understood what it would mean to make that adjustment.  Now, AdventHealth commonly works to add the hypoglycemia treatment meds to appropriate powerplans so that they appear on the MAR.

All of that is wonderful, but how do you know your program is working?  You have to look at your key process indicators and your metrics.  You have to review those periodically.  And you have to let your data drive your practice change.  Glucommander IV went live for us in early 2018, so this is pre-COVID.  One of our key metric indicators was ICU within range patient days, so how many patient days were between 70 and 180.  And the goal was to have greater than 75% of those within range. 

After our Joint Commission survey in late 2018 – very late 2018 – we added another performance measure locally, and we looked at Glucommander initiation time.  So we wanted to make sure within six hours of the patient meeting criteria, we had an order for Glucommander on the chart for them.  Our data in 2019 after we implemented this performance measure showed that 80% of the time, patients were getting those Glucommander IV orders within six hours.  And for the last few months of 2019, we were at 85% for timely Glucommander initiation.  As we all know, 2020 brought the pandemic, where there was major shifts within the ICU.  So this was our data before the pandemic.

I wanted to show you guys a little bit of our information.  This slide represents our monthly scorecard.  This scorecard is not Glucommander IV data alone.  It includes HHS patients admitted with blood sugars over 1,000 and also those patients at end of life that may have a blood sugar drop below 40.  So it’s every patient in both ICUs who have had a point-of-care blood glucose monitoring during their ICU admission. 

And what we’re looking at here mainly is that column to the far left.  That shows our within range patient days, that they’re between 70 and 180.  As you can see, in 2017, we met that goal for a full 12 months.  So 2017 is really representing EndoTool data, and we met the goal for a full 12 months.  Then there was the transition in 2018, where we went to Glucommander in February, so pretty much all of 2018.  And again, the far left column is totally green, so we met that standard for all of 2018.  And the trend continued in 2019.  So what that shows clearly is that we adopted our change process, and the new software was providing the results that we needed.

Just to dig a little bit deeper in this line graph, looking at those within range data, 75% is the goal.  So we’re way above that goal, yay!  And you see the orange line is EndoTool 2017 data, and then the green line is Glucommander data.  So Glucommander did a great job, and you can even see some separation in November and December, where we really had those high within range months at above 85%.  So really, really good.

We also saw something very interesting after the conversion to Glucommander IV in our non-ICU.  In 2018, we started to see light at the end of the tunnel in that data.  There was an improvement in our within range blood sugar levels.  Now, Glucommander is not used in our non-critical care areas, because it’s an insulin infusion software, and we don’t use insulin infusions in the non-ICU.  But it’s quite possible that we’re seeing those improvements from that IV to subQ process that I described earlier.

So in 2017, we were consistently under our goal of 75% of patient days between 70 and 180.  We did a decent job with hypoglycemia.  The two columns in the middle represent hypoglycemia.  There’s a lot of green there.  Most of the time, we were above 70%.  So as we know, talking about change management, one of our old goals was 70% of patient days, and then that was increased to 75% in range.  So we have been working really hard to meet the new goal that was laid out for us.

Remember that this represents the pharmacists’ management.  Pharmacists managed the subQ insulin, and you can see on the right, after we transitioned to Glucommander, we started to see some green in that far left column.  About four times in 2018, we were able to meet goal.  Really importantly, we saw total consistency in our hypoglycemia management.  So blood sugars under 40 and under 70, all green for 2018.  A lot went into that success, but I do believe our total culture change that was brought about by our Glucommander IV conversion played a role there.

This is that information on within range with a line graph.  So we can see that that goal of 75% – we start to go above that goal on the green line, which represents Glucommander.

Next, we’ll look at our order set entry.  All the way to the left, we can see three months before Glucommander was initiated, nurses were entering 85% of the powerplans to get the insulin infusions started.  Physicians and advanced practitioners were entering about 15% of those orders.  And pharmacists entered a whopping 0% of those orders.  So the nurses had us trained – we need to start insulin infusion, call us and we’ll get it started.

In the middle, you’ll see the first three months after Glucommander initiation.  You see a little bit of a flip-flop there.  So the pharmacists entered 33% of the Glucommander IV powerplan orders.  Nurses entered 39%.  So we start to see a drop.  And the physicians entered 28% of those orders.

Let me clarify that after Glucommander was implemented, we ended up with two different powerplans, one for basic hyperglycemia and one for DKA and HHS.  This data is really representative of those patients that are admitted.  They may have severe sepsis.  Their blood glucose increases above 300, so they need an insulin infusion.  Or a patient is placed on high-dose steroids, and their blood sugar rises above 200.  So of course, they’re meeting criteria for an insulin infusion.  This is where the pharmacists are supposed to support the physician and automatically get that insulin drip started for consult.  So we’re starting to see some improvement there.

And then to the far right, I went ahead and pulled our June 2021 data to see how we were doing.  Pharmacists entered the Glucommander IV powerplan 74% of the time, and the doctors and advanced practitioners entered it 22% of the time, with nurses making up 4%.  That 4% represented one order.  So I think that is so interesting that we had a total flip-flop in our process, with the nurses going from 85% to 1 and the pharmacists going from 0% to 74%.

And as I mentioned, there’s a separate order set for DKA and HHS, so this gives you a little insight into the physicians’ ordering practices.  Three months after Glucommander was implemented, we can see that physicians were entering 79% of the powerplan orders for DKA.  And then we also have our June 2021 data, where they’re entering 80% of the powerplans.  So that’s showing some sustained use of the new process.  And what is really exciting about this is for every patient with DKA, they’re getting their IV fluids, they’re getting the appropriate electrolyte orders, they’re getting the tests that they need, all ordered at the same time that the insulin infusion is being ordered for the patient.

Most of our patients with DKA and HHS are coming in through the ER.  They’re going to be new admits.  And for that reason, they’re going to interact with the physician first.  So they get those started really early in their admission process.  So the physicians exemplified our love me standard by adopting this change and not developing workarounds. 

What was the benefit of a pharmacist-led glycemic management program?  First and foremost, evidence-based practice was maintained.  Evidence-based practice was maintained.  We brought efficiency to a very complicated process, which allowed the physicians to focus on other important clinical factors.  We were able to define the roles and responsibilities in our program, which is something that we probably needed to do long ago.  But we were able to define those roles.  And we were able to reinforce the benefit of an interprofessional team and that collaboration that occurs with an interprofessional team.

The other thing is the pharmacists grew clinically.  They learned how to dose insulin in the critical care area.  So like I said, they had the subQ process hardwired, and they were able to learn the ICU process as well, which brought about a sense of pride.  And as you can see from the physicians adopting the process, we avoided clinical inertia that can plague some programs.

Knowing that nothing stays the same and everything must change, we used our culture, our strategic teams, and our data to bring about success.  Leadership recognized that pharmacy could be key to this change.  The pharmacy department was empowered to take ownership, but they were also supported to get the training and the education necessary to gain competency.  Because they were already a trusted member of the interprofessional team, other disciplines were willing to accept help and trust that together, we would make the new process work.  Finally, we continue to review our data to make sure that we were getting the results and keeping our patients safe in the process. 

Thank you so much for your attention, and I will turn it back over to Dr. Messler.

MESSLER:  Great.  Thanks, Angela.  That was terrific.  So many amazing pearls and wisdom peppered throughout your talk there.  What really resonated with me and what’s so essential for any improvement project is having those foundational elements which were really essential.  Angela really highlighted the importance of having a multidisciplinary team, having that team be empowered, having leadership that supports your efforts, having clear aims and data, metrics, to be able to drive that change, having a structure – within the Six Sigma realm, you have your DMAIC structure.  All those elements are so essential to continue to drive change and continuous improvement.

And doing that with these three elements we mentioned at the beginning – using technology, yes, but needing the right people, the right domain expertise.  You highlighted the importance of that network, the processes that need to be standardized to help guide that practice change.  And all those elements together help driving towards a best-in-class glycemic management program.

If you want to learn more about the elements of a best-in-class glycemic management program, I’ll forward you to a website that’s attached on your screen here, glytecsystems.com/beckers.  And I think that’ll lead us to questions.

F: Thank you so much, both of you, for that great presentation.  We will now begin today’s question-and-answer session.  You can submit any questions you have by typing them into the Q&A chat box on your webinar console.

So with that, let’s get started with the first question.  Where did you get the greatest pushback, if any, from the physicians?

HODGES:  So when we were starting our process, we decided to define which physician group would be managing insulin infusions in the ICU.  As everyone knows, you have neurologists, you have surgeons, you have nephrologists, infectious disease doctors – various disciplines working in the intensive care unit, including your critical care doctors or your intensivists. 

The intensivists felt that we were really getting good results with our previous process and more like if it’s not broke, why are we trying to fix it?  So we tried to explain that the Glucommander needed different elements that the nurse could not enter, so we couldn’t keep our process exactly the same, but they were very agreeable in allowing the hospitalists to be the go-to physician for insulin management.  And since 100% of the hospitalists allow a consult with pharmacy to manage their insulin, then we would be able to mimic that nurse-driven workflow, meaning when a patient met criteria for an insulin infusion, then the pharmacist could automatically start that insulin infusion per consult in order to make the system a little bit more efficient for the hospitalists.  So I would say that was our greatest amount of pushback.

F: Great. Thank you for that explanation, Angela.  Another audience member would like to know, do you have a diabetes education department?  And if so, what is their role in your work model?

HODGES:  This is a great question.  We have an interdisciplinary approach to diabetes education, so we don’t have one person that is our inpatient diabetes educator.  I know a lot of other hospitals have issues similar to that, but I really feel like it is a benefit in our facility.

What Joint Commission requires is that the nurse does a diabetes education assessment, and we train on that multiple times and annually on doing that diabetes education assessment.  Once that occurs, the disciplines that would be able to provide that education are brought into that patient’s case, whether it’s the dietician, the unit-based pharmacist, the physical therapist, the social worker.  Everyone is trained on this interdisciplinary approach to diabetes education, and that’s pretty much how they fit into the process.

So as I stated as far as one of our key process indicators, we looked at having a diabetes-related plan of care, so when the nurse admits that patient, they can enter a diabetes-related plan of care.  That diabetes-related plan of care notifies pharmacy and our clinical dieticians that we have a patient in the hospital with diabetes.  So we have certain criteria for automatically going and seeing that patient and otherwise.  That’s how we handle diabetes education at our facility.

F: Thanks, Angela.  Another audience member would like to know, how many pharmacists does it take to make this model happen effectively?

HODGES:  How many pharmacists does it take to make this model happen effectively?  When we started this process, we really did not hire more pharmacists, interestingly.  But what we did was shift some of the functions.  So the only additional person was my position, and actually this position kind of grew out of a diabetes nurse position.  So mine was the only additional position.  What we did was shift around functions. 

All of our pharmacists have to be able to pick up a new consult, and if they get a call from nurses, make adjustments.  Then we have one pharmacist daily that looks at all of our insulin consults for the day.  So there’s a list that can be seen by all of the pharmacists, and one pharmacist every day goes through that entire list so that we can have consistency.  Then those unit-based pharmacists pick up new consults on their units.  And then, of course, at night, they have the entire hospital.  But we really didn’t add new pharmacists to our program in order to implement a pharmacy consult model.  We just organized our day a little bit different to get that done.  And I would say I was the additional person to make sure that everything was coming together for the nurses’ education, physician education, etc.

F:We have another related question.  Is the pharmacist-led service 24/7?

HODGES:  Yes, it is 24/7.

F: Great, thank you.  Another audience member would like to know, how would you adapt this to a small rural hospital?

HODGES:  In a small rural hospital, I think first, you have to make the decision that you want to have some focus on your glucometrics, so you need your data.  If you’re not a small hospital that’s part of a big corporation, if you can get that honest glucometric data, that would be the first starting point to see where your issues are, to see what your hypoglycemia rate is, see your rate of critical hypoglycemia, whether you use less than 40 or less than 54, to see how many blood sugars you have over 300.  If you can get data for within range blood sugars, that’s great.  So first, we want to see where your problem is.

And then secondly, you want to put together an interprofessional team and try to meet monthly, if you can, to talk about what you’ve found – you’ve found issues with your diabetes education, issues with compliance with your powerplans or order sets that are evidence-based practice, issues with using sliding-scale insulin alone in the hospital.  I would look at that route.

And then in the pharmacy department, if you could, I would look at implementing an insulin dosing model.  The problem would be if you leave at night, does another hospital take over for you?  If that hospital has a consult model, then that makes it easy.  We have picked up other hospitals at night on our night shift, so that made it easy for those hospitals.  If you don’t have that situation, you just have to be agile and work around with your physician group for what you do at night when your local pharmacy team is not available.  But during the day, if you provide renal dosage adjustments and vancomycin dosing, this is an area that you can look at expanding into.

MESSLER:  Yeah, that’s great, Angela.  That’s great advice.  I was just going to add a couple of comments to that.  Certainly, you’re hearing – again, the basic advice, the importance of having a clear team, understanding your aims.  So for that question from the small rural hospital, as you would put that team together and understand your aims, understanding for cases – you have a small ICU, it sounds like, a couple of beds.  If you’re seeing DKA and HHS, really working hard to keep that in house versus transferring – is that one of your aims, to try to be able to manage more of those without having to transfer patients?  That would be certainly understanding your current state.

I just want to also chime in, because if you’re alluding to Glucommander and our software, we certainly wouldn’t have a limit based on your size, but you’d want to, obviously, be clear, as Angela’s mentioning – you’re having a team.  What are your resources?  What are your aims?  What are you hoping to achieve?  And seeing how these pharmacy-led models – having the technology, if that would fit with your goals.

F: Definitely.  Well, thank you both so much for your input on that question.  Another question is does your process include a transition to oral antidiabetic agents in preparation for discharge?

HODGES:  I can answer that, and then Dr. Messler might want to speak to what Glucommander provides for that transition.  With our process, once patients meet criteria for basal-bolus insulin therapy, they continue that during their hospital stay.  So we transition those patients back to their oral medication at discharge.  That’s the usual process.  If a patient were on metformin, and they didn’t meet criteria for subQ insulin, they may be using an oral medication in the hospital.  We restricted sulfonylureas from our ICUs.  We found those to be causing a high rate of hypoglycemia, so those have been restricted from use out of our ICUs.  So that’s one class. 

But no, we do not start patients on oral medications while they’re in the hospital.  What we do is use our dosing model to find out the patient’s total daily dose a week of insulin required, and then we convert that number to an equivalent amount of medication for discharge.  Whether that’s them going home on insulin, whether that’s adding metformin back and having to add a basal insulin with that, we base that off of their needs in the hospital of insulin.

MESSLER:  Great.  I can add a few other comments to that.  Certainly, an important time in a patient’s hospital stay, that transition.  I certainly recommend following guidelines.  There’s a great article from Dr. Umpierrez.  There’s some others, but Dr. Umpierrez did an article sort of evaluating based on a patient’s A1c what kind of recommendations at discharge.  So certainly trying to follow some standard process at your institution.

Glucommander does incorporate some of that research to make some basic recommendations at discharge based on a patient’s A1c.  But as Angela mentioned, you’d use a patient’s home medication that they’re on, their A1c, whether they have stress hyperglycemia or not, to help make those decisions on oral medications under insulin at discharge. 

And then always keep in mind we try to provide guidance with Glucommander, but obviously it’s with the patient and their primary care physician and their insurance that’s ultimately going to be able to help determine what they can take longitudinally.  So you can make a great plan at discharge, but then the patient can’t afford that medication, or the primary care physician really has a different process that they manage.  So certainly want to be in close contact with the primary when you’re making new oral antidiabetic medication recommendations at discharge.  It’s certainly great to get that process started and thinking about it, because that’s a great time to get patients on the right medications, or at least have that communication with the primary care doctor when they’re in the hospital and at discharge.

F:Great, thank you both.  It looks like we have time for one more question.  An audience member wants to know, were there any tools to help the nurses identify patients meeting criteria?

HODGES:  Yes.  Glucommander provides a dashboard option that is linked to your EMR.  If you click on that link and you click on your unit, you can see which patients have had blood sugars over 180 so that you can follow up on those patients.  So we train our ICU pharmacists on how to use that dashboard and our ICU leads on how to use that dashboard to help us quickly identify patients that have had blood sugars over 180 and those that might need to start Glucommander IV in the ICU.

F: Thanks, Angela.  Unfortunately, that is all the time we have today, but I do want to thank Dr. Hodges and Dr. Messler again for an excellent presentation and Glytec for sponsoring today’s webinar.  To learn more about the content presented today, please check out the resources section on your webinar console.  Thank you so much for joining us today, and we hope you have a wonderful day.

HODGES:  Thank you.  Bye-bye.

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