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Inpatient Glycemic Management Best Practices

 

Jordan Messler, MD, SFHM, FACP | Glytec

 

Andjela Drincic, MD | University of Nebraska Medical Center

 

You'll receive an email with a link to this video in case you want to watch it later.

 
 

TRANSCRIPT:

[00:00:00] Jordan Messler: Hi everyone. Thanks for joining this session on inpatient Glycemic Management Best Practices, strategies, and Applications. I'm Jordan Messer, the Chief Medical Officer at Glytec. I'm also a practicing hospitalist. I work at Morton Plant Hospital, which is in the Bay Care Health System here in Tampa, Florida, where I'm based.

[00:00:24] Jordan Messler: I've been an academic hospitalist and then ran a hospitalist group for about 10 years, and during that, I did a lot of quality improvement, patient safety work around DVT prevention, readmissions, and a lot of work around glycemic management. And that work brought me to Glytec, where I've been for about four years.

[00:00:42] Jordan Messler: I'm excited to talk to you today about really the foundational work for driving change in the healthcare system, the foundations, the basics of quality improvement. This will be a short review and, and maybe for many, stuff you know very well, but I find that these are the principles to come back to when you're working on quality improvement and really looking to drive change

[00:01:00] Jordan Messler: And if you find you have some struggles, go back to the basics in quality improvement. We often understand the problem. We know what works. That's this top line here where what we know. But what we do often falls way below that. And that's this implementation gap that exists and why we do quality improvement projects.

[00:01:22] Jordan Messler: There's a variety of reasons for this gap. Most commonly things like lack of awareness and that lack of awareness is often driven by lack of metrics. Frequently not standardizing. Well, if you're not standardizing processes leading to a lot of variation. So we know it works, but we have this gap. So let's think about some basics of quality improvement.

[00:01:44] Jordan Messler: And I'll talk about three main areas in this talk. The frameworks for a success and a variety of frameworks you may use to drive change in your system. People, process, technology. I'll talk a bit about quality improvement checklists. The most common, the PDSA plan, do, study, act model for improvement. The second piece really highlighting the importance of metrics to drive change.

[00:02:05] Jordan Messler: And then finally, I'll end with some principles of high reliability strategies when you're implementing improvements. Really putting these principles in place to drive that high reliability change.

[00:02:18] Jordan Messler: One of the basic frameworks we think of at Glytec and, and maybe a framework you use is looking at these three pillars, The people, the processes and the technology. Really understanding those three pillars and using them effectively to drive quality improvement project success. 

[00:02:39] Jordan Messler: So let's look at each of these pillars, thinking about the people. Do you achieve consistency of care and reduction in clinical variation? And if not, are you having the right people at the table? Do you have that multidisciplinary team, that engine for change? Make sure you have the executive support leadership involved to help break down those barriers.

[00:02:55] Jordan Messler: Accountability structure is key. For instance, in glycemic management, when you have your glycemic management team, we should often have metrics that are being reported to p and t pharmacy committee or quality committee, to have that level of accountability. Having the right champions, whether as providers, nursing, pharmacy champions, are essential to continue to have success.

[00:03:17] Jordan Messler: And then one of the hardest pieces is sustaining that success, having ongoing engagement from those champions, from that team to keep the improvement going.

[00:03:29] Jordan Messler: A little further details about some of these principles, and particularly the team, which seems basic, but so essential. Having that multidisciplinary team. We provide our sites at Glytec with a framework for the team roles and responsibilities with the core team in green, and highlighting for any quality improvement team, some of those core players that should be on your team, Making sure you have those different perspectives and roles.

[00:03:52] Jordan Messler: The team leader, executive sponsor, the champions, the physician champion, nursing champion, nursing leadership, pharmacy, and an educational resource. And then additional team players may come onto the team depending on the objectives and the roles adding in subject matter experts as well. it's also important to be deliberate about your champions.

[00:04:13] Jordan Messler: We talk a lot with our institutions, the sites that have, uh, Glucommander about provider and nursing champion and being clear on the roles and responsibilities. Your champion should understand the goals of their role: to educate, to help communicate the improvement, to have data that's shared with the front lines and not just part of the committee.

[00:04:31] Jordan Messler: And as a champion, it's a nice step for leadership development and also being clear on the roles, how you select champions and what that may mean for time and resources for particular champions. Now we'll provide our sites with clear documentation to begin thinking of it. And again, having a deliberate approach will make it more likely to have a champion and a champion that sticks around for the project.

[00:04:53] Jordan Messler: That process piece, why aren't projects to improve successful? It's often going back and looking at the processes and not just the processes that you put in place, but the processes during that quality improvement work. If you have a standardized approach to improvement, you have things like a charter to be clear on what's in scope and outta scope, clear aims and need to have that direction being really specific about your aims of the committee of the improvement team. Doing a structure like plan, do, study, act. Then begin to standardize those processes in place with clear policies and protocols. And then that third piece, that technology, are you using the most advanced technology to personalize care? If you have certain technologies taking advantage of it, but recognizing a key principle that technology is a tool just part of this three legged strategy that I'm talking about. Technology by itself is not a strategy. Thinking at the basic levels. We all have electronic health records now and we certainly use them, continue to find ways to leverage the EHR. A lot of different projects, not just glycemic management. Try to find those ways to get those real time reports and talk about that more in high reliability strategies.

[00:06:02] Jordan Messler: Simple things of having well designed order sets that have pre-checked the falls to drive best practice. Here at Glytec, we talk about our insulin software, our eGlycemic, Management System. So using the technology to help standardize and approach to insulin management, having a standardized algorithm, providing real time alerts for nursing to help drive timely blood sugar checks and real-time tools and dashboards to continue to drive, uh, change while you're taking care of patients.

[00:06:28] Jordan Messler: The framework for success, aside from people, process, and technology include many that we're familiar with, most commonly Institute for Healthcare Improvements model for improvement. When we think about the PDSA, certainly strategies such as Lean Strategies to Reduce Waste Six Sigma, which have a lot of deliberate tools to drive care, ROBUST Process Improvement, which may combine different elements of Lean and Six Sigma.

[00:06:52] Jordan Messler: Or having a strategy that largely includes checklists and culture change, which we know from the work of Dr. Provorse, Dr. Valente, having a clear checklist and driving towards a safe just culture. Briefly about PDSA, which is one of the most common plan, do, study, act, to really think of the top left, those three key elements as you're driving towards plan, do, study, act.

[00:07:12] Jordan Messler: What are we trying to accomplish? What are our aims? A basic principle that's often forgotten. Being clear on our aims. Measurements. Number two, how we know if a change is improvement. You need to have the right measurements, to know if the change is having an improvement. And finally, what are the solutions we're gonna put in place?

[00:07:29] Jordan Messler: And then test those, and then test them on a small scale, rapid change, have follow up tests, and then begin to spread based on the feedback from those changes. I try to put all this together in  in a checklist, principles from IHI, from others in a 10s checklist when I'm working on quality improvement, if things aren't going as well as I, as I expected, to make sure that we're putting those foundations in place.

[00:07:53] Jordan Messler: Let me go into a little more detail on these top 10. So the 10s, support, we talked about the institutional support, that synergy, that engine of change, the multidisciplinary team having that right structure, the framework, the plan, do, study, act, or another structure for quality improvement. The smart aims, not just general aims, I want to drive hypoglycemia, but really specific on which population and what time frame.

[00:08:15] Jordan Messler: Sensible. So outcomes alone can't be managed. They may take a long time to see the results for certain outcomes, but what are the processes and making sure those processes leads to the outcomes you're following. Again, mention, I'll mention data again on the next slide, but having that meaningful metrics to drive change.

[00:08:32] Jordan Messler: Think about segmenting projects. Start smaller scale, pilot, test things out. Standardize your approach. Like Glytec, we have our Glucommander software. Whatever solution you're putting in place, begin to think about how you standardize it across your population. That's the only way you can understand variation if you have a standard approach.

[00:08:50] Jordan Messler: Strategies, high reliability strategies. We'll talk a little more about that in a couple of slides and then swift, Making sure you're doing change rapidly. We all have a lot of things we're working on, a lot of competing priorities. When you're putting improvement in place. Do things rapidly, rapid data collection, rapid feedback and rapid continued PDSA cycles.

[00:09:09] Jordan Messler: So can't iterate enough on the importance of metrics. Metrics as a requirement for deciding what improvement projects you're gonna put in place. When you do have metrics, make sure you're sharing and displaying. Often see glycemic teams or any quality improvement teams sort of hoard the data and not get those metrics back out to the frontline.

[00:09:27] Jordan Messler: Take those metrics and transform it into stories to better understand the impact on patients, on the frontline providers, and always key to have that baseline in mind where you started and the benchmarks and how you compare with others, either in your institution or outside your institution. 

[00:09:43] Jordan Messler: I can't say this enough, in the glycemic space, we know that one in three hospitals have no clear measurements to track glycemic management. And in that environment, how can you begin to improve where you're not having the measurements to track that glycemic management and the glycemic space. This has been recognized by CMS.

[00:09:59] Jordan Messler: Starting in January, 2023, hospitals will be recording on two new metrics. These eCQMs eClinical quality measures around severe hypoglycemia patients days less than 40 and severe hyperglycemia patient days greater than 300. These metrics are here cuz we recognize that there has been a gap in measurements in glycemic management.

[00:10:17] Jordan Messler: There has been a lack of transparency and we need this data and these metrics to drive awareness and drive. And lastly, I wanted to talk about high reliability strategies. So when you're implementing solutions, we know number one here by itself won't work hard work, education, vigilance, those are all so foundational for anything that you're improving, working on.

[00:10:38] Jordan Messler: You need those things, but that's not gonna work by itself. You need to be thinking about high reliability strategies and I used to remember some of these strategies when implementing changes. D.R.A.W.S, Default action, that's simply often those pre-checks and those order sets, redundancy, trying to plug those Swiss cheese holes, doing multiple steps, to, drive change, having alerts, real time alerts, making a new solution, part of a workflow, not adding something new.

[00:11:04] Jordan Messler: And again, the importance of standardizing care. And then finally the high reliability strategy that really can drive change once you put in those right order sets, those right policies, getting a clear measure of success, 80, 90% of what you wanna achieve. But once you wanna get to that 95 plus percent, you really need to have some real time tools.

[00:11:24] Jordan Messler: What we call “measure-ventions” is coined by Dr. Maynard out ofUC Davis Chief Quality Officer there, active surveillance, identify, measure in real time. Well, those are a lot of the basics, as many other tools around quality improvement. Those are some basic principles you may be aware of. I think what's really key though, is seeing how we can take those principles and put 'em in place in the real world.

[00:11:49] Jordan Messler: So I'm excited now to hand off the rest of this session to Dr. Drincic, Professor of Medicine at the University of Nebraska who will talk about putting these tools into practice.

[00:12:00] Andjela Drincic: Thank you, Dr. Mesler for this  wonderful overview of a basic principles of QI.I feel it's something that like we are supposed to know, but we really don't get a formal training in and we are thrown into it.

[00:12:13] Andjela Drincic: So it's really great to get a theory on it. So, what I'm gonna do is really kind of show you how these basic principles can be implemented in real life and how can we achieve these glycemic targets in the real world. So what is my real life? I am a academic endocrinologist, um, and I'm also medical director of diabetes inpatient services.

[00:12:40] Andjela Drincic: And, I live and work mostly live in a tertiary care center called Nebraska Medicine. We have 700 beds, more than a thousand affiliated physicians. We are a teaching hospital with an endless number of residents and fellows that change. And, you know, with prevalence of diabetes and hyperglycemia, this means that every single day we have 250, 300 plus patients who have diabetes in hyperglycemia and in insulin, which means about 500 to perhaps even a thousand of insulin injections daily.

[00:13:21] Andjela Drincic: Being given in sort of inherently disjointed system, right? It's a system where one person checks the blood sugar, the other person brings the meal, the third person eats the meal, and the fourth person gives insulin. So how can one achieve consistency of care? So you've heard about people, processes, and technology, and this is my sort of embellishment on this,  really focusing on, on the points that Dr. Messler went over.

[00:13:47] Andjela Drincic: But also introducing the need for innovative models of care in the, the usefulness despite occasional frustration of external forces and organizational support. So what does it mean? Leadership is really important and I think of it in a kind of a, on a tool levels. One is of a more local level, the leadership of our glucose management program in our institution.

[00:14:14] Andjela Drincic: It is sort of the terrific trio of, our Diabetes Stewardship pharmacist. And I am as a medical director, part of the leadership team, and we have the inpatient diabetes education lead and we work together with our diabetes case managers and diabetes resource nurses. With help of our diabetes steering committee to basically organize these processes that are geared towards helping us achieve good glucose control in patient care.

[00:14:46] Andjela Drincic: Most of all, our steering committee is multidisciplinary and every stakeholder who is involved in this process of taking care of patients with diabetes and hyperglycemia is really present as listed here. But it's really important to understand that not only do we need to have a clear reporting structure and whatever it is whether it's an ambulatory care quality committee or whatever safety committee you can think of, what's more important is that it is, really obvious to the glucose management program and the team leadership what door can one knock on when you are asking for support of the ideas and processes you would like to institute to help tackle glucose care.

[00:15:31] Andjela Drincic: So processes are many and some are listed here. Policies, procedures, order sets. Therapeutic interchanges, standardization, having QI processes, but that is all just sort of like a letter on a piece of paper without having a way to implement these processes.

[00:16:09] Andjela Drincic: So it is well beyond order sets. So how we think about it, I think that innovative models of care offer pathways for implementation. So in our institution, those are Diabetes Stewardship Pharmacist Program, and I will tell you a little bit more about it later. We have a diabetes resource nurse program.

[00:16:31] Andjela Drincic: This is an extra education with a formal curriculum in education that we give to interested nurses that come from various floors, that get,acquire enhanced knowledge and then go back to their floors and they serve as a resource to other nurses that may have a question about a patient care.

[00:16:55] Andjela Drincic: This program has been immensely successful and actually has been tied to a decrease in readmission rates that we have achieved since the implementation of this program. The next is concept of endocrine hospitalists. This is relatively new. Everybody knows about internal medicine hospitalists, but we actually have diabetes specialists that work specifically as hospitalists and they work separately, but interchangeably in a way with our academic team, and they help us handle the care and the volume of ever, ever increasing volume of patients who have diabetes.

[00:17:32] Andjela Drincic: The next concept is that of the need to integrate care to work with other teams, including Allied Health. Sometimes, especially in large institutions, we can exist in a vacuum. We are too separate, and we live in separate corners of the world. And achieving integration is so important.

[00:17:52] Andjela Drincic: The next concept is that of do you think about, um, a really co-management, concept in really teaming up with other serving lines, with other service lines to provide care. So when you think about it, when you have one person that orders a diet, the second person that decides about transferring a patient, the third person that orders insulin, that introduces, a possibility for lots of errors.

[00:18:27] Andjela Drincic: And many times it's better perhaps for, let's say diabetes service to really give a recommendation about treatment, but then the actual primary service to write the orders. And this is really not the end of the list. There are many more things that one can think of innovation in actual models of care.

[00:18:53] Andjela Drincic: And as Dr. Messler said, technology is just a tool. I think of it as support being a catalyst tomany projects that we have and really goes well beyond order sets, alerts and those dreaded BPAs and hard stops. We use technology to help us with developing decision tree support. System enhancements, dashboard creations, AI driven orders, integration of CGM, and for some organizations, glycemic management systems.

[00:19:34] Andjela Drincic: So the next is a word on external incentives. So they actually, even though they're kind of dreaded at times, they can be utilized to leverage institutional support to get support for the action you need to improve care. So, for instance, Joint commission getting advanced inpatient diabetes disease specific certification has been very helpful to us.

[00:20:02] Andjela Drincic: It was a lot of work, but when you think about it, what Joint Commission really wants you to implement is nothing but the best practices. And the list is here for those of you who wanna read it in detail, but it really involves things. Well identify who has diabetes and what kind of diabetes they have, make sure they have A1C on admission, make sure they get point of care monitoring, establish targets for the glucose in the hospital, develop standardized insulin order sets, and so on and so forth.

[00:20:35] Andjela Drincic: So just following that will actually make your position better, to provide better care. And in a way, the same goes for upcoming measures of the CMS. I can't say enough about metrics. Metrics come in many shapes and forms, but I wanna point out that it's important to have active surveillance metrics as well as retroactive metrics.

[00:21:04] Andjela Drincic: And they all have separate roles in QI initiatives and of course benchmarking reports. I wanna show you here how really any metrics are better than none. I mean, metrics can be very rudimentary, but they can be super fancy. But look what happened historically for us. We had, like, this was more than 10 years ago when we still had paper records and we just studied our glucose management program and we just got our joint commission accreditation.

[00:21:38] Andjela Drincic: And with these homegrown metrics, We managed to decrease hypoglycemia 50% in a period of four years. And with that we also managed to decrease the length of stay and more importantly, diminish this gap between the length of stay for patients with diabetes and non-diabetes. And that translates into some like real money for the hospital.

[00:22:06] Andjela Drincic: So like I said, there are metrics and then there are better metrics. So we thought we were so great. And then thought, Well, you know, we think our metrics are good, but really don't know how does that compare to what other institutions are doing? So benchmarking is very important and we have decided to actually join an equip system that's, uh, provided by Society, Hospital Medicine, where you basically, you send your data and they give your reports back and you can see how you're doing compared to other hundred plus hospitals.

[00:22:44] Andjela Drincic: And we went from thinking, We are like the best thing ever, boy was our balloon deflated when we got our first dashboard benchmarking report. For instance, our hypoglycemia. You really wanna have very low percent days of hypoglycemia and at the same time have a lot of patients who have sugars in range.

[00:23:10] Andjela Drincic: So you really wanna be in this happy corner and our first report, We had our stain range was decent, but our hypoglycemia rate was just  you know, like bad and we did not pair well with our comparator group. That by itself helped us devise systems. And a few years later we are in a happy corner.

[00:23:38] Andjela Drincic: And so now I'm gonna give you more specific examples how we have achieved that. So this is a  practical approach to QI that Dr. Messer talked about identifying the problem, the scope of it. What is the goal? Who are the team members and what resources do we need to accomplish this goal? So when you are deciding to embark on the journey of a project, You really have to pick first the low hanging fruit.

[00:24:14] Andjela Drincic: So what is that quick win? What is that project? That with a low effort, you will have a high impact and that is really your first thing to tackle. You definitely don't wanna spend time putting a lot of effort into a low impact activities. So for us, when we got our equis report we really looked first at what is that quick win? 

[00:24:41] Andjela Drincic: So, for instance, one of the reports we got is what is the mean time between having at a hypoglycemic event and documented resolution of hypoglycemia? It's a pretty important thing. There's no question about it, and we assumed we were doing great. However, it turned out that it took more than an hour for us between hypoglycemia and documentation resolution for patient on average, and that's clearly not good.

[00:25:13] Andjela Drincic: It was a quick win for us because it was a relatively straightforward project because it was owned by nurses. And nurses are wonderful to work with and you can educate them and, and they're quite adherent to recommendations. And indeed, just by working with managers, raising awareness and education, we have very rapidly achieved a top quartile performance for this particular measure.

[00:25:42] Andjela Drincic: That was a quick win. But the hard thing is a major project, those that require a lot of effort but yet are worth it because they will have a high impact. And for us it was hypoglycemia. Our percent patient days with hypoglycemia and recurrent hypoglycemia days were quite high. And even though, and I'll show you now over the years how we made an impact.

[00:26:07] Andjela Drincic: But recurrent hypoglycemia particularly is a problem because it is a measure of inertia, right? So you wanna fix hypoglycemia. Great. Up to first figure out, what is the contributing factor to your hypoglycemia issue in a hospital and causes of hypoglycemia in any system are multifactorial.

[00:26:33] Andjela Drincic: It can be basal insulin, it can be prandial insulin or correction. It can be specialized nutrition, it can be insulin drip. Patients with insulin pumps have a lot of hypoglycemia. Treatment of hyperkalemia can end up in a hypoglycemia. Depending on a cause, the initiatives are multifactorial. So there are really two ways to look at a problem.

[00:27:01] Andjela Drincic: Actually. There are many ways to look a problem, but one way for us to look at a hypoglycemia was the highest yield, looking for that, you know, major cause of hypoglycemia. So when we analyzed and looked through all the contributing factors. It turns out that two thirds of our hypoglycemic events were caused by basal in prandial insulin administration.

[00:27:30] Andjela Drincic: That's to be expected because that's what most of our patients are getting, right. There is also a sizable chunk that are caused by specialized nutrition treatment and also, hyperkalemia treatment was quite a bit. As a matter of fact, when one looks at the same data in the other way, it turns out that each time we had a patient with hyperkalemia that was getting treatment for that, that involved insulin in dextrous, we are causing hypoglycemia in about 30% of cases.

[00:28:07] Andjela Drincic: So is that perhaps a potential quick win? So how do we go about it? How can you achieve success in tackling major projects? Well, you wanna really leverage healthcare delivery assistance enhancements. So you want to utilize the EMR capabilities, develop discipline specific workflows. Yes, educate. It still has a role.

[00:28:38] Andjela Drincic: and enhanced communication between the three key stakeholders, provider, pharmacist, and a nurse. So with that in mind, what are these combinations that we are currently doing? You know, tackling prandial insulin related hypoglycemia, we are looking at to how do we treat, meal related glucose increases  insulin used insulin carb issues. Does that need to be changed?

[00:29:15] Andjela Drincic: What is the dose guidance? Do we need a decision tree on insulin in the medical, administration record. For basal insulin? Are we applying the weight-based dosing algorithms? Is there a role for eGMS? So, I'll, I'll give you details about some of these, but you really wanna have, again, initiatives need to really tie together these multi multifaceted approaches to, glycemic treatment.

[00:29:49] Andjela Drincic: So, let's see. How did we do with our basal bolus initiatives? Suddenly, many years ago when we realized that patients need insulin in a hospital, they should be on basal bulls treatment. You know, most of us just said, Okay, here is your basal bolus disorder set version one that says, Stop oral medicine, start basal bolus, but without really any instructions.

[00:30:12] Andjela Drincic: And that works, but really doesn't work all that well. So as listed here, you can see if you have a decision support system tied to your order. That's better than, it's if its not tied, but you have to have a well integrated protocol. Your success rate will be much higher if you enhanced your protocol. The success rate will be 90%.

[00:30:39] Andjela Drincic: So this is what we are trying to do through about 5 million versions of our basal bolus protocol. And our current version that we are very quite happy about,  gives a ordering physician a clear guidance for the starting dose of basal insulin based on patient characteristics. We provide insulin advice, but we don't have a calculator yet integrated, so a provider needs to do the math.

[00:31:09] Andjela Drincic: We also remind people to decrease basal insulin for 20%. For patients where this may be needed, especially for over basal patients, we have developed something very similar for prandial insulin. Most of our patients use insulin carb ratio, and for that we don't assume that a provider will know what insulin carb ratio to start with, so we give them guidance.

[00:31:37] Andjela Drincic: How to choose a starting insulin carb ratio, depending on a total insulin daily requirement. We have a very similar approach for a correction scale. We guide people what level of correction to utilize, depending on a total daily insulin requirement. In addition, since we are, allowing patients to eat whatever they want and whenever they want, and you know, we are giving insulin based on their carbohydrate content.

[00:32:15] Andjela Drincic: We have actually developed a tool to help nurses, know. How to basically assess the carbohydrate content, not only, not for the whole meal, but rather for specific items on the meal so that they can then look and see what patient has eaten, determine how many carbs it is, and administer insulin appropriately.

[00:32:40] Andjela Drincic: Timing of the insulin has always been an issue. So we have developed a decision support system that will guide nurses when they're trying to decide when to give insulin, depending if the patient is NPO, skipping a meal, what to do with a patient who's planning to eat within an hour.  What are you gonna do with a patient who is planning to eat in more than one?

[00:33:06] Andjela Drincic: So that is just a guiding system. But, but really with all of this in place, the ongoing challenges are just really endless. So our institution you know, has been traditionally allowing meals on demand and, much of that is related to patient satisfaction. However, the timing of the blood sugar check.

[00:33:34] Andjela Drincic: Meal and insulin administration is always completely off. Patients can eat unlimited carbs. Nursing, when they're charting and doing their calculation for the insulin, they can really actually have unlimited carbs that can plug in the formula, right? We have manual data entry for the carbs. That’s always a source of a potential problem.

[00:34:02] Andjela Drincic: You need a lot of math to calculate insulin carb, uh, ratio, total amount of insulin, add a correction. You know, each time you have to do a math. That introduces a lot of problems, patients can stag their meals all they want, which may lead to insulin snacking. In addition to meal stacking, there is meal sneaking.

[00:34:27] Andjela Drincic: Do you know what the family just brought for the patient to eat and did they call the nurse? And finally, I have to say, you know, our insulin carb strategy. Beautifully until Covid and specifically until we were faced with nursing shortages and we ended up having a lot of traveling nurses, you know, Nebraska, we are a small state and, um, you know, it, it's definitely Nebraskan nice, people know each other.

[00:35:00] Andjela Drincic: You can educate, you can, there is this personal accountability. And when you have stability, this all works well. But once traveling nurses came and we had very little time to onboard them and to educate them, and most of them have never used insulin carb concept to treat anybody. This became a huge challenge.

[00:35:21] Andjela Drincic: This is leading a story, consider Meals on Demand. This is letting us reconsider should we really allow people to eat as many carbs as they want whenever they want. Maybe we should actually, we do have plan for consistent carb diet dishes that we traditionally don't use it, but maybe we should. Let's be innovative with a carb calculator and really explore options and advantages that eGMS may bring, to this problem.

[00:35:51] Andjela Drincic: I wanna show you another example for an enhanced protocol for NPO. It used to be when a physician would write the NPO order. You have to really. Remind yourself and remember whether the patient is seeking insulin or not, and whether you will do something about it. Well, now we do have basically, the system recognizes the minute you put an NPO order, the system recognizes the patient is taking insulin.

[00:36:18] Andjela Drincic: It kinda gives you the insulin dose, and it reminds providers to make adjustments to the dose. The next system enhancement that we have adopted. When we are reviewing blood sugars in a pretty standardized, way, the way Epic allows, which is what we have, we also have embedded information that will help the team make better decisions.

[00:36:43] Andjela Drincic: For instance, we remind people. What are they eating? How many carbs have they had? Are they on a tube feed formula? What is that? If they're on a tube feeds, um, what medications are they on? What is their GFR? Are they on steroids? Are they on medications that will impact sugars? What is their recent AIC?

[00:37:06] Andjela Drincic: So you have can have some sort of a sense as to who that patient is and then actually using electronic health record, decision making, support systems, is very, very important. And, Kristi Klos actually recently had a very nice review that is listed here for you on that subject. The next was our TPN project.

[00:37:34] Andjela Drincic: We had a lot of hypoglycemia with a significant amount for patients who were on TPN. This was at a time when we were not  allowing insulin to be administered within a TPN bag. So we have actually reevaluated that and whether this is a good strategy or not. And we have actually devised a very safe process for safe use of insulin in a TPN bag.

[00:38:10] Andjela Drincic: And the process, really involves restriction to diabetes service. An obligatory concept of pharmacy team. We have specific guidance on the choice of the insulin dose and the adjustment. And we also have clearly set criteria who is that appropriate patient where insulin can be safely used in a TPN bag and we have clear criteria.

[00:38:36] Andjela Drincic: That basically are outlining the need for stability of their renal function, stability of their clinical situation. You know, if somebody is septic and oppressors, that is really not a good idea and that they will be on TPN long term. And with that, our hypoglycemic events related to TPN have dramatically improved.

[00:39:03] Andjela Drincic: But here I really wanna share a recent success story that has brought me quite a bit of joy. And that is almost eliminating hypoglycemia related to treatment of hyperkalemia. So basically, as I mentioned earlier, it turns out that we had up to 10% of all hyperglycemic episodes were related to hyperkalemia treatment.

[00:39:29] Andjela Drincic: And as a matter of fact, 30% of time when we were treating hyperkalemia, we were causing low blood sugar. So we looked at it in 2020. And we decided the problem is that everybody was getting the fixed dose, regular insulin for hyperkalemia treatment. So we said, Okay, the literature says it should be weight based dosing, so let's do it.

[00:39:52] Andjela Drincic: And we did it. And as Dr. Mesler said, Don't ever assume that intervention worked. I mean, you have to remeasure to know whether something was successful. So we remeasured our hypoglycemia events and turns out they were pretty significant. So we went back to square one and  looked at the literature and decided the following.

[00:40:16] Andjela Drincic: We will have a clear process that we will check the sugar before treatment was given. We will remind people to follow hypoglycemia protocol and don't give insulin to those folks with a mild elevation of potassium, but also low blood sugar at a time. We will give them the weight-based insulin dose, but also this will be followed by not only dextrose bolus as it's a standard of care, but on top of that dextrose infusion for five hours.

[00:40:51] Andjela Drincic: And also we will have a point of care glucose monitoring hourly for five hours. You know, it's a renal failure patient. Their GFR is bad. Insulin hangs out for a long time. Turns out, that we went from having 40 events of hypoglycemia month, month to one last month. So if we can sustain that, it's truly an amazing story of QI success, turning a major project into a quick win.

[00:41:27] Andjela Drincic: For every success story, I have even a longer story where, you know, it didn't quite work well and we still struggle with prevention of hypoglycemia for those patients receiving insulin nutrition. And we've tried all kinds of stuff. We've tried, well call the MD. Well of course that's not gonna work. We've tried coming up with a laminate instruction sheet that was placed over the tube feed machine

[00:41:57] Andjela Drincic: You know where the off button is. You cannot stop the tube feeds without reading this instruction sheet. That helped, but not quite. We have integrated with our allied help professionals, so the registered dietician now actually has a precheck detail order and is actively involved in making sure that the dextrose is started if the tube feeds are stopped.

[00:42:26] Andjela Drincic: With all of that many times you have all of that and still the dextrous hasn't started. So we are, you know, still at it, working at it. And um, uh, now we are working now on a personal communication trying to understand why is the dextrose has not started, even though it's ordered.

[00:42:45] Andjela Drincic: So more to come. But this brings me to a very important concept of ACT surveillance, right? That means that you will have a system that will identify a problem and intervene in real time. And our active surveillance is  part of the Diabetes Stewardship Pharmacy Program. So we have a pharmacist that actually is in charge of this and this pharmacist stewardship is modeled after the anticoagulation and antimicrobial stewardship.

[00:43:22] Andjela Drincic: And we have a pharmacist that basically has a daily list of all the patients with diabetes on insulin that displays the average blood sugar, the displays, any event of hypoglycemia, whether they had hypoglycemia past 48 hours. Whether they have gotten a reversal agent, whether they're NPO, what is their A1C?

[00:43:53] Andjela Drincic: And we also have not quite validated, an effective tool to assign people's scores based on their hypoglycemia risk. So the score three would populate this patient very high on a pharmacist’s list. And they will be able to look at the patient, put an extra attention to prevent low. If there is a low, they will be able, They, they actually put a note in a chart with recommendation for the insulin therapy treatment plan change.

[00:44:28] Andjela Drincic: On top of that, they call the pharmacist that is on the team and give them a verbal recommendation. And with all of that, we have achieved a remarkable decrease in our hypoglycemia events. We are hoping to implement something else, which is Glucose Telemetry, which is a work from, um, Dr. Spinakis and many others.

[00:44:59] Andjela Drincic: And tackling hyperglycemia really is based on same principles, you know  that I have described for hypoglycemia of active surveillance of the checklist for the team based pharmacist of adopting weight-based insulin dosing, steroid dosing protocols, working on insulin timing, considering eGMS systems.

[00:45:27] Andjela Drincic: And the work never ends, but it is the team effort. That I'm so thankful for that has helped us achieve some remarkable success and a status of a top performer in the society hospital medicine database, and has, uh, brought us many accolades. And CDC was knocking on our door to basically join them in the efforts for hypoglycemia reporting.

[00:45:59] Andjela Drincic: So I am, I'm proud of work that we've done, but, uh, more to come. So thank you for your attention. And now I'm gonna hand it over to Dr. Messler to close off this presentation. 

[00:46:11] Jordan Messler: Thanks, Dr. Drincic for that masterclass in glycemic improvement strategies, really showing how in the real world at your health system, taking these quality improvement principles and applying them, to practice really the incredible amount of multiple initiatives, varied innovations, steps to prioritize using metrics in real time.

[00:46:31] Jordan Messler: Just really exciting work. How to take those principles, apply them for real change. So the key takeaways, I hope you got from this talk, just the basics from my talk going through that, the importance of having a framework, the importance of metrics when you're implementing solutions, making sure that they're high reliability strategies in place to get those sustained results that you want.

[00:46:51] Jordan Messler: And then I think from, again, this masterclass from Dr. Drincic on a variety of strategies and seeing how to apply those QI tools in the real world, having a structured approach, having innovative and varied solutions that are needed, having a champion,having the necessity for ongoing improvement and there's always opportunities to improve.

[00:47:10] Jordan Messler: And then lastly, I wanted to highlight from Glytec here, ways that we think about harnessing technology to drive. And then leave you with that last point. Got a lot of tools. Go out and use them, and I hope you get the success that you want at your institution. Thank you very much for, uh, for listening to this session, we appreciate your time.

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