Thank You! | Reducing Hospital Harm: The Pharmacists’ Perspective

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Reducing Hospital Harm: The Pharmacists' Perspective

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Reducing Hospital Harm: The Pharmacists' Perspective

Stephanie Ostling Mason, PharmD, CDCES | Glytec

Jennifer N. Clements PharmD, FCCP, FADCES, BCPS, CDCES, BCACP, BC-ADM | University of South Carolina
College of Pharmacy

Marina Rabinovich, PharmD, BCPS, FCCM | Grady Health System

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[00:00:00] Stephanie Mason: Hello and welcome. My name is Stephanie Mason, and I'm so glad you're joining us today for the presentation on uniting pharmacists around a culture of safety. Now, while I'll primarily be speaking from a pharmacist lens, the strategies that I share, and my colleagues share are absolutely applicable to our nurses, providers, and other members of the healthcare team.

[00:00:28] Stephanie Mason: So even if you are not a pharmacist, I would encourage you to tune in. Before I jump into it today, I want to take a moment to introduce myself and my colleagues. Like I said, my name is Stephanie Mason. I am a pharmacist and certified diabetes care and education specialist, and I currently serve as the Diabetes Clinical Pharmacist with Glytec.

[00:00:48] Stephanie Mason: Prior to joining the Glytec team, I was the inpatient diabetes program manager for a large health system in North Carolina. Where I oversaw the care provided to patients with diabetes and hyperglycemia from hospital admission to hospital discharge.

[00:01:06] Stephanie Mason: Now I'm joined today by my colleague Jennifer Clements. She is also a pharmacist and clinical professor and currently serves as the Director of Pharmacy Education at the University of South Carolina College of Pharmacy. And my other colleague, Marina Rabinovich, she is a Critical Care Clinical Pharmacy Specialist and also serves as the PGY1 Pharmacy Residency Program Director at Grady Health System.

[00:01:29] Stephanie Mason: Now, the three of us certainly understand the importance of improving inpatient glycemic management, as well as the challenges our hospitals and health systems often face to achieving that. And so today, we are going to review the people, processes and technology needed to improve inpatient glycemic management with a focus on how pharmacists can really improve the safe and effective use of insulin in the hospital.

[00:02:01] Stephanie Mason: This is what we are going to cover today. I'm going to kick things off just by highlighting the impact diabetes has on our hospitals and our health systems. I'll then pivot to really talking more about the pharmacist's role in improving insulin use in the hospital. I'll introduce the three main challenges hospitals often face to improving how insulin is used in the hospital, and then we'll wrap up by focusing on the three key strategies that you can take back to your hospitals to really improve the safe and effective use of insulin in the hospital. As I said, I want to kick things off by touching on the impact diabetes has in our hospitals and our health systems, and really this is not new information. I'm sure all of you are very familiar with the numbers and the statistics that you see on this slide.

[00:02:51] Stephanie Mason: My reason for sharing it here is to remind us why it is so important that we continue to focus on efforts that improve the care we provide to our patients with diabetes and hyperglycemia. We all know the number of individuals in this country who are being diagnosed with diabetes and pre-diabetes is increasing.

[00:03:11] Stephanie Mason: And if those numbers are increasing, then we know that we can expect to see more of those patients in the hospital setting. And if we have more patients with diabetes, prediabetes and even hyperglycemia in the hospital, then we can reasonably assume that insulin use is also increasing, especially because the American Diabetes Association continues to recommend insulin as the primary treatment of hyperglycemia in the hospital. And so, our hospitals and our health systems need to continue to put measures in place that really ensure insulin is used adequately and appropriately in the hospital. And this is really where we see a huge opportunity for pharmacists, the medication experts, to get involved in that dialogue around improving inpatient glycemic management by really focusing on how pharmacists can improve the safe and effective use of insulin in the hospital.

[00:04:09] Stephanie Mason: And so why is focusing on insulin management important? Well, as, I just shared, we can anticipate that the use of insulin in the hospital is likely going to increase, and we all know that insulin is a high alert medication. And historically, insulin has resulted in the highest number of ADEs of all high alert medications.

[00:04:30] Stephanie Mason: And as you can see here, there's really a historical precedence. And so this really tells us why focusing on improving how we use insulin in the hospital is a key strategy to improving overall inpatient glycemic management. Now if we take a look at insulin use in the hospital from the pharmacists’ perspective, I want to highlight a couple things that came out of an ISMP survey from a few years ago.

[00:04:59] Stephanie Mason: ISMP surveyed pharmacists on 40 high alert medications, and one of the things they asked pharmacists to do was to rank those 40 high alert medications based on their level of concern to cause patient harm. Now, IV insulin was ranked number one for greatest concern, and subcutaneous insulin was ranked number nine.

[00:05:22] Stephanie Mason: And so what this tells us is that our hospital pharmacists have a high level of concern about the potential to cause harm from the use of IV insulin and SubQ insulin in the hospital setting. Particularly, of course, if it is not used appropriately. Now one of the other questions the ISMP survey asked the pharmacists to do was to rank those same 40 high alert medications based on their level of confidence and the measures their hospital had put into place to minimize patient harm.

[00:05:54] Stephanie Mason: And SubQ insulin came in dead last, meaning our hospital pharmacists are concerned about the measures their hospitals have in place to try and minimize that risk of harm to the patient. From the inappropriate use of SubQ insulin in this case in particular. Now we know that insulin related errors can occur in a number of ways.

[00:06:16] Stephanie Mason: It can be related to prescribing, administration, it could be a dispensing error, it could even occur at that time the patient is being educated about their insulin regimen. And so really what I want you to take away from this is that our hospital pharmacists are very much aware of insulin use in the hospital and the need for better and more effective measures in place to ensure that it is used adequately and appropriately, so that we are always delivering safe care to our patients. And so what are some of those challenges that our hospitals face to really improving how insulin is used in the hospital? Well, in my experience, I see consistently three key obstacles. The first is a lack of knowledge or familiarity with basic diabetes or insulin management principles.

[00:07:09] Stephanie Mason: And this is not just the pharmacist that we see this in. This is also applicable to our nurses, to our providers, residents, and other members of the healthcare team. And to help illustrate what I mean by this, I thought I would use an example that I frequently saw in my previous role as diabetes program manager.

[00:07:27] Stephanie Mason: So let's say you have a patient with type one diabetes who presents to the hospital and she's wearing an insulin pump. She's coming in for IV antibiotics, for an infection. And so she plans on eating during her hospitalization. Now, when she comes into the hospital, The provider deems her unable to safely self-manage her insulin pump at that time and ask the patient to remove her insulin pump.

[00:07:52] Stephanie Mason: The patient removes her insulin pump and the provider places new orders for SubQ insulin, but the provider only orders correction insulin. Several hours later, that patient is now severely hyperglycemic, borderline DKA, or maybe even in DKA. And now we have to provide additional care that she would've otherwise not had to receive.

[00:08:15] Stephanie Mason: And I saw this type of scenario several times in my previous role, and I think what it really highlights is this knowledge gap around how we manage patients with type one diabetes and how we manage patients with type two diabetes and the differences in their insulin needs. Another example is a nurse that withholds correctional insulin at meal time because the patient says he's not hungry and doesn't wanna eat, even though the patient's blood glucose is above the target range, and correction insulin is warrant.

[00:08:47] Stephanie Mason: In this scenario, it really highlights that lack of understanding of the differences between correction insulin and meal time insulin, and I'm sure you can think of other examples as well, but these knowledge gaps that we see in our team members and pharmacists included. They create inconsistencies in the care that we provide and oftentimes can compromise patient care as well.

[00:09:11] Stephanie Mason: Now the second obstacle that I want to highlight is a lack of standardization. And an example of this is, let's say you have a hospital that really does not have a uniform standardized approach to how they initiate SubQ insulin or how they manage hyperglycemia in the hospital. So, you might have a group of providers using sliding scale insulin.

[00:09:33] Stephanie Mason: You have another group of providers who are using. Basal insulin with sliding scale insulin, even in patients who are eating. And then you may have a group of providers who use basal bolus insulin, and so you have these, again, inconsistencies in the care that is being provided. Another example may be a hospital that does not have standardized order sets to initiate IV insulin, the transition from IV to SubQ insulin or SubQ insulin.

[00:10:02] Stephanie Mason: Now the last obstacle that I want to highlight is a lack of tools or technology that could really make how you use insulin in the hospital safer and more effective. So, let's say there's a hospital that requires nurses to perform a manual calculation to determine the dose of correction insulin that a patient needs.

[00:10:21] Stephanie Mason: Well, anytime we, we require a manual calculation to be done, we know there are always risks of error here. Or you may have a hospital that uses an IV insulin dosing protocol that treats every patient who comes in with the same blood glucose, the exact same, without accounting for differences in insulin sensitivity.

[00:10:41] Stephanie Mason: And so all three of these obstacles, the knowledge gap, the lack of standardization, and the lack of technology they can do compromise the care that we provide to our patients with diabetes and hyperglycemia. So how can we really overcome these obstacles? Well, we can overcome these obstacles by focusing on three key strategies that can significantly improve the safe and effective use of insulin in the hospital.

[00:11:09] Stephanie Mason: And those strategies are people, processes, and technology. And so what does this really look like? Well, people, processes in technology, these strategies really align well with the three obstacles that I just talked about a minute ago. For example, how can we address that knowledge gap that we see among our healthcare team?

[00:11:34] Stephanie Mason: Well, we can address that by improving our people. And when we're talking about our pharmacists, it's equipping our pharmacists with the confidence and the competence that they require to be active players of the healthcare team, caring for our patients with diabetes and hyperglycemia in the hospital.

[00:11:51] Stephanie Mason: And I'm gonna dive into this a whole lot more in just a few minutes. Now that second obstacle that we talked about was a lack of standardization. So how can we improve the standardization at our hospital or our health system? Well, we can do that by improving our processes and for pharmacy, it may look like drawing up basal insulin in the central pharmacy instead of on the units. Or it may be creating a process where your pharmacists are reviewing the insulin regimen for any patient with a hypoglycemic event and making a recommendation to the provider on how that insulin regimen should be changed to avoid future hypoglycemic events.

[00:12:35] Stephanie Mason: And there are several other processes that you can really focus on here, and Jennifer is going to talk a whole lot more about that and her presentation later on. And then that last obstacle that I talked about was a lack of technology to improve how we use insulin in the hospital. And so how do you address that?

[00:12:55] Stephanie Mason:  Well, by deploying technologies that can do just that, improve insulin use in the hospital. So in the example I used earlier, instead of making a nurse do a manual calculation for that correction insulin dose, maybe you deploy an IV insulin dosing support software that takes into account patient sensitivities and other factors. And so Marina is gonna talk a whole lot more about technology in her presentation later on.

[00:13:17] Stephanie Mason: So now let's focus a lot more on talking about people now when it comes to, pharmacy and how can we really equip our pharmacists with that competence and that confidence. You could take many different approaches to that.

[00:13:41] Stephanie Mason: In my experience, talking with clients as well as talking with some of my colleagues. I see again and again that a lot of hospitals do not have an onboarding process in place to bring on new pharmacists and really give them the knowledge and skills that they need around inpatient diabetes management and insulin management.

[00:14:03] Stephanie Mason: And so I thought it would be beneficial today to really focus on that onboarding process in how we can improve our people and really bridge that knowledge gap that we may be seeing. When we think about how can we, how can we take that next step to really improving our pharmacists and equipping them again with that confidence and competence.

[00:14:26] Stephanie Mason: It's important to look at what you are doing right now. So I want you to think about your onboarding process today, whatever that looks like, how formalized or not formalized it is. I want you to really think about these questions: What are the expectations of your pharmacist today around inpatient glycemic management and insulin management? Who is communicating those expectations to your pharmacists, and how are those pharmacists held accountable for those expectations? What are the training resources and education that are being provided to new pharmacists as part of that onboardinf process. Who makes those things available? How are those things provided to your pharmacists?

[00:15:15] Stephanie Mason: And finally, what is the process for training and assessing new pharmacist knowledge and skills around inpatient diabetes management and insulin management? Who is responsible for that training? How are the pharmacists being assessed? So these are just some of those core questions that I really want you to ask yourself so that you get a better sense of what are you doing right now today? Because once you know what your current state is, then you can build an action plan on where you want to go tomorrow and in the future. So to help put all of this into some context and give you an example of what this could look like, I'm going to share the process that I went through of revamping the onboarding process for our new pharmacists in my previous role as diabetes program manager.

[00:16:06] Stephanie Mason: And so to give you a little bit of background on our organization and expectations of our pharmacist, we had a decentralized pharmacist model with pharmacists on most of our inpatient units. Those pharmacists would also rotate through the central pharmacy, and of course, we had a dedicated central pharmacy staff as well.

[00:16:26] Stephanie Mason: We did have an IV insulin dosing protocol, or I'm sorry, an IV insulin dosing support software. That managed our IV insulin infusions, and then we had a standard weight-based dosing protocol to guide our providers on initiating SubQ insulin. And there was also some guidance in there on how to adjust insulin regimens based on the patient's blood glucose.

[00:16:51] Stephanie Mason: Now, when I came on board, we really had a mixed bag as far as level of comfort across our pharmacy team in being active players with insulin management, our very seasoned pharmacists were quite comfortable with making recommendations for SubQ insulin. Our critical care pharmacists were very well versed in the IV insulin dosing support software and could field a lot of questions from nurses.

[00:17:17] Stephanie Mason: But we certainly had a group of pharmacists who are not at all comfortable with how to address questions related to SubQ insulin or more complex cases for patients who are on an IV insulin infusion. And so we very much had a mixed bag there. Now it was expected that pharmacists verified the insulin orders, which they did, but it was also expected that our pharmacists would review the insulin regimen for any patient with a hypoglycemic event or a blood glucose less than a hundred milligrams per deciliter, and make a recommendation to the provider on how that regimen should be adjusted in order to prevent any future hypoglycemia.

[00:17:59] Stephanie Mason: Our pharmacist would also get asked questions on insulin regimen recommendations as well in the context of steroids and at the time of discharge. And so we had pharmacists very, very active, as far as glycemic management and insulin management. But again, the level of confidence there was not standard I would say for all of our pharmacists.

[00:18:22] Stephanie Mason: And so when I came on board, we did not have a formal onboarding process at that time. I wanted to make sure that any new pharmacist that came into our organization was getting that same foundational knowledge and skills required to meet those expectations that we had for them at the organization.

[00:18:47] Stephanie Mason: And so the first thing that I did, I created a training guide, and that training guide was really adapted from the resources I used to educate our residents and our providers. Now, that training guide highlighted a few things. It had, questions related to just basic inpatient diabetes management. It had questions specific to insulin management, and then there were also questions tailored to how we manage diabetes and hyperglycemia at our hospital.

[00:19:17] Stephanie Mason: And there were questions about our insulin dosing protocols and things like that. The training guide was a mix of true, false, multiple choice, short answer, and case-based questions. Now, once I had created that training guide, I ran it by some of our seasoned pharmacists who provided feedback, and made sure that I was capturing all the, the problem areas and the pain points.

[00:19:38] Stephanie Mason: Once I got that finalized, I worked with our pharmacy leadership to build in an hour of time with me, with all new pharmacists to our organization, and I would meet with a group of new pharmacists about every two to three months to review that training guide. I took that approach versus doing several one-off sessions because I needed it to be sustainable and scalable as I was the only one who was going to be delivering that onboarding education. Now, prior to the training session with me, I sent the training guide to the new pharmacists and asked them to complete it and bring it to our session.

[00:20:17] Stephanie Mason: When they came in for the, the training session, we would review the guide, I'd answer their questions. I would expand a little bit on those questions. I would expand on our internal policies and protocols related to inpatient diabetes management, and I would also review a short slide deck on our IV insulin dosing support software. So even if there was a pharmacist not on one of those units, if for some reason they got a question about it, they would have some sort of context around how to answer that question.

[00:20:47] Stephanie Mason: As far as expectations related to reporting insulin related safety events, as well as other safety events and the expectations around reviewing patient's insulin regimens, if the blood glucose was below a hundred, or the patient had a hypoglycemic event. Those expectations were delivered by one of our other pharmacy leaders.

[00:21:07] Stephanie Mason: And overall, this approach worked very well for us. It standardized how we’d onboard a new pharmacist, and our pharmacists felt a lot more comfortable entering into their role on the healthcare team caring for our patients with diabetes and hyperglycemic. Now because I know many of you listening in may not have a formal onboarding process and that you may be interested in some sort of a training guide to take back to your own institution, I created a training guide template that will be delivered to you via email as part of this conference, and I encourage you to take that back to your organization, see what you're doing today and use that training guide as a jumping off point to really educate your pharmacists. And if you already have a solid onboarding process in place, you may think about using that framework for continuing education or an annual assessment. And as you do that, I want you to think about three things.

[00:22:08] Stephanie Mason: The first is think about your problems and your pain points, and if you're not sure what those, look at some of the safety events and take a look from that pharmacists’ perspective. How are the pharmacists involved in insulin related safety events? Ask your seasoned pharmacists, I'm sure they hear a lot when they're training your new pharmacists, and you can even ask your new pharmacists directly, What are your burning questions when it comes to diabetes and insulin in the hospital?

[00:22:35] Stephanie Mason: The second thing to think about is how you can make your process sustainable and scalable. If you are a party of one, don't try to do everything one on one. See how you can group new pharmacists together and make that process much more sustainable for yourself. And the last thing to think about is how you will measure your success.

[00:22:57] Stephanie Mason: And I know that may be a little difficult to do with education, but the way that I would go back to those seasoned pharmacists and ask them, are you seeing these problems and pain points as much as you were before? I would always review insulin related safety events. Am I seeing less of some of these things?

[00:23:15] Stephanie Mason: So, use whatever data that you have on hand to really measure your success with that. But that wraps up my portion here for today, and now I'd like to introduce Jennifer, who's going to talk more about the processes needed to create a culture of safety.

[00:23:31] Jennifer Clements: Thank you Stephanie for that introduction to this presentation.

[00:23:35] Jennifer Clements: I'm pleased to be here today to talk about the process, and my name is Jennifer Clements. Currently I'm clinical professor and director of pharmacy education with the University of South Carolina College of Pharmacy. But prior to this position, I practiced at Spartanburg Regional Healthcare System doing inpatient diabetes management, as well as transition of care.

[00:23:58] Jennifer Clements: When thinking about process from a pharmacists’ perspective, of course we are going to focus on medications. And on this slide, you see the steps in order for the medication use process. We are all familiar with these steps, knowing that the roles and responsibilities of the healthcare professional will vary depending on what step we are addressing, but no matter what, we begin with the patient, and we end with the patient. Meaning that we need to evaluate the individual and assess them in order to choose the right medication all the way to the end in reassessing the individual to know how they are responding to the medication, and therefore documenting any abnormalities or normal values with laboratory parameters. Now, using a specific example, but also kind of general, we know that if there's gaps in this process, then it can lead to adverse events.

[00:24:58] Jennifer Clements: So, imagine there is a patient on U 500 90 units subcutaneously three times a day. If there isn't a process in place at the hospital or healthcare system, then ultimately this could lead to adverse glycemic events and emergencies. Particularly if providers are not familiar with U 500, it isn't on formulary, There isn't a policy or protocol set in place.

[00:25:26] Jennifer Clements: Especially if the individual is started on a suboptimal insulin regimen, like insulin glargine 20 units given what they take at home. Now, this is just a general example, before now we move on to something more specific. So, as I go over this case, just think about where there could be some gaps in the process.

[00:25:49] Jennifer Clements: Imagine we have a 55-year-old male who's admitted to the general medicine floor due to acute pancreatitis. A brief medication history was completed when the patient was in extreme pain. At admission, insulin glargine was started at 20 units subcutaneously in the morning with an insulin list pro correctional scale given four times a day.

[00:26:13] Jennifer Clements: Now these orders were entered as separate entries and not through an order set. On day one, his dietary intake was NPO as far as the status, and on day two, the glucose level was 75 milligrams per deciliter at 7:31 in the morning in which the nurse held the morning dose of insulin glargine. Hopefully, from reading that specific case, you identified that there could be a lack of a process or maybe a process in place that wasn't necessarily followed.

[00:26:48] Jennifer Clements: Starting with first the brief medication history. Second, ensuring that the insulin regimen should be optimal. Perhaps he was taking insulin at home, and we need to make sure we're close to that prior to admission dosing. Insulin was put in as separate orders rather than through an order set, which an order set may have additional orders for monitoring and reassessing, particularly with point of care glucose monitor.

[00:27:18] Jennifer Clements: And then lastly, the understanding of insulin in which the glargine was held due to the potential or maybe the concern of hypoglycemia later. Now moving on with this same case. On day three, there was clinical improvement in nutritional orders adjusted to consistent carbohydrate dietary order. A glucose level was 268 milligrams per deciliter at three 3:30 in the afternoon in which he got a large amount of insulin lispro, but the tray was delivered at 6:01 in the evening in which the person was found unresponsive with a blood glucose, a 58 milligrams per deciliter.

[00:27:59] Jennifer Clements: The nurse provided rescue medication as an override from the Omnicell, but there were no additional triggers in the electronic medical record. Lastly, the patient was discharged on insulin in which he had no insurance. So again, hopefully from reading this specific case, you identified that there's some areas of improvement potentially with the delayed meal tray, and also aligning the bolus insulin when once the tray is delivered.

[00:28:29] Jennifer Clements: Lastly, the initiation of the hypoglycemia policy. So that triggers can be fired within the EMR. And making sure there's appropriate discharge instructions, that it's person-centered treatment plan put into place to ensure adherence and good transition back to the outpatient setting. So, moving past the specific case, we want to look at why do adverse glycemic events occur in the first place.

[00:29:03] Jennifer Clements: And the Institute of Safe Medication Practices has really provided great evidence in looking at certain events, and these are considerations and factors that may lead to those adverse glycemic events. Probably the most common reason is the omission or delayed initiation of a protocol. Specifically related to hypoglycemia or hyperglycemia.

[00:29:27] Jennifer Clements: Some hospitals may have a hypoglycemia protocol in place and follow other protocols with DKA or HHNS management, but do you have a standard hyperglycemia protocol that can be followed by providers and medical teams? When looking at medication administration, there can be several issues to come up. Maybe the administration of a specific drug if it's too quick.

[00:29:54] Jennifer Clements: But also, we know with insulin there can be errors, with that high risk medication, such as look alike, sound alike. Therefore, certain things need to be put into place, so we know exactly which insulin we are ordering. There also could be mix up with giving the wrong dose and the wrong insulin for the purpose such as mixing basal or bolus for when it should be given.

[00:30:19] Jennifer Clements: As noted in our specific example, there can be misalignment of insulin with dietary status and intake, always needing to reassess, to make sure we have the right amount of insulin or make any adjustments with the insulin regimen. And then the last two, there could be the lack of an order or no fire task in the EMR for reassessing glucose levels.

[00:30:47] Jennifer Clements: Throughout the day, or even in response to hyperglycemia or hypoglycemia, if it was treated, and then also at the time of admission, the lack or an incomplete medication history, which is going to be so important to do. Now, shifting gears, we're talking about general concepts on this slide for what hospitals and healthcare systems can do to improve their processes as a whole.

[00:31:14] Jennifer Clements: Do really reflect where you are and know do we have all the policies and protocols in place? Is there anything that's missing in which we need to develop? But also, how often are we reviewing these policies and protocols to reflect best practices and evidence-based guidelines? Second, how can we ensure rescue agents are easily accessible, but also given in a timely manner for when it's needed, whether it's hyperglycemia or hypoglycemia.

[00:31:38] Jennifer Clements: In terms of the formulary, streamlining insulin products will be key as well as assessing which ones are available as vials in your hospital or system as well as pens. But with that in the pharmacy, they should be stored in certain areas with the tall men lettering, any other warnings to ensure that the right medication will be dispensed.

[00:32:14] Jennifer Clements: But the same needs to be done for when the provider is ordering that product to the nurse as well, who will be administering the insulin to the patient. At the time of hospital admission, there can be other things to evaluate to improve the processes that you may already have in place. What will be a multidisciplinary approach, depending on where you work, is to have a timely and thorough medication history and reconciliation.

[00:32:47] Jennifer Clements: In which all parties should be contacted if the patient is unable to provide a history on what they were doing at home. And what I mean by that is contacting caregivers, parents, or even the pharmacy where they're getting their medications dispensed. At the time of admission it's important to use maybe certain risk scoring to assess hypoglycemia concerns during an omission.

[00:33:13] Jennifer Clements: In which insulin adjustments may need to be adjusted to be a little bit lower than what they were taking at home if there's concern, but also initiation of the hypoglycemia protocol so that we're able to monitor glucose levels throughout the day and treat if needed. There should be glucose surveillance put in place to address hyperglycemia as individuals may need their insulin regimens adjusted. They also may need rescue therapy if it's a critical lab value, and so that may lead to certain reports that are generated and are available in the EMR or through team rounding. And lastly, through these protocols, whether it's hyperglycemia or hypoglycemia, we definitely need to reassess the individual in front of us, so we know the regimen that's ordered.

[00:34:06] Jennifer Clements: Is appropriate or needs to be adjusted, but also we can treat when needed if those situations occur. Now during a hospitalization, there's several things to consider to improve the process, and I think our example, the specific scenario is one definitely where we in the hospital want to have that alignment of the meal trays with the bolus insulin, anywhere from a 15 to a 30 minute window.

[00:34:35] Jennifer Clements: In addition, the individual needs to be reassessed on their intake status as well as alerts to know that they're NPO, which leads us to hold the bolus insulin rather than the basal insulin. Of course, barcode scanning can help with any sort of process before the medication is given to the patient, and we definitely wanna do that before and not after the fact.

[00:35:00] Jennifer Clements: But lastly, does your hospital and healthcare system have any protocols and policies in place to communicate critical lab values that indicate hypoglycemia or hypoglycemia to the provider and medical team? And is that policy, is there any way it can be streamlined so that it's feasible for the nurse to do on top of what they're doing, as a whole taking care of multiple individuals?

[00:35:28] Jennifer Clements: And then prior to discharge, we want to ensure there is comprehensive medication management done for the patient's success at the time that they leave the hospital. Depending on where you work. Um, whether it's a hospital or a system, we wanna consult individuals or the team that are the specialists with diabetes care and education because it's so important.

[00:35:53] Jennifer Clements: It's a critical time when an individual is in the hospital to provide that education, but these specialists or teams can ensure. Care coordination with case management or outpatient endocrinology, outpatient diabetes management clinics. So the patient is set up for more success at the time that they leave.

[00:36:18] Jennifer Clements: So, with that, some specific examples, but also general concepts related back to the medication use process. Which again, we see the steps that are in place that may vary depending on your role in the hospital and healthcare system, but all of this is to encourage you to go back and think about how can we improve the processes here in where I work through strategic planning, whether that's a gap analysis, and then doing updates to order sets, policies, procedures.

[00:36:51] Jennifer Clements: Taking in input from multiple stakeholders and providing that education can all be part of the strategic planning to help reduce the risk and occurrence of adverse glycemic events and emergencies. I thank you for your time in listening to this part of the presentation, and I'm gonna turn it back over to Stephanie.

[00:37:13] Stephanie Mason: And now I'd like to introduce Marina, who will be talking more about the technology you can implement in your hospital to help create a culture of safety.

[00:37:24] Marina Rabinovich: Thank you, Stephanie, for the introduction and for the opportunity to participate in this discussion and share our experiences with using technology to optimize patient care.

[00:37:33] Marina Rabinovich: Um, as Stephanie mentioned, my name is Marina Rabinovich. I am a Critical Care Clinical Pharmacist at Grady Hospital in Atlanta, Georgia. And here to discuss some of our, um, implementation of technology at our institution. Before I share a story, I think it's important to remind you that while technology is great, it's just a tool, not a strategy, and that successful implementation and integration of these tools is necessary for optimal results.

[00:38:03] Marina Rabinovich:  A technology tool we're discussing today is eGlycemic Management Software, or eGMS, which is an EHR integrated cloud-based software solution that supports state and effective glycemic management and insulin dosing. Glytec’s eGMS is Glucommander, which is the only cloud-based FDA cleared software able to personalize IV and SubQ insulin dosing support patients with and without.

[00:38:31] Marina Rabinovich: There are many benefits of eGMS, which I'll talk about as I share our story and how we benefited from using this technology. At our institution, we utilize Glucommander to manage IV insulin with meal bolus as well as hypoglycemia treatment. We have both DKA and non DKA protocols to treat patients with and without diabetes.

[00:38:56] Marina Rabinovich: It all started for us, um, said several years. Through a quality improvement project, we identified that a large percentage of our ICU patients experienced at least one episode of hypoglycemia and many experienced multiple episodes including severe hypoglycemia while being managed with IV and SubQ insulin.

[00:39:18] Marina Rabinovich: At that time we started looking at ways we could minimize harm while harm optimizing patient care. And we had paper protocols in place, but they were not personalized based on each patient's situation and included arbitrary manual calculations that nurses had to do, but not based on patients, individuals changes in blood glucose.

[00:39:45] Marina Rabinovich: So, in 2016, we implemented phase one of Glucommander integration into our EHR system, which is Epic. We started in the ICUs only followed by an extension to intermediate care units two years later, based on our very successful implementation into in ICUs and most recently, we expanded to the OR, and PACUs and even our extremely busy emergency department.

[00:40:16] Marina Rabinovich: Our next phase is planned for this next year to expand glucometrics use to our OB units as well. Here's an example of what our paper-based protocol for non DKA insulin IV orders looked like, where nurses had to do calculations for the starting doses of insulin as well as titrations based on decrease or increase in blood glucose from previous value.

[00:40:42] Marina Rabinovich: So, they had to look into the patient's previous blood glucose readings and figure out what the next insulin rate should be which obviously allowed for potential errors to occur. Additionally, non DKA insulin orders didn't encourage for nursing staff to prevent or treat hypoglycemia and those orders had to be ordered separately by the provider.

[00:41:07] Marina Rabinovich: When we transitioned to Glucommander, our IT department was able to integrate it into our EHR which again is Epic, pretty seamlessly. We were able to consolidate and group all of our necessary orders and monitoring in one place and indicate the intensity with which insulin should titrated to reach ordered blood glucose goal based on patient status.

[00:41:31] Marina Rabinovich: For example, elderly patients or patients with renal disease are ordered less aggressive titrations,versus cardiac surgery patients. In addition, hypoglycemia management is included in these orders and is individualized by glucmetric software based on the degree of blood glucose decrease. Similarly, to our non DKA paper-based protocol, our DKA paper-based protocol lacked a personalized approach based on patient's individual response to insulin therapy and required complex and manual titrations with built in alerts and alarms for the nursing staff.

[00:42:07] Marina Rabinovich: And now our DKA Glucommander order set is in Epic including appropriate IV fluids, as well as individualized hypoglycemia management by Glucommander software. The next few slides will describe the nursing workflow and MAR documentation. Here's what the Glucommander insulin orders look like on the MAR for nursing documentation and handoff, where displays administration instruction to the nurse, as well as orders the blood glucose goal range and multiplier for that particular patient.

[00:42:40] Marina Rabinovich: There's also a button at the top that can take them straight to Glucommander tracking and other information, and also where they enter the patient's blood glucose readings. And here's the information that is available to the nurse with all of the previous Glucommander insulin titrations to get patient to go quickly and safely, as well as an alert and a reminder to obtain the next blood glucose at a specific time.

[00:43:08] Marina Rabinovich: Usually every hour, sometimes every two hours or more frequently if necessary, from the screen. All they have to do is click enter blood glucose and it'll take them to the screen where they can document patients reading. Blood glucose documentation for the nurses is also pretty straightforward.

[00:43:28] Marina Rabinovich: There's an interface with the lab to send over glucose results from glucometer. This interface will send the value after glucometer has been done. But if the nurse chooses to use another value or manual entry other than the one displaying in orange here on this slide from the glucometer, all they have to do is click added blood glucose button and they will be prompted to enter a manual entry of blood glucose for that patient.

[00:43:57] Marina Rabinovich: Based on the glucose entered, the new insulin fusion rate will display for the nurse to program into the pump. So, no calculations are looking at patient’s previous blood glucose is necessary. So no risk of making that error that way. Another great lab interface with Glucommander is the display of a patient's anion gap.

[00:44:19] Marina Rabinovich: If your patients anion gap is elevated, it will be displayed in red on the patient's detail screen. Once the anion gap is normal, um, in a normal range, which is defined by each facility, it will display green. Since for us, a common problem in the treatment of DKA patients was the inappropriate transition, or premature discontinuation of insulin, blood glucose has been brought into the glycemic target, but before the anion was normalized.

[00:44:51] Marina Rabinovich: Having this lab promptly displayed has been extremely beneficial and allows the nurse to ensure that therapy continued until appropriate. Heres what would happen if a nurse attempts to discontinue treatment or transition to SubQ insulin and the patient's anion gap is still elevated or has not been resolved. They will receive this warning at this point. They will have to decide if they would like to still discontinue therapy or continue on the Glucommander. Another built in safety feature of the Glucommander algorithm is the detection when blood glucose is dropping too rapidly. Here we have an example of a patient who presented to the emergency department with the blood of over 500.

[00:45:43] Marina Rabinovich: The patient was started on Glucommander with a multiplier of 0.03 to reach the ordered goal blood glucose. Notice the blood glucose drop, which is greater than a hundred milligrams per deciliter per hour. When this happens Glucommander prompts for more frequent glucose monitoring, which is called glucose velocity warning, and this allows for a quick fraction of the insulin dose without the rest of hypoglycemia.

[00:46:11] Marina Rabinovich: However the benefits of the safety feature and optimal glycemic outcomes is highly dependent on the timeliness of blood glucose checks. In this case study, the patient was a postoperative habit patient being transferred from the OR to the ICU with the last blood glucose before the transfer being 170.

[00:46:32] Marina Rabinovich: GlucoView alerted the nurse that the blood glucose was late on admission to the ICU and the next blood glucose dropped by almost a hundred milligrams per deciliter and almost resulted in an hypoglycemic episode. If there was not an alert built in or an alarm for the nurse to check that the glucose was late and to check the glucose as soon as possible, a patient would've had a significant event

[00:47:02] Marina Rabinovich: Here's another example of how technology and Glucommander integration into EHR can help optimize patients glycemic control. This is a monetary report we were able to build an EHR system that displays glycemic management, including blood glucose readings and any insulin administration based on the patient's blood glucose.

[00:47:27] Marina Rabinovich: Here you can see huge variability in patients blood glucose readings while they were managed with SubQ insulin and the seamless transition to insulin IV managed by Glucommander software with very quick control of blood glucose. This report is available to a provider for every patient at our institution Glucommander or not and is a great way to validate patients glycemic control with different strategies.

[00:47:55] Marina Rabinovich: When you implement Glucommander, you get more than just the software to support insulin therapy. For patients on Glucommander IV therapy, Glytec created an application called GlucoView that is similar to central monitoring system or site station. The snapshot from GlucoView includes a HIPAA compliant list of patients in the unit in real-time.

[00:48:16] Marina Rabinovich: Their are last glucose result insulin rate, and the timer that counts down an alert of when the next glucose check is due. GlucoView also provides real-time glucose surveillance that identifies patients in the hospital with blood glucose greater in 180 in the last 24 hours, who are not on insulin therapy and displays them on a dashboard so that unit leaders or glycemic champions can easily identify patients at risk that could benefit from insulin therapy.

[00:48:51] Marina Rabinovich: Here we have a picture of our displays in the units, including a 50-inch monitor display in our emergency department that's very visible from multiple places in the emergency department. Other benefits that come with implementing Glucommander software is the ability to do analytics and reporting to better monitor patients, our performance as a unit and identify patients at risk.

[00:49:16] Marina Rabinovich: This is an example of report I can run daily or weekly or monthly to analyze how we are doing with management and any missed opportunities for optimization of patient care. And these individualized reports can be displaced in each risk active unit to demonstrate how well the unit is performing as far as glycemic control and if there's opportunities to improve.

[00:49:41] Marina Rabinovich: One of our barriers with successful management of IV insulin therapy was, for us that nursing staff put it mostly as labor intensive and dangerous due to risk of hypoglycemia. So displaying these reports really changed the perception, that they had of IV insulin therapy and their impact on patient care when they could see the extremely low or non-existent rates of severe hypoglycemia and our patients managed with Glucommander.

[00:50:07] Marina Rabinovich: And lastly, another great feature of implementing eGlycemic Management Software such as Glucommander, is the wealth of online support and resources to help provide education and training to our frontline staff when it comes to glycemic management. And thank you for having me here today with you, and I'll pass things back to Stephanie.

[00:50:30] Stephanie Mason: Thank you for joining us for today's session. Remember, keep an eye on your inbox for that training guide and we hope to collaborate with you and your pharmacy team in the future to help you create a culture of safety.


MAR-0000948 Rev 1.0