Success Stories: Continuous Improvement Spotlight Sessions

TRANSCRIPT:

Sonia Cooper: I am very excited to be here today to share our story and our journey through glycemic management for our healthcare system, as well as some details from some of our unique individual sites. I am Sonya Cooper and I am currently the Chief Nursing Officer at Sentara Princess Anne Hospital. Part of the Sentara Healthcare system, which is present in Virginia and North Carolina.

As you can see, I started my journey as a student earning a bachelor's in psychology, but then transitioned to nursing, where I was able to really experience my passion for making a difference and for interacting and delivering care to humans. So one of the things that led me to want to really engage with our glycemic management of our patients was I have had the great opportunity of working with medical and surgical populations to critical care, to trauma.

When I was an ICU nurse, the complexity of the patient really stood out to me and what a difference the glycemic management can make in their outcomes, in decreasing their length of stay. But then it was also the awareness of recognizing that patients are experiencing a deficit and the knowledge and the education that they have and how to manage their own glucose, not only while they're in the hospital, but more importantly when they leave the hospital.

So I became a super user of Glucommander and as an ICU nurse, and then I evolved to join our hospital committees so that I could continue to share the benefits of what we recognize with our Glucommander product. So I am currently serving as a co-chair for Sentara Healthcare's Glycemic Management Committee with my colleague Dr. Mike Genco who is the Chief Medical Officer at Sentara Obici.

A little background on our health system. We are home based in Norfolk, Virginia, and um, we have a 2,700 bed network. My specific hospital, Princess Anne in the picture, is one of our 12 acute care hospitals and Sentara as a whole was named to IBM Watson's Health Top 15 Health Systems in 2021.

And then what really I think led to the invitation for me to join you today and share our story is in 2012, we were an early adopter of Glytec eGlycemic Management System, which you will often hear me refer to as Glucommander, and bringing in the evidence based, computer guided approach to insulin management.

So, as I've shared, we were early adopters as a healthcare system of the eGMS. We recognized that we wanted to be able to provide a tool and a resource to normalize the delivery of glycemic management. As all of us throughout the various disciplines have studied, what is best practice? What does the science tell us?

How can we ensure that we are keeping up to date as well as individually managing our patients' needs? When we looked at deploying, um, this software across our patient population we recognize that it did not need to only be in the critical care units, but it actually needed to span our entire patient population.

So as you can see, we actively have deployed in the emergency department, in med surge units, intermediate care units, critical care our obstetrics, pediatrics, perioperative, and our skilled nursing units. One of the key takeaways that we recognize that helped us to better implement IV insulin management as well as to help us prepare for utilizing the SubQ modality was to have glycemic management meetings, not only at individual sites, but also a system led meeting that would be able to take into consideration all of the, as I said, the unique needs.

When I spoke earlier about our 12 hospitals, we range from a very urban academic level one trauma center to a very small, less than a hundred operational beds in a very rural setting. So we had various needs when we looked at the hospitals and the caregivers and where some may be more willing to adopt and others may need more support.

One of the keys that we recognize, which was really an evolution and a collaboration, a collaborative effort, was to establish a nurse driven protocol, which allowed for automating insulin order initiation in response to hyperglycemia by the nurse at the bedside. This was coordinated through a collaborative effort so that this protocol is approved by our medical staff and it is clear, evidence-based.

And really just helps to promote the collaboration in trying to optimize the outcomes for our patients. One of our lead sites, as you will soon be introduced, they were able to initially look at all of their order sets and recognize that we had a multitude, 14 to be exact, and they were able to consolidate to one order.

We initially only went live with that process at one hospital. But now as you'll learn, I'm happy to say that we've been able to incorporate that across our system. We also have been able to tell our story in other ways in that we've published over 18 studies in collaboration with Glytec, and most importantly, we have treated 2 million patients on Glucommander since the deployment.

So when you look at our background of the timeframe, October 2020 to September of 2022, so two years, we're very proud to look at the percentage of patient days with severe hypoglycemia, which is a blood glucose of less than 40, and that percentage is 0.12%. We're very proud of that accomplishment.

And more importantly, proud to say that our patients, did not experience many days with a hypoglycemic event. And then also when you look at the total days, that is 35 patient days out of 28,050 total days. I'm really proud of that and I hope that you too can strive to reach that goal. One of our clinical diabetes educators who works here with me at Sentara Princess Anne Hospital shared her opinion about how the IV program could automatically calculate the drip rate, which really helped with the nursing workflow.

When you look at the SubQ program, she recognized that the doses were based on blood sugars and carbohydrate intake which made things so much easier in such a complex world that we provide care. And the bedside nurse definitely felt the benefits. So then we will look at how we started and then we recognize that this couldn't be a big bang that we needed to really take a phased approach.

So as you've seen our accomplishments with IV usage, we recognized that we really wanted to move forward into the SubQ usage and optimization. So in 2019, pre-pandemic, we rolled out SubQ Glucommander across our facilities, but we encountered a hurdle and a barrier that we did not have consistent adoption nor usage of the program.

So of course we then used our process to go and seek input from our end users to help us better understand something that we thought would bring value to our patient outcomes. Why were we hesitant to use? So the main concern that was lifted up, and I really commend our bedside nurses for escalating this concern through the appropriate channels, but it really, focused on safety.

Given that they were manually entering data, they recognized that there was a risk for them to transcribe numbers. There was a risk for them to misunderstand a communication from another caregiver, whether it was a blood glucose that was verbally stated, or maybe even handwriting that was not clear. And then we recognized that when the initial order entry was manually entered, to the data points that the software program needed, that that, again, was a risk point that we could have set up the wrong programming from the beginning and it may have not been recognized early on.

So this really caused our organization to hesitate and to pause in the delivery and usage of SubQ. And we went back to Glytec and asked how can we decrease the manual entry? How can we work together and partner. And luckily we were able to work together and effectively work towards more of our integration from the software into our electronic medical record, which was Epic.

So more to come on that later, but I want to also share that we recognize there was an educational need that some of our providers were focused on primary diagnosis, not taken into account the glucose management that also needed to be considered. There was also this tendency to risk hyperglycemia over hypoglycemia.

We also, as I have shared, we are 12 hospital system. We are in many different settings across the state of Virginia and North Carolina, and we recognize that as our various hospitals joined our healthcare system at various timelines, some were more in tune as well as aligned with where we were headed and what our overall vision was.

Whereas others were still adapting and adjusting and acclimating to Sentara. So I think that also was a factor that contributed to the inconsistent adoption. And then lastly, we recognize that with turnover throughout all disciplines of healthcare, but specifically looking at nursing and our physician colleagues, that we needed to establish a more thorough and a more consistent educational offering to ensure that we were not only responding to the questions, but also of the end users, but also relying on the most recent evidence-based practice as well as what other colleagues around the nation were finding in the use of Glucommander and in glycemic management.

And now I would like to share, as I referenced earlier, how one of our hospitals was our earliest adopter and really has become our prototype. My sister hospital, Sentara Virginia Beach General was able to implement Glucommander early, early on, and really helped provide house-wide education and really show the benefits of the software usage.

But what they really recognized, and they were the advocates for safety, was we need to integrate this with our EMR. But more importantly, they had their administrative buy-in from both their CMO and their CNO, and they were fully supported in making sure that they were connected to all of the stakeholders.

The CMO maintained close contact and communication with the hospitalists and the specialists and the providers who were able to work alongside the nurses who were then actually given educational offerings that were mandated. And I know that's a word that we try to avoid in healthcare, but we recognize the significance of understanding the why and the how in order to make this be successful.

So nursing education at Virginia Beach General really took this on as a great task and truly have turned it into something that they're quite proud. And that the usage by their nurses and the way that their nurses can articulate the use of Glucommander is really remarkable and a great resource for us within our healthcare system.

As I mentioned earlier, they were the hospital who was able to recognize that we had competing in multiple order sets, which could be confusing. So they were the ones that recognized, let's narrow these down to one order set with all available options in a queue in a way that is logical and, incorporates everyone's needs.

So I really give great kudos to my sister hospital, Virginia Beach General for helping lead the way. As you can see, you had, they experienced a 47% reduction in incidence of hypoglycemia, which is remarkable. They had a 37% reduction in incidence of hypoglycemia, less than 70 milligrams per deciliter. And then lastly, a 28% incidence of hypoglycemia which is a blood glucose of greater than 300.

You can also see one of our users, Susan De Abate, who was a great champion throughout this process to really help coordinate and lead the efforts and advocate and support the caregivers directly, but also ensure that she was advocating for the necessity through our administrative leaders.

And here is a quote directly from Susan. So she is proud, as I've said, as being one of our champions to be able to sustain at Virginia Beach General a significantly high usage of SubQ. And I also want to share, as I may not have referenced it earlier, they were able to implement this across all of their med surg and intermediate care units.

When we look at patient at workflow for the nurses, we know that this is sometimes a challenge for some sites, but I will recall the emphasis on education is what made a difference. But you can read her quote it, she stay shares that it becomes even more important so that poor glycemic control does not become an issue that leads to extended length of stay, especially during our healthcare situation and crises where beds are at extremely high need, extending length of stay because failed to pay attention to the blood sugar levels or glycemic control is certainly one area that we can totally avoid by using the SubQ Glucommander.

So you can see Susan is a great advocate and voice for the use of this tool. So I've referenced our phased approach. So what we recognized once we have shared that we have a safety concern, Glytec was able to respond and say, ‘Okay, we've developed the tool that will integrate with your EMR.’

We were ready to begin to roll out, but the, we then experienced as you did as well, the pandemic. So, we truly defined this that we would have to go in various phases and we really used an assessment to see who was the most ready based on current usage and current understanding and knowledge.

So for phase one, we were going to integrate the system into Epic. We recognized clearly that Virginia Beach was ready for this to go live throughout all units. And then for other hospitals, some of us were using SubQ Glucommander in a minimal capacity, but we recognized that there were five hospitals, including Virginia Beach General, that we could redeploy SubQ, and that we had enough content knowledge that we could expand upon that and really help set our goals so that we could provide this tool to increase the safety, but also improve the patient outcomes.

So that was our phase one and I mentioned the pandemic. We started that initiative I believe at the middle of 2020. And we were able to actually redeploy SubQ in May of 2022.

And that, of course was many pauses, many hesitations and many virtual meetings so that we could continue to hesitate when needed in response to surges, but also continue on from the it build behind the scenes when necessary. So where we are currently is in a phase two, we are looking at how can we optimize and how can we improve our utilization.

So we are now developing the plan to roll to our other divisions within our system. We are actively providing leadership oversight, and then more importantly, we're using the data to tell the story. And then future, we recognize that we will be able to just see how can we continue to grow? How can we take this information and how can we work with our physician colleagues in order to standardize our workflows and ensure that we are comfortable in using the most evidence-based practice that we have available and we can continue to improve our patient outcomes.

So when you think about how do you get this system wide buy-in, how are we going to be able to look at all of our providers and all of our nurses and be able to be successful? All of us probably have little pockets where we know it's an easy adaption and then there are others where we have to we have to provide a little more information.

So we really rely on our prototype of Virginia Beach General. They have wonderful data that they can help us tell the story, and then we recognize that executive support is key as well as that mandated training. So instead of going back and looking at where we've been, we're really wanting to learn from the past and move forward to see where we can continue to grow.

I really just want to say thank you to the partnership with Glytec in that we were able to really move through the pandemic concerns and recognize collaboratively where we needed to pause and where we needed to continue. So really this last, this last highlight of the IT and our clinical relationship was probably I think probably the key to our success.

There was a lot of hand in hand working. But also recognizing on one hand had to move a little faster than the other, and IT was able to maintain their active work in the background while the clinical folks needed to refocus and provide care to our COVID-19 surges as well as. Also recognizing that we needed a chance to allow those people to re-energize and to not be fatigued moving on to the next initiative.

So I have referenced that I am a co-chair of our system steering committee. So that is really where it began. And that is a system representation from multiple disciplines. And then we actually mimicked that same structure into how are we going to roll out this integration and how are we going to move this forward successfully.

So we were able to recognize that in our clinical committee we needed nursing, pharmacy, clinical diabetes educators, IT and providers. We maintained our leadership executive presence as a resource, as needed when a decision that was really probably evolving the COVID-19 surge, or when we recognized we really needed to move to one order set.

Those were opportunities where we as the CNO and CMO were able to give direction and then lift up for support as we needed to. But then the subcommittees that formed out of our integration efforts, was really what was key in that. We, again, looked at the key stakeholders, who do we need? Because we can build a plan that nursing thinks is wonderful, but really did not work well for pharmacy.

So it was the collaboration, the coordination, the communication, and the great partnership with Glytec that helped us be successful and that rollout that which we accomplished in May of this year. And I think that the other point that I just want to highlight for you is really we recognize, as I said, the individuality of our divisions within our system, but we also recognize the strength in our system.

So we relied on each other from either historical knowledge or from specialty and specialization and where one could contribute in a way to make sure that we were all pulling together to really use that synergy that we created to get the best product. And then I have referenced, because I think over the last two years, we all know what the pandemic has brought us.

So I referenced it throughout, but really that was our biggest challenge. And if I could take that away, I think the rest of it would be so incredibly smooth. But we recognize not only did we have patient surges that each of us were feeling at different timelines just based on the geography of where we were within our system and within our state.

But then as most of you are aware, knowing that with this COVID population, there was an increased usage of steroids. And how does that impact the glycemic control and how are we going to adjust any of our approaches to managing the glucose. And then our priorities were shifting continually. As we know internally, we had to focus on our teams and on our patients.

And then our IT teams were focusing on meeting deadlines and ensuring that the practices and the integrations were going to work so that we finally were ready to hit the go, that everything was all set. So really COVID was a challenge and a great learning opportunity, which goes back to the reference of the strength of our system.

So the other opportunity that we have really recognized was probably more when I share the timing of when various hospitals joined our healthcare system was ensuring that we had the trust of the providers because our providers are knowledgeable and they are managing and leading the care of our patients.

And for us to share that we have this tool. We really recognize that it wasn't just saying, ‘Please use,’ it was really providing data, information, the why, the knowledge so that they could trust that this was a tool that they could rely upon to ensure that their goals were met in patient care delivery.

And then our other challenge internally was that we switched to a new software platform that managed our clinical education as well as all of our HR, some of our finances, our supply chain, multiple disciplines and modalities were included. Well, this go-live was occurring in April of 2022.

So that did delay some of our computerized training knowing that we did not want to work out of two systems and then have two different tracking mechanisms. So that again, was one more delay that we had to work through. But the collaboration across the team came up with a solution and everyone adjusted very well.

And then lastly, we recognize that we often like to build a playground setting within our EMR so that when we are training our staff, that they can go in and experience what it will be like in real time, but in a playground. But on this situation, we had to make the decision that that was going to delay us even further.

So we actually opted out of building that as an option. And as the solution, we decided to create tip sheets that were using screenshots of the actual program and we were able to see that it was a change from what we have provided in the past, but it really did not impact the end user adoption or understanding.

So that is an option for sites moving forward that perhaps the playground is not as valuable as we once thought it to be when it's something that the team was familiar with. And I do think that's key. As I shared, we rolled out this integration into our EMR in our phase one planning, two hospitals that were already users of Glucommander and Epic.

So it really was just enhancing and decreasing the number of steps and it completely erased the manual entry. So I think that probably is a caveat that needs to be considered when you're looking to consider a playground or not. So our key takeaways, I think you have heard the collaboration is a consistent theme throughout my talk.

But I really think when you look at your key stakeholders, making sure that you're including them on the sub teams as well as in the steering team. Sometimes our steering committee obviously is intended to be smaller so that we can make a higher-level decision as well as not get into the details and into the weeds.

But we still needed thorough representation from all of those stakeholders. We needed to ensure what we learned through the collaboration was just make sure that IT is not moving forward without incorporating the clinical input. And then make sure that those clinicians are also not moving forward with perhaps a little more of a, you know, a narrow view and not recognizing how their rollout and their request ultimately would impact another discipline.

And then it is key to ensure that you have your executive leadership involved as well as able to lift up concerns as are needed for those key decisions when you may have to make a turn and adjust to your plan, but really, moving forward, and that's, you know, where I'm excited that we're moving in phase two and looking forward to phase three, that it is an an opportunity for us to just continue to grow.

Definitely want to ensure that you are tracking your outcomes. As you heard me reference with building the trust of the resource and the software. The data is the best storyteller that we have. We like to add our stories so that you can better understand the whole process and really better understand the complexity.

But the data is really what is going to get you the most support, and I think leverage the greatest buy-in. And lastly, I want to highlight what we have recognized that was important for us in order to be successful. So I think, you know, as I've shared, we're 12 hospitals and we have unique needs and unique staff members.

We have unique data points that are specific. So I think what's really important is that you recognize that while we're trying to optimize and more move more towards a normalization, that standardization word is not always is not always received well because of those individual needs. So I think it's really important to listen and to be able to adjust and be able to speak to the goals and then adopt as needed.

I really would recommend that all other entities think about that phased approach. It's really helped us, I think, with a rollout success as, you may recall, I mentioned in 2019 we had rolled out SubQ and that was not willingly accepted by everyone throughout our system. So we recognize that we just need to continue our check-ins, make sure that this phased approach is right, that we have put things into the right timeline, and then it just continue to be flexible.

The flexibility is key. And then with the educational component, we all know that there are many initiatives and many sources of information being shared at our clinical providers at all times. But if we don't provide the education to why and the how, then it's going to be very difficult for them to do.

Make sure that you consider the education is not optional. It's necessary. And then lastly, I guess our biggest successful aha was it's okay to take a pause, catch our breath, and reset as long as there's a plan. And I think when I referenced about COVID earlier, not only were we handling and dealing with the surges, but it was really important for us to allow our team to, um, to kind of get some rest and be ready and refreshed so they could come back and take on the new initiative. But we had a timeline and we had a plan, and we were able to frequently check in.

And I really thank you for your time. I hope I've been able to provide you with some insight and a little bit of a perspective of our story across our system in the usage of Glytec and Glucommander, and helping us reach that time to target goal. So as you see, you have my email address. Please reach out with any questions, and I wish you a great day, and thank you again for allowing me the time that I have been able to spend with you.

And I wish you well. Thank you.

[00:28:57] Cody Ericson: Good morning and thank you for the introduction. My name is Cody Erickson. I'm part of the advanced practice team at Kaweah Health. I specialize in inpatient diabetes management. I'm part of our Glycemic Steering committee with us developing a gold standard of inpatient diabetes management at. A little bit about Kaweah Health.

We are located in Visalia, California, which is in Central Valley, California. We are a mix of rural and urban. We are 581 bed academic medical center with a level three trauma designation. Our last Leapfrog Hospital Safety grade was an A, which we are very proud of. We partnered with Glytec in 2016 and it's been a great transition with us going forward with our inpatient diabetes. So taking another step further to look at the burden of diabetes that our institution faces, we have the highest prevalence of diabetes in the state of California. We rank 39th out of 50 counties in death related to diabetes.

Up to 40% of our Kaweah Health inpatients have a diagnosis of primary or secondary of diagnosis to diabetes. So our volume is tremendous. Our outstanding counties related to Tulare, Kings County, Fresno County, and Kern County. You can see that a coronary disease, cerebrovascular disease in vascular disease is in and of itself is rampant.

We have looked at length of stay opportunities and they keep on escalating with opportunities up to 25 million in terms of diabetes care. So where our journey began at Kaweah Health… We were able to do a retrospective study in 2016 to 2017 where we implemented Glucommander from our journey from sliding scale insulin to basal bowl of insulin.

So our practice change, when we implemented Glucommander we were able to move away from sliding scale. At our institution at the time, we are 95% of our orders were with sliding scale insulin. So elimination of using sliding scale insulin was SubQ and IV order sets were able to completely change how our insulin delivery was accomplished at our institution.

We were able to add A1C testing to help our providers understand glycemic risk. We were able to standardize order sets that were evidence-based practice to the current times. We were able to create staff awareness with onboarding of education for all multidisciplinary, and we were able to achieve clinical results and related cost improvements.

We were able to reduce hypoglycemic events and hyperglycemic events, so up to make events pulling up the $7 million in their overall. We're able to reduce our length of stay and give our back our providers time with related to other multidisciplinary time with overall orders. We firmly believe that with the use of bringing on biotech and Glucommander to our institution, we were able to bring a safer overall delivery of insulin to our institution going away from sliding scale insulin.

So bringing on Glucommander, we were able to make practice change, and now how do we continue to build forward? We've had Glucommander IV and SubQ in multiple different specialty areas within our ER, both our ICUs, Obstructs, Skilled Nursing, our step down ICUs, and our medical surgical units. So over the past 12 months, looking at our data, our practice is solidified.

95% of our patients that meet criteria for the use of insulin are treated with Glucommander. This has been established by consistent and solid foundation of our nursing education and leadership buy-in. We have created standardized processes with training for all onboarding for our residents and our nursing teams with overall development of super users.

The consistent messages delivered throughout our institution that our high-risk area needs a further understanding of inpatient glycemic management and the use of Glucommander. So continuing to build on our improvement processes. The opportunities have been identified with our diabetes management team.

We have high risk patients that are inpatient. We have patients that have end stage renal disease, recurrent hypoglycemia, persistent hyperglycemia. U-500 resistance patients that are on steroids and prior history of difficult inpatient management. These patients have been identified with the use of GlucoSurveillance and overall looking at hyperglycemia and hyperglycemia reports.

The next step forward was to look at how do we offer additional support for our multidisciplinary team with an inpatient diabetes provider, knowing that Glucommander can do amazing things, but 80% of patients can be overall management with Glucommander, 20% will potentially fall out with these high risk patient populations.

We've identified that these patients that fall outside of Glucommander need clinical support at that time. So the hope was to build a diabetes care model that would have diabetic educators, Advanced practice providers, endocrinology support to have a 24/7 robust coverage for our inpatient diabetes program.

We know that we need more for long term success and to overall continue to build upon where we're at with ongoing staff education and glycemic best practices for all of our multidisciplinary to help with overall best practices. So what we were able to do… we were able to form our first inpatient diabetes management structure.

Myself being an advanced practice nurse, I became the primary champion of our glycemic management team. This model is started in February of 2022. I started on Amion, which is a call service that is available Monday through Friday for these difficulty patients that we identified with our high risk patients.

The role of the inpatient diabetes management team was to daily review of glycemic excursions, looking at GlucoSurveillance, we were identifying patients that were greater than 250 and less than 90. Those were patients identified for having the greatest risk make in the moment. Insulin adjustments to optimize glycemic control, respond to current reports, review patients, and provide recommendations for our inpatient services.

Provide continued education with super user training for our nurses. And what has been a great success is getting from and getting in front of our GME residents and helping them have a better understanding of what, how Glucommander functions and what inpatient glycemic management looks like. I'm an active member of our Glycemic Steering Committee, reviewing monthly data, developing action plans and goals to help us move forward.

Some of our biggest goals are awareness of our inpatient diabetes support. I am on-call and reducing time to target and reducing instances of hypoglycemia. What we're able to find out is that 59% of the patients were seen for four days or less. So with us being able to look at GlucoSurveillance and looking at patients that were identified for having the greatest risk, rather than 250, less than 90, these patients needed to be identified early.

And treatment was able to be optimized within those four days. Looking at the inpatient diabetes referrals, we were able to see that our hospitalists and our CT surgery group was using the service line the most, which gave a good understanding that our providers needed help with in the moment adjusting of insulin. We now have a better opportunity to expand the overall awareness of our inpatient diabetes management team.

That is a hope to go forward. So from 184 consults between early February to late May, we're able to see that 78% of them were from hospitalists and CT surgery group. So the complexity of inpatient management continues to rise. What we're able to improve upon now is that we need in the moment clinical decision making, so having a clinical specialist with the aid of Glucommander, we're able to make impact, reducing the risk of adverse events, improve transitions in care, primarily from IV to SubQ, reduce readmission risk based on these patients being identified. These patients that are high risk are going to be potentially reoccurring patients. Now that the inpatient diabetes management team is able to see these patients on a recurring basis these patients can be identified earlier with optimizing their like to make manage. Which will overall lead to improved quality outcomes with redirection of hypoglycemia, reduction of hyperglycemia, and overall improvement in time to target. The further findings were we were able to reach a standard of care with using IV insulin in our critical care areas.

With this implementation, it helps with smoother transitions and less number of complex cases. This was further expanded upon with being able to be in front of our GME resident group on a rotating basis to help them further understand how Glucommander functions and the gold standards of inpatient glycemic management.

So looking at our data and how we did a practice change with adding inpatient support… Glucommander does a tremendous job of dialing patients in, but those patients that fall out of Glucommander related to how we identify those high risk patients, those patients with renal disease, those patients that have persistent hyperglycemia, the patients that have overall difficulty in patient management with adding that in the moment, clinical support.

Since February, we're able to see our data and overall our needle move in terms of inpatient glycemic performance. So if you look at the very top data point, you can see that our patient hypoglycemia days are now reduced and they have been reduced for up to seven data points. Also, our time to target, our time of being within 70 to 180 has improved for all those data points that correlate with us implementing in February, our inpatient diabetes management team and reduction of hyperglycemia with patients overall experiencing glucose is greater than 180. These all correlate to the implementation of a clinical specialist being there to help our inpatient provider group for these difficult management cases. So the expansion of our diabetes care model, we understand that specialists support is needed for these complex inpatient management cases.

We know that we need 24/7 coverage. You need to experience better overall. We're able to see how our data is improving with one sole person at the helm. The hope is to expand to a further overall team. The goal for Kaweah in the future is to have all of our Type One and Type Two patients treated by our inpatient diabetes management team with the use of an eGlycemic tool with Glucommander.

Further additional opportunities come from just the sheer volume of patients that we have, and we need a full-fledged team. Utilization of GlucoSurveillance further identifies that we just need more people here to help out with the patients that have hyperglycemia, persistent hyperglycemia, and the need for inpatient diabetes management oversight for those high-risk patients.

I want to thank everyone again for the opportunity to speak here today. If there's any further questions my email is there and I appreciate the time and thank you again.

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