Thank You! | So You Bought an eGMS…Now What?

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Thank you!

 

So You Bought an eGMS…Now What?

Barbara McLean, MN, RN, CCNS-BC, NP-BC, CCRN, FCCM | Grady Health System

Tiffany Young, BSN, RN, CDCES | Northeast Georgia Health System

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TRANSCRIPT:

[00:00:00] Hannah Day: Thank you so much for joining this session So You Bought an eGMS...Now What? In this presentation, you'll hear success stories from partners about implementation and continuous improvement.

My name is Hannah Day and I'm a Nurse Practitioner at Glytec. I'm joined by Tiffany Young, the Diabetes Program Manager at Northeast Georgia Health System and Barbara McLean, Advancing Evidence-Based Practice Clinical Specialist at Grady Health System. I'm going to hit things off by sharing my own story as someone who was involved in an eGMS implementation project prior to my tenure at Glytec. In particular, how a successful implementation starts early with organizational buy-in and share how that impacts successful adoption.

I've been in the healthcare field for 20 years, 14 of those years, I've spent with a focus on diabetes management, as a diabetes educator, and then a nurse practitioner. I'm certified as a diabetes care and education specialist for 11 years and also board certified in advanced diabetes management for four years.

Prior to joining Glytec, I served in multiple clinical and leadership roles at Northeast Georgia Health System, but most recently, Diabetes Program Manager and administrative director for hospital medicine. In these roles, I've led initiatives to improve glycemic management across the system, including Glucommander IV implementation and development of an inpatient glycemic management team.

Northeast Georgia Medical Center is part of Northeast Georgia Health System, which is a community hospital with four campuses across Northeast Georgia and over 700 beds. Northeast Georgia Health System began a journey several years ago to improve diabetes care across the system in both the inpatient and the ambulatory settings.

The inpatient improvement efforts were largely focused on standardization and implementation of glycemic management best practices with the overall goal of preventing safety events, improving glycemic outcomes and ultimately improving length of stay, readmission rates, and morbidity for our patients.

One arm of the inpatient improvement focus was specifically related to insulin infusion protocols. We embarked on a couple year, two to three year journey to optimize the current insulin infusion protocols, to educate on those protocols and then to monitor their effectiveness and ultimately, leveraging technology through the implementation of Glytec's eGlycemic Management System, including Glucommander IV.

Implementing Glucommander was a cross-functional project with significant impact on glycemic control and it's a project I'm proud to say that I was part of. Looking back, I can identify elements that I believe contributed to the success of that project and I'll share these key elements with you today. Then, I'll introduce two clinicians who hear their success stories for implementation of eGMS and continuous improvement.

 So leadership engagement and support is key to the success of any initiative. Leveraging the impact that glycemic management has on system level goals can help drive this necessary support from leadership. Many health systems measure and track outcomes like length of stay, readmission rates, serious safety events for example, with goals to reduce these through providing safe, quality care to patients. Research tells us that improving glycemic management can positively impact all of these goals. So positioning this project as a strategy to achieve these higher outcomes, it not only helps ensure leadership engagement, but also increases awareness of the importance of glycemic management across the system.

For example, we know that up to a third of patients in the hospital may have diabetes or experienced hyperglycemia during their stay. Improving their outcomes, specifically hypoglycemia and hyperglycemia rates, for even that portion of patients is likely to impact the system level outcome metrics related to morbidities, such as post-op infection rates, serious safety events, et cetera.

Northeast Georgia Health System identified glycemic management as a safety pillar goal several years ago. This was in part due to multiple safety events reported around insulin management in the hospital, as well as community surveys that identified diabetes as an area of needed focus. As one of the goals under the safety pillar umbrella, diabetes improvement work, received the much needed leadership support at that system level.

 Another key concept as we think system level, is the broad impact of glycemic management across the system. Even when we think of the hospital setting, the impact of glucose management is not just in the common inpatient areas we tend to relate this to like ICU medical, surgical units, cardiology units, et cetera.

So keep in mind the impact that glycemic management has in the ED, the Emergency Department, the perioperative setting, obstetrics, behavioral health areas, pediatrics, for example. All areas of the hospital can be positively impacted by efforts to improve glycemic management. Therefore, it's valuable to include representatives of experts from all of these areas and engage them in the work and the efforts.

 Keep this in mind as leaders are identified, provider champions, pharmacy champions, nurse champions, for example. Make sure there are leaders representing all of those areas impacted. At Northeast Georgia Health System, the executive sponsor of the project was the Vice President of Hospital Medicine and Quality.

We identified physician champions, which included an endocrinologist who also had inpatient experience, a hospitalist who was also a physician informaticist who also had a particular passion for diabetes improvement in the hospital. We identified an intensivist with a special interest in glucose control.

Also an OB physician, an Emergency Department physician, and a advanced practice provider from the CV surgery area. We also included in the project, a pharmacy clinical coordinator who had a long history of engagement in diabetes improvement work over the past several years. The diabetes educators, of course, were involved to provide that system level viewpoint and nurse leaders from each of those service lines were also identified and involved.

So again, it was key to identify multiple leaders and champions across the system from all the areas we know can be impacted by glycemic management. Then as we think further about leadership involvement, consider some advantages of identifying leaders with certain roles or attributes. So clinical and IT knowledge is a positive.

The ability to collaborate across departments or someone who has influence across departments is also key since this is such a widespread project, it impacts multiple areas. And then of course, somebody who has a passion or expertise in diabetes management is definitely a plus. Identifying the right leaders will ensure vast awareness of the project, collaboration across multiple areas and a holistic approach to problem solving.

 I'd like to share one example of collaboration across departments during the Glucommander IV implementation at Northeast Georgia Health System and how optimizing glycemic management involving the right people, the process and technology, improved safety and workflow for clinicians. A patient presents to the Emergency Department with a clinical presentation of DKA, diabetic ketoacidosis. DKA is diagnosed and the patient needs treatment started immediately.

And in, GHS it was determined to start Glucommander IV in the Emergency Department. Therefore order sets and processes were created to support this workflow. The ED provider champion, the ED nurse leader, diabetes educators and the ED pharmacist were all involved in the order set, build, and the education to the Emergency Department.

The intensivist and the ICU nurse would receive these patients and continue the treatment once that patient presented to the Intensive Care Unit. So it was a seamless process that ensured the patient was treated timely and safely across departments. During a sense of surge particularly in COVID, patients may remain in the Emergency Department longer until transferring to the Intensive Care Unit.

So starting the treatment of DKA in the Emergency Department helps to prevent any delays in care. And in GHS, this was more difficult to achieve with complex paper protocols. It was difficult for the Emergency Department nurses to follow the complex DKA protocol in a busy ED environment. Errors were probably more common than we realize, but leveraging technology made this possible.

 So I'll leave you with three key takeaways related to successful adoption and organizational buy-in. First, align glycemic management efforts with system level goals, and that will help drive the leadership engagement and support that's important. Also, track the process metrics and the outcome metrics. And when you see improvements in those metrics, share those, highlight those with your leadership.

Secondly, be sure to appreciate the system impact of glycemic management and identify the right champions. Keep in mind those who have an expertise in glycemic management, those who are leaders among their peers, for example, and remember to identify champions in the specialty areas that are impacted as well. Identifying these champions early in the project will help to support the order set develop, and any best practice workflows that need to be developed as well.

And thirdly, both number one and number two will drive an increased awareness of glycemic management and the importance of that across the system. Take advantage of that awareness, which will then drive adoption. So whether you're implementing Glucommander at the beginning of your health systems journey to improving glycemic control or if it's happening further along your journey, leveraging that increased awareness and the engagement of leaders and champions will not only ensure successful adoption of Glucommander, but it can be leveraged to validate and enhance and create any best practice workflows that are needed around glycemic management.

 Now I'd like to turn the presentation over to Tiffany Young, whom I've worked with at Northeast Georgia Health System. She'll pick up the story and share how Glytec partnered with Northeast Georgia Health System to support the needs of clinicians, patients, and the organization through implementation and Go-Live.

 

[00:12:34] Tiffany Young: Hi, everyone, like Hannah mentioned, my name is Tiffany Young and I am the Diabetes Program Manager at Northeast Georgia Health System. So I am over inpatient and outpatient diabetes education departments, but focusing here on inpatient diabetes management as the program manager, I have oversight with collaborating with the care team as a whole.

We consult on best practice in real time, as well as assisting with updating policies, procedures, and order sets. Lastly, I'm a resource for the bedside nurses to help with their patient care needs while they're on IV insulin infusions, or sometimes even seeing patients for education. The diabetes education team or our CDCES they are consulted on all insulin infusions, whether that be for patient education or nurse guidance. We are also consulted on things regarding uncontrolled diabetes, newly diagnosed diabetes, changes in home regimen. And our consults are unlimited. So they're able to consult for anything as well. So even if a patient was uncontrolled in the hospital, we could get consulted and recommend the patient go onto IV insulin infusions as well.

We do get a lot of phone calls and questions just about Glucommander in general. So we will go to the bedside with the nurse, walk them through steps and then lastly, we consult with the physicians on ordering and transitioning from IV to our SubQ insulin order set.

As you can see, all of our IV insulin infusions are only used in certain areas. So we use them in critical care, which is our ICUs, our CVICUs and CCUs. We also use it in the ED, our Immediate Care units, Progressive Care and in L&D.

All of the order sets are physician driven, except for our CV surgery order set, which nursing can order when the patient returns from their surgery if their blood glucose is greater than 40 per the nursing protocol. And then nursing drives all the titration and then also, typically requests for transition if the patient is appropriate for transition before provider rounding, which occurs in all of our critical care areas.

Next slide. During Go-Live, it was very important for our training materials to match our workflow at Northeast Georgia Health System. Glytec helped us create these training materials and we used a train the trainer model. So, we had our unit educators and diabetes educators be our trainers a nd we tried to get as many real-world scenarios from those unit educators for our education as possible.

And most of our nurses, of course, had never used a computer directed software before. We're a very small rural hospital beginning. We've expanded certainly, but most of our nurses had worked here for their entire careers and of course have never used anything like this. So of course during Go-Live, one of our biggest hurdles was trying to figure out how to get all these patients that were on our paper protocols, transition to Glucommander itself. So we used a report within Epic that told us which patients were currently on our paper-based protocols and then we would go to them directly with Glytec and transition them using that reverse algorithm for that downtime form to get those patients on Glucommander.

There was a hurdle and, with the collaboration, with the physician and the nurses to determine, okay, is this patient going to be on IV insulin for six hours so that we could get that recommended total daily dose. Is the patient appropriate to just transition right now to get them moved out to the floor.

So there were a couple other things that we just had to take into a ccount, not just that we wanted to get these patients on Glucommander. We wanted to make sure it was appropriate for the workflow so that we could continue with throughput for our patients.

The week of Go-Live, it was so important for our stakeholders to be present. So we had nursing leadership, physician leadership present in our command center and they were able to support and communicate any needs on a larger scale through our own huddle system. So that was very important for our successful Go-Live.

And then of course the Glytec team was available 24/7. They were rounding on the units and they provided real time support, which I think helped nursing, you know, know that they were there with them to help make this process smooth and they were available to answer any questions. And as far as, you know, current education and support that's needed, Glytec is very easy to get in touch with. Our process currently is for the end user to contact diabetes education first or myself, to determine if we can help with troubleshooting.

You know, most of the time we can help with troubleshooting, but there are some IT items that, of course, as nurses, we are not IT savvy. We'll direct them to put a ticket into IT. And if IT then can't resolve the issue, they reach out to Glytec and Glytec responds typically almost instantly with how to help to get the problem solved.

And so that has been really helpful to our team and to our success as we rarely have downtime, rarely have issues, rarely contact Glytec support because we're able to have everything set up prior to Go-Live to, you know, continue to have success.

And then also one thing that's really helpful to myself is that we have monthly meetings with our customer support at Glytec. So they're very open in sharing our data, data from other organizations that helps us determine where we are and how we're doing with our Glucommander numbers. And then most of the people that are, that we're working with have use of the software before at their previous organizations or like Hannah, used it here in GHS. She's giving her input to make processes better for other organizations.

So that's very helpful to have those people who have used the software before, and aren't just sitting behind the computer, giving their feedback. They've used it in real time as well.

In preparation for our Go-Live, we had, like I mentioned previously, the train, the trainer model. And with that, we trained over a thousand nurses and we did what we call in the seat training or, you know, your live person to person training, then we used computer based learning for our Hospitalists, Intensivists, CV surgeons, our ED physicians, OBs and APPs, and we had 90% of those providers trained before Go-Live. And again, it was so important that our upper leadership with nursing and physicians, they were very adamant that we needed to have these goals attained so that we could have the better support for our patients.

Like I mentioned in our previous slide, our training materials were specific to our hospital, which was very nice of Glytec to allow us to create our own slides. Some things are different per hospital and with the use of the train, the trainer model, we're able to get those nurses in the seats and have them play in the play environment within Glytec and give them real time scenarios. The only thing of course we could not do was about transition due to the simulation patients needed to be on Glucommander for those six hours, meet the other criteria. But otherwise we were able to utilize all the different features within Glytec in our training, which was very helpful and I think to help make for a smooth Go-Live.

The Glytec support that was onsite during our Go-Live helped with that reverse algorithm for transitioning these patients from the paper protocols to Glucommander which again, very helpful and ensuring that we were safely giving these patients on the right dose to match what they were already on. So that way we didn't start the whole process over in turn, keeping the patient in the critical care areas for an extended period of time.

During the week of Go-Live, there were frequent touch points with leadership as well as Glytec. We would have our morning huddles and they would discuss with nursing, Glytec, leadership, physicians, IT about the things that went well, the things that we needed to work on as well as the starting point for tomorrow, where we need to start.

So it was very helpful to have those huddles and have people understand where we were and what we could do better on cause that always, of course, makes anything work better whenever you're given goals to strive for.

And then lastly, having all of these team members be in the same room or be on the line really opened it up for good collaboration for moving forward within our Glucommander ahead at GHS because everybody knew who to go to going forward and who to reference whenever things were needed. So it was very helpful.

So we conducted a study not long after we went live to compare our paper-based protocols to our new computer directed algorithm or Glucommander.

So we completed this study within the MICU, the Medical ICU, at our Gainesville campus only. We studied our, your hypoglycemia hyperglycemia time to target and hospital length of stay. And some very significant items of note was that we reduced our time to target, which we defined as two blood glucoses less than 180 by 36 minutes compared to our paper-based protocol. So in doing that, we were able to get our patients out of critical care sooner, as well as increased throughput. So we were able to get a different body in that bed if needed to help with our patient flow.

The biggest thing that we saw was our decrease in our hospital length of stay.

So these patients that we studied were all on DKA or non-DKA insulin infusion. So of course, hyperglycemia of some sort, and we reduced that length of stay by 3.57 days which again, increases throughput because you're able to get somebody out of the hospital quicker which in turn allows for somebody else to be in the hospital as needed.

Very eye-opening statistic that we were able to have with our organization. Again, very important to hospital stays in general to reduce them, reduce complications, morbidity mortality, especially in our patients with diabetes.

Great study that we did that we felt like we got some good information out of, and really we want to go back and look and see, okay, we've reduced the length of stay in the hospital, did reducing that that time to target by 36 minutes get that patient out of the ICU quicker? And I would say that it would likely be that it was the case, but that is something we are looking at going back to do.

 So I reached out to some nurses who utilize our paper-based protocols and then they also were utilized our IV insulin infusion software, Glucommander ,and I had some really good responses. Especially during the time that we're having right now with COVID, to see these positive responses from nursing really does make it evident that what we did for our organization was completely worth it.

So starting with Kris Brown, who works in our Cardiovascular Step-Down Unit, he said that Glucommander takes a lot of work and worry out of having a patient on an insulin drip. And he also said that Glucommander is very straightforward, easy to use and has been a great addition to Epic.

So having that Epic integration as far as, you can see Glucommander within Epic and you don't have to go outside of our Epic application, has really helped with our workflow. You're not printing out documents for paper based protocols. So I think it has really helped nursing in a sense of decreasing their time, which you can see in Lois' response, which she works in our medical ICU.

She said Glucommander makes the insulin drip protocol easy by removing calculation from the nurse's responsibility, reducing time and potential for error as well as Glucommander also provides unit reminders so that keeping up with blood sugar checks is a team activity.

So having our Glucoview monitors on our units, the nurses all over the unit are able to see if a patient has a blood glucose due. And if they have a blood glucose due, and somebody's busy, another nurse is able to help that nurse out. So it really helps bring a team around and knowing that somebody else is looking out for your blood sugars as well.

So it's very helpful. And then again, reducing those calculation errors. Some of our paper protocols were seven pages long. So it really reduces that error for flipping back and forth between those pages and doing math, so certainly helps there.

And then we spoke with Cami Rideway and she was also one of our trainers. So she ,has of course a lot of experience, but her quotes are that Glucommander has helped simplify our protocols and made managing insulin drips much easier. She also said it is nice having visibility on the Glucoview monitors to get a quick snapshot of how many insulin drips there are and who needs help.

Again, having that team nursing to help out whenever you see that somebody may be struggling to get a blood sugar is very helpful to not only the patient to get their blood sugars in on time, but nursing to help decrease that workflow, if they're overwhelmed.

And then lastly one of the diabetes educators who really works with the physicians and nurses the most she says that Glucommander takes the math out of titrating and it makes it easy for me as a diabetes educator to help physicians and nurses with transition. And that's Rachel Oswalt.

So we really have seen an amazing growth with our implementation of Glucommander and our Go-Live process was very smooth and I think it wouldn't have been as smooth as it was without the help of our leadership and the constant communication with Glytec. They are very responsive to our emails. They're very responsive to our phone calls and it makes things a lot easier when you're working with a very easy organization.

 Thank you for your time. If you have questions, please feel free to reach out to me or submit your questions during this presentation and we will get back to you as soon as possible.

Thank you again.

[00:27:57] Hannah Day: Thank you, Tiffany.

Now I'd like to introduce you to Barbara McLean from Grady Health System. Barbara will share how Grady, an eGMS partner since 2016, has expanded on their successful mature program and share how they've managed long-term success.

[00:28:16] Barbara McLean: Thank you so much, Hannah. Thank you colleagues. Thank you everyone who's joining and thank you all for your efforts to actually promote glycemic management for our critical and acute care patients. I'm so grateful to be here today. Really, really am honored to have this opportunity to talk about our practice at Grady Health System and really looking at how we have expanded both on our short term and our belief of long-term success.

It was quite interesting. I have been here before, but in this go round in my career, I've been associated with Grady for 11 years. And a lot of times people say, oh, you're such a long timer. For me, 11 years doesn't seem that long.

And also we at Grady hospital are considered a long-term customer and utilizer of electronic glycemic management. Of course, what we're using is Glytec utilization for the Glucommander. And that is really what I'm here to talk about today. And to talk a little bit about our program which, just like me, it's considered to be mature, which I really adore.

So I want to share with you just a little tiny bit about myself. I've been about 44 years in critical care practice. I've really always worked in critical care with a focus on critical care. I am a nurse practitioner and a clinical nurse specialist, and I have a master's in physiology. So I have many points of education that I've brought all to bear.

And this wonderful opportunity to actually introduce and innovate electronic glycemic management at Grady Health System. Grady is a hospital that is a safety net hospital providing care for all persons, regardless of ability to pay or immigration status. We are actually in the center of downtown Atlanta and we have poverty and persons that have actually grown up in and around food deserts. So you can well, imagine that we have a very significant population of persons who actually have diagnosed diabetes or who have undiagnosed diabetes and who the first time they present to us could be in HHS or in DKA.

I am very fortunate to have my relationship with Grady. Currently, I am the critical care program specialist and I have a very strong focus at this time in our emergency care center. We see somewhere around 450 patients per day in our emergency care center and especially related to the pandemic and COVID alterations in terms of admission and discharge of patients, we are frequently managing critically ill patients, intubated, ventilated on three vasopressors plus insulin in our emergency care center, sometimes for 48 hours. So my focus has really been to work with this fantastic staff in the Emergency Department to develop a more standardized method for transitional critical care.

 I publish and present all over the world. And before the COVID pandemic, I would spend about three and a half months out of the year, actually speaking in other areas and I've been to every single continent except for one. And that has been spreading good news about management of critical patients, relationship to hemodynamics and glycemic control.

So Grady hospital, as I mentioned, is a large urban safety net hospital. We are a part and parcel of the Emory residency rotation. Many of our physicians are Emory physicians and we entertain those residents, but we are not Emory, we are Grady. We are a safety net public hospital.

We also are very honored to be participating in the Morehouse College of Medicine as well. We have Morehouse physicians and Morehouse residents and Morehouse fellows, very similar to the Emory program. And there has been a significant, very successful move over the last few years to really actually join those two programs together in the Grady aspect.

We have been using Glucommander for continuous IV insulin since October of 2016. So Happy Anniversary Grady and Glucommander. So five years we've been using Glucommander for our continuous IV insulin for both DKA and non DKA.

We have greater than 110 ICU beds, greater than 150 step-down beds and now on October 7th, we went live in our emergency care center making Glucommander available for 120 beds. Now that's not all of the beds in the ECC, but there are some areas where we actually believe it would just be best not to have continuous IV insulin.

Our next step is four new step-down units. We're moving forward to PACU OR and by the end of December, we will be live in our four new step-down units. So for us, we will have over 500 opportunities for Glucommander for our patients, which is for most folks, probably bigger than their whole hospital.

And it's been a significant and fantastic journey and the partnership with Glytec and my marriage to Glucommander. And by the way, I have never considered divorce, although I'm sure some others have. So just to remind you that we are here in this academic, urban, public medical educational facility. And I think all of us know that when you have variability in your providers, so for us, our attending physicians change weekly. Our residents and fellows change monthly. They might be rotating through and have very little knowledge about endocrinology. Frequently, they don't have a lot of knowledge about critical care. And if you're in the Emergency Department, as you know, emergency medicine is really trained to deal with the presenting problem and not really look at longer term effects because that's the focus of the Emergency Department.

Understanding that and appreciating that challenge, that our attendings change weekly, that residents and fellows change monthly. There's a lot of variability in practice and we have a lot of new providers and those of us who really have fallen in love with glycemic management and insulin and intensive insulin therapy recognize the incredible sensitivity of insulin.

 Also the significant danger that can be associated with continuous IV insulin that is not very significantly well managed. Now we also have a developed relatively new APP program. It's less than 3.5 years of age, and now we are starting to see APPs throughout the system and that has changed, for the significantly better, the continuity of practice. And that's been really beneficial for us as well.

But during this period of time, we actually suffered prior to October of 2016. In the year before electronic glycemic management was implemented, we have 37% hypoglycemia rate. Now that was across all insulin. So not just continuous insulin, not just in the Emergency Department or the ICU, but all insulin administration throughout the house. And secondary to that, we had four sentinel events with hypoglycemia and again, inclusive of all insulin types. So it's not just related to the Emergency Department or the ICU, but anywhere patients are receiving insulin.

In January of 2016, our Chief Medical Officer, Dr. Robert Jansen, and at that time, our Vice President Critical Care, Kate Kennedy, who was my direct boss, actually approached me and said, we would like you to take on a project to work with this corporation, Glytec, to develop strategies for us to actually change outcomes for patients receiving continuous IV insulin.

Let me just say, I am a scientist, I'm a practitioner, I appreciate everything that has to do with scientific and evidence-based management and the way in which we incorporate that, but I would say I was very uninformed about glycemic management and the profound, significant effects that just a 5 or 10 minute delay could actually create for patients who are receiving insulin.

So remember I said, Glucommander, I married Glucommander but before I married Glucommander, I was a glycemic virgin.

So, very important to appreciate how much my practice has grown and changed. I'm not a diabetic specialist, I'm a critical care practice specialist. But when Ms. Kennedy, who's now Dr. Kennedy, and Dr. Jansen approached me, part of what our discussion was that we really recognized that we needed to have a standardized approach for all of our patients, certainly based on the work of Van den Berghe and others being settled in 2004.

And of course, all of us know that we all embraced this intensive insulin therapy after Greet Van den Berghe's presentation in Barcelona in 2004, and the incorporation of that into surviving sepsis guidelines, that we all embrace this glycemic management, utilizing paper protocols, and what we, of course, all experienced was significant profound hypoglycemia.

So the idea was that recognizing the significant mortality and morbidity benefit of glycemic control and recognizing that we needed to do that consistently in a standardized approach. And we really needed to eliminate as much as possible, the human factor that influenced calculation.

Not the human factor that influences the evaluation of patients, caring for patients doing the right thing. Simply the human factor errors that can be associated with calculation when using paper protocols and with the application in using a paper protocol.

So the idea was to bring in a methodology,a circle of p atient safety. Not just guardrails, a real circle of patient safety that reduce the needs of very, very burdened individuals at the bedside. Nurses and other practitioners at the bedside, to reduce their requirement for calculations while also incorporating the body surface area, insulin sensitivity, response to insulin increase or decrease and propagating.

Also in circle, our patients on here at Grady, even though part of our protocol is if you're getting IV insulin, you can't eat, but we're here at Grady, people sneak in food, they've got something stored away, they eat, and just being able to care for them safely in this environment.

So our focus was, first and foremost, to create a circle of safety, to protect patients from incidental hypoglycemia or rapid drops in their glucose related to uncontrolled paper protocols or bolus therapy. And secondly, of course, was to achieve safely a target of glycemic control. Our target being 140 to 180 without too rapid a drop in our patients glucose.

So there are so many things to share about our success and of course we now have five years of data and we have a lot more information, but I'm going to just show you our first three years of data. And if we're looking at that hypoglycemic reduction from October 2016 through December of 2019, what you can see is that in patients who had insulin therapy managed via standard protocols, our usual care; paper protocol, people setting their pump but now they're really busy in another room, they don't hear the pump go off, they don't realize it's time to do the blood glucose an hour goes by before they get it back, you can see 0.44% of patients had, and these are in IV insulin patients, had a blood glucose less than 40 compared to 0.01%.

And for blood glucose that's less than 70, which require a pause of the insulin, but not nearly as aggressively manipulated as patients with the blood glucose less than 40, you can see that with usual care, that was 2.44%. And with our Glucommander and the eGMS, is 0.31%.

And I just want to call to your attention that sometimes these issues were related to patients sneaking something to eat, not reporting it, and therefore the next glucose you measure is quite elevated, you adjust your insulin way up and then of course, patients bottom out. And also can be related to shivering, to seizing, to hyperinflammation, hyperthermia. And yes, it could also be related to a delay in time of measurement of blood glucose.

And I would tell you that around 60% of glucose that drops below 70 is either because there has been a delay in the measurement of the blood glucose, and that's very rare now. Uh, And also sometimes that there's maybe there hasn't been a constant carbohydrates source, which is part of our protocol.

And basically for all patients receiving IV insulin, they get a very minimal, constant carbohydrates source to protect them from incidental hypoglycemia.

Now this has really helped us because of course, the number one concern worldwide about continuous IV insulin, is that patients may actually suffer from hypoglycemia, which of course is life threatening in the moment.

Whereas hyperglycemia is concerning for mortality and morbidity, particularly when we think about COVID 19, sepsis, neurologic injury and acute myocardial injury, but isn't necessarily life-threatening in the moment.

So the fear of hypoglycemia was something that we had to significantly overcome when we started really rolling out our newer methodology, but it really helped us to appreciate best practice care. And by the way, we have not had one Sentinel event from hypoglycemia since we started. Now, we're now five years in and we just went into the Emergency Department. We have not had a Sentinel event from my continuous IV insulin since we went live with Glucommander.

So we have a lot of competence. Actually expansion is just unrolling really quickly now. We are now live in our Emergency Department. We are partially live in the Operating Room and going fully live in the OR, and the PACU and a new kind of tent ICU within the PACU. The Critical Care OB will be soon to follow and our four new step-down areas. So we just continue to expand. Once we've gotten all those areas live, we'll be moving forward with other projects as well.

So I do think it's really important to talk about what happened to us during COVID and we were not hit as hard as most of the hospitals in New York, but there were frequently days when 60 to 75% of our total ICU beds were occupied by COVID positive patients.

So one of the things that was really important, especially in the early times of COVID, was trying to control our PPE and trying to avoid going into the room to make a measure of your blood glucose every single hour. So we actually adopted some of the fantastic protocols for sliding scale, long acting insulin in COVID patients.

We also actually were part of a study using Dexcom to help us evaluate our patient's blood glucose continuously so we could respond to that blood glucose without necessarily having to go into the room. But quite honestly, in the end, what we discovered is we had much better control if we were doing continuous IV insulin and we were doing q. 1 hour blood glucose checks or q. 2 hour blood glucose checks, remembering that with our eGlycemic Management System, 4 blood glucoses in a row within target, actually transitions to every two hour measurement. So that was really part of our intensivity was to talk about, let's try to get to every two hours if possible, and get there as quickly as possible. And the only way you can do that is you got to stay right on time. Got to stay on time with the blood glucose. You immediately respond to your insulin adjustment.

 Lots and lots and lots and lots of focus for our patients. So very strong focus on importance, value, and urgency of glycemic management and insulin administration. Really trying to change people's perspectives and their methods of evaluating that. Basically, I always just correlated to, if your patient's blood pressure was 40, nothing else is going to prevent you from going into that room to actually address their blood pressure of 40. And the same thing is going to be true with blood glucose and continuous IV insulin management.

So lots of things happened over time. Certainly one point that we know is that when we integrate eGlycemic Management at first, it's an adjustment. It's, it's a change in culture. It's a change in strategy. It's a change in methodology. And in the short view, workflow becomes more intense for bedside nurses, but over time, there's a huge adjustment to that. And now it becomes part of the daily practice and awareness of the benefit of eGlycemic Mangement.

To talk about system-wide and particularly as it relates to myself and my colleague pharmacists, we became very aware, very aware about the impact of steroids, because we have a really big neuro unit.

We use a lot of steroids there and looking at the impact of steroids on our glycemic management, how we can address that, what we want to do. And we're looking at that now. Thank goodness we have Glytec as our partners to help us try to make good adjustments for that .Also really important that we are able to look at real-time data and historical trends.

We can evaluate what we've done, what kinds of problems we've had. And look at that algorithm and the dose recommendations of the algorithm, which we have not ever really had any issues with. But a big thing for us, and it's been a struggle, especially in the Emergency Department. Although again, it was, it's really been short, is differentiating the difference between DKA and non-DKA.

Now, all of you listening to this, you might be glycemic gurus and insulin kings and queens and princes and princesses, I don't want to leave anybody out, but here's the thing. Actually appreciating that the protocol is a hospital-based protocol, I always call Glucommander is my realtime insulin doctor.

I'd actually call them my real time endocrinologist but the only thing that we're working with with Glucommander, is this really strategic methodology to achieve time to target and protect patients from hypoglycemia. And there's a wide venue that is applied in this electronic glycemic management system that assists us with that. And identifying patients who actually have a high requirement for insulin, but our protocol is our hospital protocol.

And one of the big factors for us, because we have a DKA protocol and a non-DKA protocol, you only get the DKA protocol if you're making ketones. And we're usually relying on the anion gap as a rapid methodology to evaluate those patients. Anion gap, as we all know, is not perfect, but it is a valuable tool for us because of course we recognize that ketones in the urine, ketones and the serum may take time to disappear. So we look at the gap. As soon as that gap is narrowed, you should come off the DKA protocol. That's been a little bit of some issues in terms of proactive and reactive care benefits.

So what you're seeing here is a picture of some of my wonderful team, a pharmacist, a physician, and two bedside nurses, and we've just measured our blood glucose on our first patient that we went live on. Now, I want to talk about how we actually propagate Go-Live. So as you are probably aware, glycemic management is a really significant strategy and particularly in acute and critical patients.

And it's quite amazing to recognize that people have graduated from medical school, graduated from nursing school, have graduate degrees yet we still don't really have a lot of education on glycemic management and the properties of insulin. So in that interest and after all this learning that I've had with five years, typically before Go-Live, I provide a number of sessions.

So for the Emergency Department, we have about 215 nurses. I did 24, one and a half hour educational sessions, one in the morning and one in the evening at change of shift. I did that over three weeks. And I educated over 200 emergency room nurses live. Now I've done other education, virtual education, et cetera. I've done education with the pharmacists, education with the providers, but the people who really have to manage all of this are the bedside nurses. And I think any time you ever change anything to do with how nurses intensivity changes, you have to assure that you've educated them well, and that they're prepared.

And honestly it pays off so much. So this was such an opportunity, not just to talk about the utilization of glycemic management system and Glucommander, but also the opportunity to educate in regards to insulin and in regards to our protocol. And it's amazing how much people actually would come to the room, I'm mandated to come this class, not going to get my incentive pay if I don't come to class.

And at the end of the class, they're like, oh my God, I never knew this. Thank you so much. I had people calling me and emailing me, talking about how their knowledge had increased. And I'm going to share with you in just a minute, what they're saying to me now about the Glucommander as well. So again, doing faculty and residency education for them, it's mostly a focus on our order sets and that they have to give up control of insulin.

And that may not be politically correct to say but, in the Emergency Room, it's been really easy because they're like, we're very happy to do that to something that's going to do a better job of management of glycemic control. We're really happy for that. Sometimes it's a little harder in the inpatient, the in hospital, the internal med, medical ICU, et cetera.

Sometimes it can be a little more difficult because they might have a different point of view than the Glucommander, but Glucommander is our doctor. So that's what I always say. I'm careful to say it though, in a very nice way.

So the other thing that's really important is the significant integration into your electronic health record.

We use Epic. We have a beautiful integration. We also have key pharmacists, very involved with all the integration and we have gone live successfully 10-07-2021. So today is 10-18, it's a little bit before you're going to hear me. We've had 18 patients in the Emergency Department on continuous IV insulin.

Only three of them actually required admission into the hospital and their admission was for something other than glycemic management. So for us, one of the big aspects of this is we've been able to control our patients and transition them and do so safely and beautifully in the Emergency Department, which actually now frees up our medical ICU and our step-down beds for other patients who are not quite so easy to manage. And that's been quite quite a wonderful benefit, but it really does take a team.

So here, you're going to see this is one of our pharmacy residents, who's been working very closely with me. That's her to the left and to the right, this is our first ordering ECC physician, Dr. Sam, so fantastic to work with. And he and I sat down, we looked at the protocol, we talked about what we were going to order and then we implemented on our very first patient. Everyone was so excited. Everybody wanted to be involved. And that's the other picture that you saw, was that very first patient.

And now we're just rolling. Like we've got grease on our wheels. If you have hyperglycemia and it's sustained and we need IV insulin, we're putting you on it and the bedside providers and the clinical providers in ACC are doing such a fantastic job. And it actually is going to significantly, we'll see, over the next six months, significantly change our throughput and profoundly improve our patient outcomes.

So I'm going to give you some quick key takeaways. The learning curve for actually learning about how to utilize electronic glycemic management, the learning curve for utilization is short. The planning time is long, and especially if you have EHR, you've got a plan with your colleagues for implementation, for testing, for testing, for more testing.

And the way that I teach is I always have test patients so that I can sit in a room with nurses at 25 computers, myself on my computer, projecting to them saying, we're putting in this glucose and we're going to put in this in. We're going to put a meter max, we're going to put a meter min, we're going to give glucagon, we're going to start a meal. We do all that.

Remember, these are test patients, not real. We're just testing and learning. So not real patients, but we'll put in multiple blood glucoses to get an overview approach of how we're going to adjust to it.

Acculturation though, of electronic glycemic manner is a journey. And depending on where you are actually investing and evolving, it's a different journey.

It was a different journey in the medical ICU where we had really strong physicians who felt really strong. They weren't endocrinologists, but they felt strongly, they knew best. But as time went on, they realized that they did not really know best, that actually eliminating human factor in calculation actually provided us with much better strategic control and much better management.

And by the way, you can't argue with your own data. And so when we look at our data, it's just like mind blowing, my head explodes. It's amazing when we look at our data, how much more effective we are in glycemic management than before we went live.

And now we're going to actually analyze a retrospective cohort in the Emergency Department to what we're doing now and everyone already sees it and says, this is so much better. And quite amazingly, of course, probably when anyone's talking to me they might be cautious, but quite amazingly, I really do have many nurses, the people who are responding to those alarms, many nurses reaching out to me saying this is so much better. I feel so much safer.

I want to share with you at one of the courses that I was teaching for the integration of glycemic management utilizing Glucommander, that I had a nurse who came up after, she said I've been a nurse for four years. I've been in the Emergency Department and for six months I've never left my work and cried on my way home until last week. And I cried on my way home cause I had two patients on the DKA protocol with paper and I just couldn't get them under control and they kept dropping their glucose and then it would go up and I couldn't figure out how to get it managed. And I felt like I was not able to provide best practice care.

And this was before we went live, but after an education program and she said, I love this. So I just saw her last week. She has had three patients on Glucommander and I said, are you still in love? She said, yes. Because I use that term all the time, get married to Glucommander. She said, I'm married for life. I'm never getting a divorce. I just loved that so much, but it is acculturation.

 In the Emergency Department, I had the monitors and the sound board hung suspended on the wall. So that alarms couldn't be turned down and we have had some physicians say to nurses, you need to turn the alarm down. My incredibly fantastic Vice President of Emergency said, Nope, we're not turning down the alarms, they're there for a reason. This is a patient safety initiative. So when I say culturation, it's a change in your mindset. Some folks say, oh, more alarms? But this is not a nuisance alarm. This is an alarm that says, if you do this one thing, which is measure your patient's blood glucose, input, your data, change your insulin, your alarms stop.

It's an alarm that tells you, you have an issue, and this is an issue that you can control. And for bedside nurses, particularly folks that work in acute and critical care and Emergency Department, especially right now, so much is outside of their control, but glycemic management is inside their control. And understanding how that affects long-term outcomes, short-term outcomes, and long-term outcomes. Looking at the data in sepsis, looking at the data in COVID-19, talking about mortality morbidity benefits in their hands. And safely in their hands. Unbelievable.

Always encourage you to develop good strong protocols to differentiate DKA and non-DKA and not to get too far down into the weeds, but to really look at those two different types of protocols and always just be prepared.

As you start, that you need to be prepared that you're going to have some issues with the protocols, with the alarms, with meal activation, with steroids, shiver, seizure, temperature, just for an example. An incredible opportunity to expand people's points of view and to blow their minds and to actually achieve something controllable in this incredibly uncontrollable world that we all love and live in, and that is the world of caring for acute and critically ill patients.

I hope that you've enjoyed this session and I look forward to seeing you again. Thank you very much. Thank you Glytec for continuously supporting us and helping us to achieve better patient outcomes.

And thank you for inviting me here today. Back to you, Hannah. Bye bye.

[00:58:59] Hannah Day: Thank you so much, Barbara. And thank you again, Tiffany. I appreciate your stories and your commitment to optimal glycemic management. Feel free to reach out to any of us if you have questions and thank you for joining us in this session. I hope you have a great day and thank you for joining us at Time to Target.

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