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Customer Case Studies Accelerating Change & Optimizing Glycemic Management

 

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

 

Debra Dudley, BS, CDCES, RN | AdventHealth Waterman

 

Susan M. De Abate, RN, MSN/ED, CDCES| Sentara Health Care

 

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TRANSCRIPT:

[00:00:00] Kerri Doucette: Hi everyone and welcome to our Customer Case Studies session. My name is Kerri Doucette and I am a Senior Clinical Customer Success Manager here at Glytec. I'm so excited for you to be joining us today, especially because I've been in your shoes as a Glytec customer. Hearing how other hospitals systems embraced change and collaborations to create their Glucommander success stories is a great way to spark new ideas for your journey. I'm pleased to be joined today by three of our amazing customers who will be sharing their experience and real-world insight on how they partnered with Glytec to accelerate change, and improve glycemic management at their hospitals. Today, you'll hear from Angela Hodges, from Texas Health Huguley Hospital, Susan De Abate from Sentara Virginia Beach and Debra Dudley from AdventHealth Waterman.
If you have any questions for our speakers, you can enter them into the session Q&A at any time, we'll answer as many as we can during the session, or we'll follow up by email if necessary.

I'm now pleased to introduce Angela Hodges, who will be sharing how a pharmacy-led initiative helped manage practice change in the ICU.

Angela Hodges, PharmD, is the Diabetes Center of Excellence Manager from Texas Health Huguley Hospital, part of AdventHealth. Angela, you have the floor.

[00:01:28] Angela Hodges: Okay, thank you for that introduction and thank you all for joining us today. Texas Health Huguley is a CMS 5-star facility as of 2021, so we're really proud of that. accomplishment. It's a 291 bed, acute care hospital located on the edge of Fort Worth, Texas. We serve a mixed rural and urban population. Our facility is a joint venture between Texas Health Resources and AdventHealth with AdventHealth managing our clinical functions. We are the only acute care hospital in Tarrant county, the joint commission advanced inpatient diabetes certification and we also have a certified outpatient diabetes education center.
So one thing that makes our program unique is that we have an automat ic pharmacy, insulin dosing consult model, our basal/bolus insulin dosing that we've had for a while. And currently pharmacists manage about 90% of patient insulin dosing. So today, I'm here to talk about change. Our facility changed our insulin dosing software. And I will tell you how a pharmacy-led initiative helped manage that practice change in the ICU.

The Greek philosopher, Hereclitis, is credited with saying change is the only constant in life, nothing stays the same. So first allow me to explain our standard process before our work conversion to Glucommander IV.

So the American Diabetes Association and the American Association of Clinical E ndocrinologists, even the Society of Thoracic Surgeon, they all agree hyperglycemia in the ICU should be managed with an insulin infusion that also prevents hypoglycemia.

So we had a system in place to initiate an insulin infusion when patients have blood glucose values greater than 180 times two within 6 hours in one of our ICU's. It came in the form of an automatic nurse-driven protocol. The ICU nurses initiated the insulin drip for say called PowerPlans in Cerner, which is our EMR, and we utilized EndoTool at the time. And this protocol was approved by the medical executive committee and physicians admitting patients to one of our ICUs could not opt out of this process.

The ICU nurses were extremely consistent and the process was expanded to allow Emergency Department nurses to start EndoTool on patients meeting criteria who are being admitted to one of our ICU medical care units. For years, both ED and ICU nurses were trained on this process and they did a great job. Pharmacy, physicians, administration, everybody knew it. And criteria was met. Nurses started patients on an insulin drip using this software.

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

Another area for improvement involved ill time coverage of patients receiving insulin infusion. So this process wasn't really clear cut, and it wasn't really consistent.

Also want to tell you about our non-critical care units. We had a similar evidence-based practice in the non-critical care areas, but it was pharmacist led. So hyperglycemia in non-ICU areas should be treated with long acting basal insulin and rapid acting mealtime insulin coverage. And this is known as basal/bolus insulin therapy. And I want to add that sliding scale alone is not recommended for inpatient. So the criteria for non-ICU was two blood glucose values greater than 180 within a 12 hour timeframe, so we had a little bit more of an expanded timeframe for you to meet criteria. And another difference is physicians opted in to this automatic protocol by signing an agreement with the pharmacy department to manage their patients once criteria was met.

A large number of our physicians utilize this service, including all of our hospitalists, our cardiothoracic surgeons, to transition those patients from IV to SubQ after open-heart surgery, our orthopedic surgeons, and most of our other internal medicine physicians utilize this service.

So the insulin dosing consult model requires that all pharmacists competently evaluate the patient's risk for hypoglycemia

 or hyperglycemia, and that those pharmacists are able to make dosing adjustments accordingly.

Now that you have some context, let's dig into motivation. The tech was falling a little behind and we weren't getting enough support in that so there was a little frustration at the previous decision support software is not making changes that seem to improve the product. We wanted to make sure that patients had the insulin coverage when they want an insulin infusion and also receiving a meal. So those that cover those prose prandial glucose levels, and our desired outcome was to optimize DKA and HHS here for our patients in hyperglycemic crisis.

As a glycemic manager, I noticed that physicians did not always initiate the needed order set to treat patients with DKA and HHS. This was most likely because of the separation in that clinical t ask was built into our process. The nurses would order the insulin drip, and then the physicians will order everything else. So then they had an opportunity to order those at separate line items. And we wanted to make sure that was all ordered in a evidence-based PowerPlan. We also wanted our patients to transition safely toSubQ insulin, without excursions, and we knew that might help our non-ICU reached their glucometric goals. Of course, our top priority is patient safety and a whole care patient experience.

In the ICU, when patients meet criteria for an insulin infusion, we really like to see them continue on that insulin infusion until they're ready for their next level of care and that's usually when pharmacist is involved. Pharmacists will put a basal insulin on the MAR for the nurse to give to the patient and then once the basal insulin is given, they cover with an insulin infusion for a couple of hours, and then the patient goes to their next level of care, whether that's a progressive care unit or a med surge

unit or something like that.

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

You may be asking yourself, why didn't you just continue to use the nurse-driven process and allow them to put the Glucommander or plan in since they were getting good results.

So I'll let you know, Glucommander requires a clinical evaluation and decision. The provider has to assess the patient's risk of hypoglycemia and hyperglycemia, from that information, multiplier has to be selected and a target range is determined. The higher, the patient's risk for hypoglycemia, for example, the lower the multiplier to be selected and the higher your target range would be. So this type of clinical evaluation is outside of our ICU nurses scope of practice, Those weren't previously required inputs for EndoTool

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

AdventHealth and Texas Health Huguley have always supported empowered leadership. As a true daughter of AdventHealth, Texas Health Huguley operates with a focus on collaboration. So Tammy Ellis, our CNO, Sharon Washburn, our quality admin, Dr. Laue, our CMO and diabetes champion at the time, along with Barbara Willis, our ICU admin and James Hall, our pharmacy director. All believe in the pharmacy department's ability to help decrease the chances of clinical inertia and continue great glycemic results in our critical care area after this conversion. The interprofessional team saw potential in the pharmacists expanding their role into the ICU.

Having clear ownership is important. Not one to back down from a challenge and not wanting to lose ground on all the nurses had built, pharmacy leadership took ownership of the new process. Empowered leadership creates family, you will do anything for your family. It all comes down to our service standards: keep me safe, love me, own it and make it easy. They are self-explanatory and beyond reprove.

Next, our strategic teams. Success would take training. It was determined that the pharmacist should understand what the nurses would see, even though the pharmacist wouldn't actually touch the software in practice. So every pharmacist at Huguley completed Glucommander nurse training, and every pharmacist completed Glucommander physician training . There were additional sessions within the department to help them understand critical care glycemic management and how it differed from non-critical care areas.

I am the queen of pocket card creation, which I am, but with Glucommander IV, I became the queen of the schematic. So I created schematics on our pharmacy consult model workflow, the workflow schematics on ordering the Glucommander PowerPlan and to my surprise, the physicians even found these schematics helpful and useful as for them to be posted in their area.

Collaboration is a winning tool to decrease waste, errors and variation in order to provide sustained positive results. I was blessed to be a part of two collaboratives at the time of the transition. I facilitate our local hyperglycemia collaborative and I co-chair the AdventHealth corporate glycemic monthly collaborative. So we invited facilities to present at the corporate collaborative. We have to get creative and figure out how to engage people in different units, departments, or even regions to share wins and challenges that will promote growth.

Just recently, Jason Hoffman shared with the collaborative how AdventHealth Kissimmee completed a pilot program for a pharmacist led glycemic management model after learning of Texas Health Hugeuly's success.

So creating a culture of collaboration, brings opportunities, and relationships that would not occur but, how do you know your program is working You have to look at your key process indicators and your metrics. You have to review those periodically and you have to let your data drive your practice change. So in short, our tool box was filled with our culture, our strategic teams and our honest data.

Glucommander IV went live for us in early 2018. So this is pre-COVID One of our key metric indicators was ICU within range patient days. So how many patient days were between 70 and 180. And the goal was to have greater than 75% of those within range. After our joint commission survey in late 2018, very late 2018, we added another performance measure locally and we looked at Glucommander initiation time. So I wanted to make sure within six hours of the patient meeting criteria, we had an order for Glucommander on the chart for them. And our data in 2019, after w e implemented this performance measure showed that 80% of the time patients were getting those Glucommander IV orders, within six hours. And for the last few months of 2019, we were at 85% for timely Glucommander initiation.

As we all know, 2020 brought the pandemic where there were major shifts within the ICU so, this was our data before the pandemic. So what that shows clearly is that we adopted our change process and the new software was providing the results that we needed.

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

We also saw something very interesting after the conversion took Glucommander IV in our non-ICU, there was an improvement in our within range blood sugar level. Now, Glucommander is not used in our non-critical care areas cause it's an insulin infusion software and we don't use insulin infusions in the non-ICU, but it's quite possible that we're seeing those improvements from that IV subQ process that I described earlier. And really importantly, we saw total consistency in our hypoglycemia. A lot went into that success, but I do believe our total culture change that was brought about by our Glucommander IV conversion played a role there.

Okay. Next we'll look at our order set entry. So all the way to the left, we can see three months before Glucommander was initiated, nurses were entering 85% of the PowerPlans to get the insulin infusion started, physicians and advanced practitioners were answering about 15% of those orders and pharmacists entered a whopping zero of those orders. So the nurses had us trained. We need to start insulin infusion, call us and we'll get it started.

In the middle, you'll see the first three months after Glucommander initiation and see a little bit of a flip-flop there. So the pharmacist entered 33% of the Glucommander IV PowerPlan orders, nurses entered 39%, so we start to see a drop, and the physicians enter 28% of those orders.

 After Glucommander was implemented, we ended up with two different PowerPlans, one for basic hyperglycemia and one for DKA and HHS. So this data is really representative of those patients that are admitted. They may have severe sepsis, their blood glucose increases above 300, so they need an insulin infusion or, a patient is placed on high dose steroids and their blood sugar rises above 200, so, of course they're meeting criteria for an insulin infusion.

This is where the pharmacists are supposed to support physician and automatically get that insulin drip started for consult so we start to see some improvement there. And then to the far right, I went ahead and pulled our June 2021 data to see how we were doing. And pharmacists entered the Glucommander IV PowerPlan 74% of the time, and the doctors and the advanced practitioners entered it 22% of the time, with nurses making up 4% and that 4% represented one order.

So I think that is so interesting that we had a total flip-flop in our process with the nurses going from 85 to 1, and the pharmacists going from 0 to 74%.

And as I mentioned, there's a separate order set for DKA And HHS. So this gives you a little insight into the physicians ordering practices. A few months after Glucommander was implemented, we can see that physicians were entering 79% of the PowerPlan orders for DKA and then also have our June, 2021 data where they're entering 80% of the PowerPlan.

So that's showing some sustained use of the new process and what's really exciting about this is for every patient with DKA, they're getting their IV fluids, they're getting the appropriate electrolyte orders, they're getting the tests that they need all ordered at the same time that the insulin infusion is being ordered for the patient.

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

So, what was the benefit of a pharmacist led glycemic management program? First and foremost, evidence-based practice was maintained. We brought efficiency to a very complicated process which allowed the physicians to focus on other important clinical factors. We were able to define the roles and responsibilities in our program, and we were able to reinforce the benefit of collaboration that occurs with an interprofessional team.

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

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

Finally, we continue to review our data, make sure that we were getting the results and keeping our patients safe in the process.

Thank you. Bye-bye.

[00:22:21] Kerri Doucette: Thank you, Angela, that was excellent. We've definitely seen how important it is for pharmacy to be a key part of the glycemic management team and it's great to see pharmacists leading the charge at Texas Health Huguley.
Now, I have the pleasure of introducing Susan De Abate , who will be sharing her experience with standardizing best practice care at Sentara Virginia Beach General Hospital. Take it away Susan.

[00:22:46] Susan De Abate: Hello everybody, my name is Susan De Abate. I am the Diabetes Prevention and Diabetes Coordinator for Sentara Hampton Roads and Team Coordinator for the Diabetes Center at Sentara Virginia Beach Hospital. I am happy to be here today, speaking to you on one of my favorite topics, diabetes. Next slide.
So just to give you a little bit of background of Sentara Virginia Beach, we are a magnet hospital, 273 beds. I will say we have been operating with Glytec and in partnership with them utilizing Glucommander for quite some time. And we'll be going over a particulars of that and our journey and how we continue to move forward on the path of glycemic control. When we started this journey, and to be honest with you, this was really over 30 years ago, we started with a partnership utilizing Glucommander when it was still hardware. So we are happy to say that we are now in the software mode of utilizing Glucommander and we did come across some bumps in the road from here moving along with our journey with Glucommander and thought that it would be helpful to point out some of the missteps, some of the wins and successes in providing glycemic control in the inpatient setting.

One of the first things I want to emphasize when we're looking at this information is truly the importance of buy-in from your providers. And where are they coming from? And really understanding their concerns about moving into a new practice.

 As most of you probably already are very much aware of, many people, not just physicians but many people are not anxious to change and there has to be some good education, good answers to the why are we making these changes? And what is the purpose and what, from our perspective, definitely the improvement in patient outcomes.

Some of the barriers that we saw truly was that when patients are coming into the hospital and being admitted, many times they're not being admitted primarily for their diabetes. It may be a car accident, and it may be they're going for some other kind of surgery, and so their focus is truly on that and glycemic control has kind of been not the priority, even though everyone recognizes that a poor glycemic control causes complications, even in the acute care setting and increases length of stay and certainly from a patient satisfaction is a big factor.

However, with our current environment of healthcare, we're definitely in the mode of trying to take care of the problem of what they came in for and get them out in a safe manner. So to do that, trying to engage our physicians in this process has really been a journey that has continued on a daily basis.

And we have great physician support and then we have new physicians coming in all the time. And one of their biggest fears that we hear over and over again, as we address some of those with our new physicians is they don't want their patients to have hypoglycemia. And so they personally would rather have a patient who has hyperglycemia in the hospital rather than having a hypoglycemic event.

So what has been helpful is our ability to demonstrate with glucometrics, some of the information that Glytec has been able to provide, supporting our, really our own data, our own information, identifying reducing hypoglycemia in the inpatient care setting. And that has been very helpful.

One of the biggest challenges in the beginning with the Glucommander usage and, especially the SubQ, the IV truly was an easier sell if you would because the nurses were using a paper protocol and following those guidelines in the ICUs, at step downs and in our particular facility, we actually have IV Glucommander throughout the entire hospital.

That being said, the adoption of that, the need for that, for those patients with DKA, HHS, et cetera, the expectation was that we needed to have much improved and tighter management and the focus was the blood sugar and the glycemic control. But when we moved into the SubQ Glucommander area, it did not really become as much of a focus area because as I mentioned earlier, it truly was something else was the priority and they just happened to have diabetes as well, and so the attention really was not focused there.

And so originally we had the usage of the Glucommander as an option. And I will say from experience, optional was not successful cause optional created a lot of issues and I'll go into that in just a second.

So, some of the other pieces was to make sure you have buy-in both from the physicians and the providers who are actually providing the orders and writing the orders.

Of course, you also have to have significant education on both sides, provider, as well as nursing and then also have administrative buy-in for the use of the product.

On our nursing side, again, some opportunities for improvement. Lessons learned, definitely, providing the opportunity for education as a mandatory part of ongoing education.

For example, when we have new employees come in, new nurses, they automatically are required to go through Glucommander training. We now have a wonderful CBT that Glytec has provided. We've been able to upload into our Onelink L earning and then in addition to that, during the orientation process, we then have hands-on as part of our diabetes orientation, additional opportunities for them to ask questions.

That, that initial CBT education opportunity, providing that as not an option is definitely much more successful because that means every nurse coming on board has had a strong foundation in the Glucommander usage from the get-go. When it was left open and at some of our other sites where it was optional, if you have 700 nurses on staff and only 20 actually came to the education, the opportunity for you not to be successful, definitely is much higher.

That definitely is a lesson learned, we took that to heart and have been operating that way at Sentara Virginia Beach for some time. And so, from the beginning with what we call the redeployment of the Glucommander, it has always been mandatory education for Glucommander on orientation for all new employees. And so that, that really has helped significantly.

And then really kind of making sure that nurses were comfortable and had an ongoing resource when we built the educational kind of schematic, if you would, for our team, it really allowed for nurses on the floor to be super users and divide them up into a group for those that would be end-users.

So, in addition to the diabetes educator team here at the beach, providing support throughout the the day for those off shifts, the 7P to 7A so to speak, or weekends when the diabetes educators were not available, then truly they still had someone who had additional expertise and experience with the use of Glucommander that they could turn to on their own units. And with the help of Glytec, they were able to provide us additional education at a higher level for those that were identified as super users.

When nurses don't have access to people to resource very easily and they're not utilizing Glucommander routinely, then the nurses sometimes then also get involved in this vicious cycle where you have the nurses are looking at it as this is very complicated. If you don't want a lot of calls from us perhaps you don't need to order the Glucommander. For those of you that are nurses, you know, how much opportunity you have to influence physician discussions and care for your patients.

So if the nurse is skilled at it, then she's more likely to continue to use that and she's going to support it because, I will say most of our nurses really like Glucommander in terms of its usage and its ease. When we get our new nurses on the floor, sometimes they have to do a few extra calls to us to help them with a couple of pieces but for the most part, they really are self-sufficient and do very well. And then when there is a new Glucommander order, they're not kind of looking to discourage it, so to speak. So that really is a very important key.

 At one of our sites, we've done reeducation to the nurses and the physicians multiple times but then there was no really emphasis to continue the usage of Glucommander. So then the use of Glucomman, Mander dropped off and then the nurses didn't have the practice and so then they were unfamiliar with it again and so they lost their skill ability to use Glucommander. So whenever, once in a while, the Glucommander order came up, they really didn't want to use it because they didn't remember all the pieces and all the steps.

So that really becomes a very vicious cycle in not adopting best practice. And again, as a magnet hospital, we really need to be striving towards best practice evidence-based practice. And that's where we want to continue to move forward.

So providers certainly drive the adoption We had great support from our VP of Medical Affairs and when we did what we called the redeploy, we had an opportunity to redeploy SubQ Glucommander because EPIC, which is our EMR actually had the ability to bundle the orders in one place. So almost like an umbrella, so to speak where you had the initial access was Glucommander. So you put in for a Glucommander order set and under that order set, Glucommander orders were in that one order set. So it walked you through the steps basically. So you choose Glucommander, then you choose whether or not it's IV or subQ and further looking at custom dosing, whether you're going on weight-based et cetera.

And that really walked the physicians through the process very easily and finding it in one place, instead of having to remember several different order sets, depending on what they did with the Glucommander, depending on what were their next steps. If they were looking to transition from IV to subQ, they hit the transition order set. If they were going from a IV to an insulin pump, then they transitioned from the Glucommander onto an insulin pump. If they were looking to transition to the subQ Glucommander, all they had to do was hit the transition to subQ Glucommander. So it made things easier rather than looking for several different areas. And when they go to save it to their favorites, they're truly saving one order set p rimary access point and it did make things easier for them.

 And then the other piece of this is truly other than just explaining the why for the physicians. So why this is important, how is it impacting our data? What do the numbers really look like? The other piece was really just physically walking them through the steps in their view. What do they see on their computer screen when they're going to put in an order and walk them through the steps? And we had the support of an endocrinologist on our team and he was able to provide that education in real time for our patients. We've met as a group and he walked us through the order sets and that was real helpful.

When the Glytec team was at the hospital, they did that with isolated physicians as they were available but of course even during that time, we weren't able to capture every single physician. So this was another additional thing that we did and went to the hospitalists meeting and provided that real-time education and have them walk through the order set itself.

So that helped to solidify and provide the physicians an additional reason of why we were going to do this and why this was a best practice and what our data really looked like. But then, it gave them the ability of how to do it and not just a verbal conversation about how to do it. They actually walked through each steps on their screen so that was real, real helpful.

And again, we revamped the nursing education. Instead of all of it being an orientation and a presentation during the orientation phase, we did move to the CBT with the redeploy and that has been extremely successful so that during the orientation phase, they come in with experience, even if they haven't experienced it yet on the floor with full integration, as far as the ability to access Glucommander in the CBT.

It's not one of those CBTS that you could just keep hitting up forward, or next, next, next and get through to the end and call it a day. You will physically have to respond to the questions, put in as if you are operating Glucommander, put in a blood sugar, put in an insulin, treatment hypo, et cetera. So it really does walk you through the steps and allows the nurse to really have real experience in editing in Glucommander as needed and documentation in Glucommander and that had, was very, very successful.

And so I will say, continuing to do orientation on other aspects of diabetes care with our nurses as they come in, the questions regarding Glucommander usage at that point is significantly reduced, even though they may have only had a couple of weeks and experience with Glucommander on the floor at that point.

So this was one of those key pieces that we were able to demonstrate after the redeployment. It kind of really illustrates what's the option on. And if you look at the line in yellow and look at that curve of where we were, that was before the emphasis on that all patients coming into our organization who did not require the IV Glucommander but had diabetes would be on subQ Glucommander.

Now, there are a few exceptions and our VP of Medical Affairs was very supportive of that mandated use of subQ Glucommander. But also recognizing there may be a few exceptions, as long as the physician was able to truly clearly identify those few exceptions and met that criteria as we had established and recognized.

And there are still times when a physician may not necessarily, many times it's a newer physician, may not readily jump on ordering the subQ Glucommander, but they usually are very receptive to the gentle nudges that the patient meets criteria for Glucommander, they should be on the subQ Glucommander and we get that enacted on. Whether it's a little extra push from the nurses themselves on the units, or as diabetes educators, as we see the trend on our screens and identifying and recognizing that the patient had not been initially placed on the Glucommander.

So it does help to prove that point. And we truly have been able to sustain a significantly high usage of the subQ Glucommander. And I will say it's become even more important so that poor glycemic control does not become more of an issue to extend length of stay even further. Especially during our current healthcare situation and crises where beds are at extreme high need. So extending length of stay because we didn't 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 again, a little bit of support, especially for that recognition of that hypoglycemia that seems to be one of those pieces that physicians were fairly comfortable running higher blood sugars so that they would avoid an hypoglycemic event but as you can see by the slides here, risk of hypoglycemia on Glucommander is pretty negligible.

Especially that severe less than 40 range. But even so, even the higher end of less than 70 that we do for safety to give us time so we can intervene and provide treatment as needed are still very small numbers and it is not an area that we have struggled as a system or individually as a Sentara Virginia Beach, where we have struggled with low blood sugars or hypoglycemic events with high ranges.

So, of course our big one to continue to work on and continue to tackle is that hyperglycemia and that blood sugar greater than 300. Certainly improvement was seen with the redeployment, a significant drop of over two points, from the 6.48 down to the 4.65, and that's real significant.

But again, still opportunity for more improvement, certainly, but definitely a win. The Glucommander usage and the results are in the numbers, you know, there, the data speaks for itself.

So i'm very happy to say that I've been working at Sentara Virginia Beach and have the opportunity to utilize the Glucommander because of some of the difficulties of the buy-ins from other, some of our other sites, the adoption of it wa s slow. So we have the best of both worlds and Sentara Virginia Beach does lead and serve as a model for the rest of the system because of our success and because of the methods that we use to employ it. And we've been at it longer, we learned some lessons a little sooner and implemented the changes and we were able to move forward. And so we continued to do well with Glucommander.

So just some key takeaways. Make it mandatory, the optional choice is not going to work plain and simple. You have to have executive buy-in, putting all the weight on the diabetes educator, even the nurse on the floor to encourage that activity is not going to be successful. It really has to come from your VP of Medical Affairs, your your nurse executive administrative work groups to really get to this point.

And then ongoing education. This is not an opportunity for one and done. It is also an opportunity for you to have a process that is established for all new employees coming in, as well as ongoing education and resources and having the availability, if in real time, when there is difficulty or they perhaps were new to using Glucommander and maybe they made a mistake. Maybe they, they did something they weren't supposed to do and didn't document something appropriately and chose the wrong order set or did some of these other things, how do we fix it? And rather than just throwing up your arms and say, can you just order something else? No. They have the ability and we have the ability to walk them through and get the order placed correctly of what the physician intended.

And just a little plug. Hopefully soon, we we will be moving into full integration and a lot of those issues that we did have will magically go away. And so, I anticipate even more of a reduction in some of those calls, because truly, it becomes very intuitive. It's the logical choice, it walks you through the steps you need to do but you do need that initial education and then an ongoing support system to make it successful.

So thank you all.

If you need to reach me, feel free to call me, send me an email. I'm more than happy to speak and provide any additional guidance and direction in terms of what worked and what didn't work and how to really accomplish this successfully for your own individual facilities or hospital systems.

Thank you so much.

[00:43:09] Kerri Doucette: Thank you so much, Susan. It's great to hear how you and your team identified the knowledge gaps and came up with strategies to address the challenges in your initial deployment of Glucommander subQ. I think it really drives home how important it is to have the entire care team engaged in glycemic management best practices and how that consistency and best practice care leads to positive patient outcomes.
Our next session speaker is Debra Dudley from AdventHealth Waterman, who will discuss using facility-level pilots to drive system-wide change. Debra. I'll turn it over to you.

[00:43:44] Debbie Dudley: Hello, my name is Debbie Dudley, and I'm going to be talking today about how Waterman Hospital, had a pilot to help drive system-wide change
As I said, I'm Debbie Dudley. I'm a Clinical Diabetes Educator at AdventHealth Waterman. I've had 50 years in nursing and almost 30 of that in diabetes education and glycemic management.

I work at AdventHealth Waterman. AdventHealth is a very large health system of over 60 hospitals in 13 states. Waterman is a small community hospital. We just graduated to 300 beds in Tavares, Florida.

We are small, but mighty. We are often utilized for pilot studies for the entire Advent system. We treat about 14,000 admitted patients every year and about one third of those that are admitted, require insulin. We do between 350 and 400 open-heart surgeries every year.

We do like technology here. We like futuristic technology. So our critical care uses ECMO, Impella, CRRT, and we actually utilize the Apache scoring system for critical care.

 Waterman Hospital is actually in Tavares, Florida and Tavares, Florida is located in Lake county. Lake county I always say is a sweet county, but not always in a good way. We actually have in Lake county, twice the national average of people with diabetes. Where the national average is 7, Lake county has about 14% of our population has diabetes.

So at least 30% of our inpatient population every day are living with diabetes and more than 35% of those that come through the emergency department are living with diabetes.

We are very progressive in our glycemic management. Uh, we use insulin on 100% of our open-heart patients up in CVI.

We switched to basal/bolus insulin therapy in 2013 and got rid of sliding scale. Although we have no endocrinologist at Waterman and have had none for the past eight years, we did implement an insulin dosing software system in 2013 called EndoTool, and we used it to do IV insulin dosing in the ICU, the CVI and the PCUs from 2013 to 2017.

 We realized that we have challenges for not meeting our corporate goals and therefore change was needed in the way that we handled glycemic management. We were not meeting corporate goals for severe hypoglycemic events. Those are events where blood sugars go below 40. In 2017, we actually had over 250 of those events.

We also had issues with prolonged hyperglycemia. Those are blood sugars, over 300. They were not receiving optimal treatment soon enough.

We also realized we had some workflow challenges. In the month of August of 2017, one of the slowest months in the past eight years, we actually had over 3000 monthly calls that nurses had to make to providers to change insulin doses. Lots of time for providers and lots of time from nursing that's being wasted by trying to communicate that we needed to change an insulin dose.

We also had some known challenges. We had providers who were reluctant to begin insulin therapy when it was needed in a timely manner. We also had providers that would begin insulin therapy on patients when it wasn't absolutely necessary.

Often when a patient comes into the emergency room, they have a high blood sugar because they're in pain or they're ill, but they're not diabetic and within eight to 12 hours that blood sugar has been controlled by the body. They were starting them on insulin right away and that led to a hypoglycemic episode or a low blood sugar.

We also needed to improve how insulin dosing adjustments were being made. They weren't being made in a timely manner when patients acuity changed or when the insulin needs of that patient increased or decreased.

We also realized that nurses would stack insulin. This often happens between breakfast and lunch. Nurses are really busy at seven o'clock in the morning. They have plenty to do with plenty of patients. And so where insulin should be given within 30 minutes of the mealtime, the breakfast insulin was often being given at 9:15 or 9:30 instead of 7:30 to 8. So at lunchtime, they were given their insulin on time at 11:30 but what happened is that those two insulins became stacked, meaning that both of them were having action at the same time, which often led to hypoglycemia in the late afternoon before dinner.

So looking at our key performance indicators, we realized that for the improved patient safety and to improve our goals in providing optimal care, we needed to address the severe hypoglycemic events.

And we also wanted to give that time back to both providers and nursing in the time that was being wasted into constantly calling providers to change insulin dosing.

 We did realize that there would be some barriers to success. Nurses already have more than enough to do. They were too busy to go to classes. They felt like they didn't want any more technology, they already deal with computers all day and all different kinds of, uh, insulin pumps and, uh IV pumps, and, um, technology, they just didn't want anything more.

We had those that said that they already knew how to use computer software, they didn't feel like they needed to learn anything more. And we even had a few providers that said they were so good at insulin dosing that they didn't think that insulin software could do any better than they already were doing.

 What we realized is that we needed was a marriage of changing the culture and an advanced technology that would help us to meet our goals and improve the safety of our patients. So to improve that glycemic management, we needed to address the people that would be involved, the process and possibly changing the workflow and adding a new technology.

And to achieve those goals, it was a corporate decision to implement Glucommander in some of our key hospitals for pilot studies and Waterman was chosen among those.

One of the most important decisions that we here made at this facility, is that we would enforce mandatory utilization from the very beginning of Glucommander on all inpatients requiring insulin.

So we started on December 5th in 2017 and in that next 24 hours, we actually moved all of our insulin users, both IV and subQ, to Glucommander. And we, to this day, continue with mandatory utilization and carry almost a hundred percent utilization of Glucommander throughout the hospital over the past four years.

So the steps in our process were actually to engage our providers, that would be both our medical staff and our nursing staff. We needed to educate both those staff so that they would think very differently from the way that we had always given insulin, which was that providers decided what doses would be and we would see if that would be effective or not.

We needed consistent communication all the time before the process through the process and continuing on to maximize the end user engagement. We were very blessed in that we had great communication and great support from both corporate and facility leadership to allow that to happen.

One of the barriers that we looked at was that Glucommander actually performs much better if you accurately carb count, it gives better recommended doses. It's really difficult to think of teaching 650 nurses, how to carbohydrate count accurately, considering that about 20% of nurses leave one facility and move to the next every year.

So what we decided to do was to actually do carb counted menus, and that has turned out to be an amazing bonus to nurses because they're learning to carb count every day as they count the carbs that their patients eat at each meal. But it also gives an opportunity for patients to take home those menus where they're already carb counted for them.

So it turned out to be a great success and a win-win on every level.

We also looked at that we had 14 glycemic policies before we started Glucommander and we decided to streamline that while we had the opportunity and we moved that down to 3, and we also put a process improvement in place.

 So our journey to improve patient safety and to reduce clinical errors actually came by the implementation of an eGlycemic Management System, which was Glucommander.

So I'm going to show you some of the data that we had. What are the first things that we did was we wanted to choose those things that we could make a change in. So we took the data over the 12 previous months, previous to the implementation, and we did a root cause analysis of those critical hypoglycemic events. And we divided out the ones that we could not change, we could not impact and we chose the top four that we felt like we could make great change. decrease the total number of hypoglycemic events most effectively.

One of them was that at the initiation of insulin, that the wrong dose was ordered and therefore administered. Second was the failure to adjust that insulin dose as the patient needs changed, that might be daily or even more often.

We also found that nurses were stacking insulin doses like I talked about before, often giving the breakfast one late and the lunch one early leading to a hypoglycemic event in late afternoon.

And also we had some issues with nursing failure to follow policy, probably because we had too many that involved glycemic management. And so we decided that we needed to look at those and intervene.

So we needed to utilize education and, and make people accountable for what they had learned. We realized that we needed to change the workflow and that we were going to look at shorter, more effective, easier to find policies. And of course our biggest intervention was to utilize Glucommander.

 All right. So looking at our key performance indicator, looking at our four opportunities for improvement and comparing the data pre-intervention to post-intervention. So taking those, the number of hypoglycemic events and what caused them the year prior to, and comparing it to the year post-intervention, we used the same months so our census should not interfere with the numbers.

We found that wrong dose insulin ordered was reduced by almost 54%. Failure to adjust insulin doses in a timely manner was reduced by 87%. Stacking of insulin doses was almost completely eliminated and this is because Glucommander prevents it from happening.

When the data is placed into Glucommander, the blood sugar, it will give a big red warning sign that says you can't give insulin yet, you just gave it a couple of hours ago. So it actually prevents it and you can see by the change that we really did improve upon that. It was very significant drop. I hardly ever see that that is an issue anymore.

And failure to follow policy from pre-intervention to post-intervention was a reduction of almost 44%. And that probably had to do with the change of the number of policies going down from 14 to 3, and also recent education intensively on every level.

 So looking at these graphs, where pre-implementation of Glucommander on the left and post-Glucommander on the right. You'll see, on the pre-Glucommander days, then there were months that we actually did meet and exceed corporate goals, but they were erratic. Those months were erratic. There was no rhyme or reason that we could find that some months we did really well and some months we did not so well.

So what we did was compare that to a year post-Glucommander implementation. And what we found is that the percentage of patient days with blood glucose levels below 40 in the beginning, actually increased. So why? Well, we had 650 nurses having a new workflow, using a new software system and we had 125 providers who weren't really excited about using a new software system and learning how to do it.

And so the, it's what I call the storming phase, is that it took a while. This was actually the learning curve that is involved with any new process that you put in place, but after that consistently for nine months, what you see is a significant drop. And not only do we achieve corporate goals, but there's a continue, consistent below goal average that we got in the following years after the implementation of Glucommander.

 So one of the things that people don't consider with hypoglycemia and the dangers of hypoglycemia, because the dangers of hypoglycemia are many and can be catastrophic. I don't know whether you know it or not, but the effects of hypoglycemia don't just last the 90 minutes that it takes to correct and stabilize that patient, or even the 90 hours that they may be in the hospital post glycemic event, but it actually impacts their mortality for 90 days.

And to me that's so important for people to realize that when a patient suffers a critical hypoglycemic event, is that it really does increase their risk of dying for the next 90 days when they will not be in the hospital. It also costs the hospital money, it really does. You have an intensive care that needs to be taken care of that patient.

We're checking their blood sugars and treating them every 15 minutes for an hour. We're also involving providers. We have to call them. We have to let them know what has happened. It often increases length of stay. It may need the changing of medications. It may involve giving additional medications like D50 IV push.

So it becomes an expense to the hospital. And looking at the literature, I actually took the lowest estimated cost of a single hypoglycemic event, which was just under $3,200. And I took the reduction in hypoglycemic events for the next two years compared to what it was the year before. And looking at that, that after one year, we probably saved the hospital about $350,000 just by the reduction of number of hypoglycemic events after the limitation of Glucommander.

So have we successfully changed the culture?

I think so. And for me, one of the biggest wins was the change in the attitude and the culture of the medical staff. This was really difficult for them.

They had learned from the first days in med school how to write insulin doses, how to calculate it, how to change it and we were now changing everything that they believed that they were in charge of. And it was really quite a storming phase. But one of our biggest opponents of Glucommander actually said in one of our meetings, "I confess I was the biggest opponent of Glucommander, but now I'm the biggest proponent because it really works."

And that was Dr. Bisht after nine months of Glucommander. And I have to tell you, this is a giant win.

 We also had some unexpected benefits. We had greater adherence to hospital policies and that was probably because we narrowed the number that had to be looked up, the number that had to be learned.

We did intensive education prior to, and at time of implementation of Glucommander, but we also improve rates of A1C testing on all our insulin users. Prior to Glucommander, testing was done, but it wasn't done consistently and it wasn't done all on the first day or on admission, or even by the third day, sometimes it was done by discharge.

An A1C gives the provider a real idea of what that patient's baseline glucose's control was before they came into the hospital. Because of the order set, because of Glucommander wants you to put a recent A1C in there, every patient that is admitted from the emergency room, an A1C is, tested for them if they're going to be placed on Glucommander.

If they're going to use insulin, we are going to have an A1C and we are going to be aware in hours what the baseline of that patient's blood glucose control was prior to admission. We also obtained an easier transition for patients using insulin from hospital to home.

Glucommander has this marvelous little button that you push on the top and it will calculate an appropriate dose of insulin for that patient when they go home. Many patients start using insulin for the first time while they're in the hospital, going home on insulin is traumatic. Not only that, but providers have to take the time to be able to calculate a dose that they feel is right. Glucommander takes the last 48 hours of patient's blood sugars and the insulin doses that they needed and their reactions to them, the carbohydrates that they've eaten and they actually calculate that out. So the doctor just pushes a button and they get printed out what a recommended dose for home would be. It makes it very easy. We also had more than a 75% reduction in first time calls to providers to change glycemic management. This was a win for everybody because it saves lots of time and I tell you, it really has made our providers so much happier that they're not called 30 times during the night to change various patients insulin levels so that their blood sugars are managed.

So lessons learned, we learned that there would be challenges and there would be barriers. Uh, we were aware of some of them so in the beginning we brought all the key stakeholders together so that we could help to realize those barriers and meet those challenges before the implementation.

But some of them we did not even realize until afterwards. We learned to assume that there are knowledge deficits on every level. Doesn't matter if a nurse has been giving insulin for 40 years, it's a totally different animal when you give it with an insulin software system. And we learn not to get discouraged because there is a learning curve and our data shows that so blatantly there is a learning curve.

It takes time. A change in culture is difficult for everyone and we did have difficult periods in the beginning but you just learned to be patient. It takes time and the successes are so rewarding. We learned to celebrate and share each one of those successes. If one unit did exceedingly well on that month, we would give them treats and give them stars and make it known that they did a great job.

We were very, very blessed to have really great leadership and support both corporately and facility-wide, we were very transparent with them and they were transparent with us. And that really helped us in our success. You need to be collaborative in working when you implement such a huge change in culture.

 So here we are almost to the day, four years later. And have we been successful? Oh, I think that we really have. I think that Waterman has become a model of success in using Glucommander in achieving glycemic management. Because of our data, almost every AdventHealth facility has already implemented IV Glucommander in their ICUs, most of them in their PCUs, some in their OB department and many of them in their emergency rooms.

And it is hope in the near future that AdventHealth will also spread the use of subQ Glucommander throughout those facilities so that we can improve the safety of our patients and improve our glycemic management system wide.

[01:05:17] Kerri Doucette: Wow. Thank you, Debra. We all know change isn't easy, but you show with the right training, collaboration and leadership, it is possible to achieve success.
I'd like to thank Angela, Susan and Debra for sharing their presentations with us today. Their information is here on the screen if you'd like to reach out and connect with them on any followup questions. You can also reach out to the team at Glytec at timetotarget@glytecsystems.com.

We hope that you enjoyed this session. We ask that you please take a moment to complete the session survey and share your feedback with us.

On behalf of our speakers and everyone here at Glytec, we thank you for joining us at Time to Target, and we hope you enjoy the rest of the conference. Have a great day.

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