Uniting People, Process and Technology to Achieve Optimal Glycemic Management
Ineffective glycemic management has consequences that reach far beyond the patient bed, and stakeholders throughout the hospital have a role to play in ensuring the safe and effective treatment of patients with glycemic issues.
Presented by Glytec's Chief Medical Officer, Jordan Messler, MD, SFHM, FACP, this session provides a high-level overview of the "must haves" for creating a best-in-class glycemic management program and the people, processes and technology that are needed to achieve excellence, improve patient safety, and reduce the cost of care.
Kara Joyce: Hello, everyone. We are just going to wait a few moments while all of our attendees join and then we'll get started.
All right. Welcome. And thank you for joining us today. My name is Kara Joyce and I am a member of the commercial team here at Glytec. We appreciate you taking the time to be with us today for our clinical webinar, titled uniting people, process and technology to achieve optimal glycemic management. Just a few housekeeping notes before we jump in first, this webinar is being recorded.
We have allotted some time at the end of this session for questions and answers. If your question does not get answered during this portion, we will follow up with you directly via email. I am now pleased to introduce Dr. Jordan Messer, the chief medical officer here at Glytec. He'll be leading today's presentation and be with us through our Q and a section at the end, Dr. Messler, take it away.
[00:01:17] Jordan Messler: Thanks so much, Kara. Hi everybody. Thanks for joining us on this, uh, beautiful afternoon here in Florida, to talk about people processing technology and achieving optimal glycemic management. As Kara mentioned, I'm the chief medical officer here at Glytec where I spend the bulk of my time.
I do still work in the hospital. I'm a practicing hospitalist in the bay care health system. Uh, here in Florida. I also spend some time in USF college of medicine in the medical humanities division there, and as well, I've done a lot of work with the society hospital medicine most recently was the past physician editor of their hospital leader.
So the next 30, 35 minutes, I thought we'd go through the status quo of glycemic management. Really understanding how people process technology can help improve patient outcomes, outcomes, get a good introduction to Glucommander if you're not familiar with Glucommander and then really try to illustrate the combination of using people.
Process technology, particularly Glucommander through a couple of case studies with IV glycemic management and SubQ glycemic management. So, what is the status quo of glycemic management in the hospital setting? Well, a few things let's talk about hypoglycemia and hyperglycemia. We know that hypoglycemia is common, costly, and largely preventable.
It's common, uh, in some studies up to 22% of patients in the hospital experience and mild hypoglycemia, less than. Preventable. We know that patients with hypoglycemia to 40% of patients will have a recurrent hypoglycemic event. And when patients do have hypoglycemia in the hospital, when it's related to insulin or other medications that lower blood sugar, they often don't have their medication regimen changed.
And costly, severe hypoglycemia has been linked to excess cost up to $21,000 per episode, or higher, um, in some studies, 40% higher cost for each less than 40 that occurs. And this, uh, trans has translated into length of stay increases. Um, what we know again, the morbidity and mortality are related to hypoglycemia, but seeing that length of stay and cost increased as well.
Uh, at Glytec, some of our sites have done independent studies. We worked with some of our sites to further analyze the impact of hypoglycemia costs, uh, prior to using, uh, going with Glucommander admin health had done a study to really, uh, understand that their, uh, system, what the impact of severe hypoglycemia meant for costs and compared to normal glycemia episode of severe hypoglycemia led to 21,000, uh, excess costs per patients.
Um, $33,000 has been seen of cost of recurrence, severe hypoglycemic events. Some patients have multiple, uh, hypoglycemia that recurrent are in the hospital and those costs could even be higher. One health system. Uh, that, uh, used Glucommander whole house, uh, went Glucommander IV and SubQ, uh, saw almost $3,000 in savings per prevented, uh, less than 70 event in the hospital system.
So that's hypoglycemia, hyperglycemia also common, largely preventable and costly. Uh, Common study going back to 2002 showing up to 40% of patients in the hospital with diabetes or hyperglycemia and some institutions. That number seems to be closer to one and two, uh, preventable hyperglycemia is often not treated.
Uh, we see sliding scale, insulin alone and outdated therapy, commonly used for hyperglycemia and often cited of, of why it's not being treated is a fear of hypoglycemia. And we'll talk more about that. Again, costly impact associated the cost to our patients with morbidity and mortality, and that morbidity relating to, again, increased length of stay and real dollars for health systems as well.
And we know what works. We have standards out there. The American diabetes association puts out their standards of medical care each year at the end of the year, uh, with a section on inpatient management, endocrine society just recently, uh, last month, uh, put it forth there, uh, hyperglycemia guidelines in the non ICU setting.
So updated their guidelines and then national societies like SHM. The society hospital medicine tries to translate that evidence into practice puts out implementation guides that are, uh, freely available. Try to begin to understand what we know works, how to put that into practice. And this is really the challenge is implementation gap.
We know a lot about how to manage patients successfully in the hospital. That knowledge continues to grow, but we do not keep pace with that knowledge in what we do. And there is this large implementation gap for a variety of reasons, whether it's lack of awareness, lack of metrics, meaning lack of insight, or lack of a standardized approach to how I would managed by CIA in the.
So when we have this gap, what does it look like for the patient? So what do we do despite what we know? Well, we may delay that initial start. So this is a simulation of patient, maybe waiting to get on treatment. Those blood sugars bouncing around, up and down high in the red. They get started on an IV protocol.
That's a paper protocol. Um, involving calculation steps, delays in blood sugar checks, get those blood sugars in control, but perhaps a delay. And then the blood sugars are still bouncing around without a standardized approach to transition. You'll continue to see that hyperglycemia get rebound hyperglycemia.
And if you're using sliding scale insulin approach, you might be familiar with seeing these blood sugars bounce up and down with a reactive approach. That's not uncommon to see. And again, in the health system, we don't have a very good insight. One in three hospitals really have no clear measurements to track glycemic management and up to half of hospitals, generally, I only have one or two measurements to gauge a glycemic, uh, success in the hospital, glycemic metrics.
And how do we gauge glycemic management success? Looking at these three pillars, we're working to prevent hypoglycemia and try to measure those hypoglycemia outcomes, treat hyperglycemia as mentioned and really driving optimal utilization of the policies, procedures, order sets that we put in place. So we're using what we put in place and those order sets and we're using.
What are other things that we think about and overcoming that implementation gap? Well, having a standardized quality improvement approach, do you have a, a QI methodology that you use regularly, either model from improvement, IHI plan, do study act lean six Sigma, some standard approach, uh, at least some common elements from these approaches, implementation science.
Are you using, uh, readiness for change tool to make sure that your system. Is ready for change, identifying stakeholders, champions for whatever projects you're doing. And again, here, we're talking about glycemic management. So you have the stakeholders, the committees, the champions in place, and certainly thinking about change management strategies, whatever it is, implementing new order sets or implementing a new technology.
Like Glucommander. Need to understand the readiness for change and understand the change management strategies for those frontline providers. We understand the intrinsic motivators that get us drive towards patient safety outcomes or those extrinsic motivators that are in place. Some of them that do work well.
And some of them that don't work well. When we think about change, I always think about this quote from Dr. Alden. Every system is perfectly designed to get exactly the results it gets. So if you wanna change, if you wanna get better results, you have to change the. There are a variety of other strategies they could think about and engaging physicians.
In my perspective, as a hospitalist, I've talked about this a lot and I work with colleagues. Uh, how do we engage physicians often, top of mind, and we're working with health systems. This is a, uh, several ideas that come out of, um, Dr. Provos that was published a few years ago in the joint commission journal of quality.
So selecting quality issues. Quality issues that clinicians care about emphasizing those patient centered outcomes. Using intrinsic motivation, as mentioned as a leader, and some attributes of intrinsic motivations are getting providers to master a concept, giving them some of that independence back autonomy choice.
And that sense of purpose. Again, patient safety being one of those highest sense of purpose are the incentives that fly to the organizational level, not just thinking about the providers, but at the unit level group, level hospital, really getting, uh, teamwork, uh, team based concepts involved for incentives as well.
And they mentioned building that capacity for research. If you're doing all this good work, quality improvement, are you sharing that just at, at poster sessions at your health system at conferences at national conferences, do the good work and then share those successes. So speaking of motivators, extrinsic motivators in particular, well, there's one that's here.
Uh, CMS, Medicare has a new quality reporting measure, two new measures around glycemia. So there hasn't been anything around glycemia before. You're all very familiar with regulatory measures around readmissions, heart failure, sepsis. And now we have two around glycemia. So there's one call with severe hypoglycemia based on patient stays less than 40, within 24 hours administration of insulin and severe hypoglycemia looking at patient days greater than 300, excluding those first 24.
So patients stay less than 40 patient day, greater than 300. These are two new measures. In the E C QM system. Certainly talk more about this if there's questions, but hospitals will start collecting data on this January 1st and decide next year, whether they'll report on these two, uh, in the, in the menu of about 11 E C QM metric metrics in the CMS quality reporting program.
All right. So what are the elements of a best in class glycemic management program? Again, I'd like to think of that framework of the people process technology. Best in class management programs tend to have elements in common, even if some of the details differ around the people achieving that consistency of care, the processes optimizing those workflows, standardizing care and using technology, whether it's the medical, the EMR, or adding technology solutions, like our EGMS, uh, solution here at Glytec.
So thinking about the people, think about the people. Why is there a lack of consistency of care and reduction to clinical variation? That's one of the good questions to ask, uh, looking at, you know, people or is there administrative support sometimes at sites that aren't having success? It's. Pretty standard to have a glycemic management team.
If you're not having a good multidisciplinary team, often that's a factor in success, staffing ratios. And generally just that inability to overcome that fear of hypoglycemia. When thinking about glycemic management change. How about the process? Why aren't projects to improve successful? Well, is there that standardization, if you don't have that standardization, that's a big barrier, perhaps no systemwide diabetes committee policies and protocols are often unclear and metrics.
Uh, again, as mentioned are, are not gathered in lack of insight. How can you change something now, if you can't measure it? And then the technology, uh, are you using the most advanced technology to personalize care? We'll do a little deeper dive into Glucommander in a little bit talking about the technology that we have.
Uh, obviously the EMR, we're all familiar with EMR implementations and thinking that many aspects of the EMR we're gonna solve a lot of our problems, but we've learned over and over again that we know technology is a tool, not a strategy. You gotta implement these tools, uh, successfully. So the roadmap to glycemic success.
This is one framework to think about having the right people, the process technology, and again, measuring that glycemic success around that those steps to prevent hypoglycemia, those preventable hypoglycemic events related to insulin or medications that lower the blood sugar, treating hyperglycemia, not delaying treatment, treating timely, treating effectively and utilizing.
Order sets those processes. You, you put in place technology, uh, using, using 'em and using 'em ly. I wanted to take a minute to talk about a checklist. I often think about whatever quality improvement project that we put in place. There's some. There's are random elements that, that are good to think about.
If a project is not moving as well as you'd like, do you have all these items in place? So the 10 item checklist based on a lot of work out of the IHI, the Institute for healthcare improvement, the model for improvement, my checklist, my checklist has these tens, the support, the synergy structure, smart aim, sensible stats, segment, standardize, strategize, and.
So those 10 elements are the support, and we've alluded to several of these already having that institutional support, having that synergy, a multidisciplinary team, that's working towards change, having a clear structure, the framework, uh, for quality improvement, making sure you have aims. This is a simple one.
That's often overlooked, very general aims. Uh, let's try to improve glycemia, but you really need those specific aims. Um, really looking at that per that population, uh, that timeline of really making sure that you have smart aims for any project you're working. Sensible. So are the metrics that you're looking at, the process metrics lead to the outcomes that you want, having that meaningful data to drive change number seven is that segment often it's helpful to pilot in a smaller population and standardize the process.
Can't say this enough. I think I've used the word standardized about 10 times was ready. Whether you're implementing something like Glucommander or other processes, be sure to standardize so you can understand vari. Strategies in particular high reliability strategies and whatever change you're doing.
We know we have to do it swift. We know there's multiple priorities, uh, implementing a, a project rapidly, getting rapid data collection is a key to driving change. So a good checklist to keep in mind. So let's try to think, um, uh, as we get to our case studies in a minute, let's try to, um, understand a little more about Glucommander and what that could lead, uh, to better outcomes as we think about a complete solution for best in.
Uh, glycemic management. So here at Glytec, we have, Glucommander a brief story of, uh, Glytec our origins go back to 2006, the first EGMS eGlycemic Management System, uh, that received FDA clearance for IV insulin titration over time, have a tried and tested and validated. Algorithm and process to implement Glucommander at health systems.
And we have over a hundred studies that are, uh, freely available on our, on our website. And we work closely with our sites and continue to have a vision and a roadmap for the future building a future of optimal glycemic management. And you can see in the bottom, right. Of some of the recent recognitions that we've had.
So again, uh, Glucommander let's uh, go through some other basics of Glucommander Glytec E complete EGMS platform, really working with the entire care team, providing analytics, reporting, surveillance, workflow, work alerts, key things that as I've. Went through the structure for optimal, um, quality improvement steps, the things that we've implemented and put in place in our EGMS system, a system that integrates with your EHR to make it as seamless as possible.
Thinking about cybersecurity with any technology that you use, we're high trust certified and cloud based. And the algorithm, uh, the way Glucommander works, having a personalized insulin decision support at the point of care interface, guiding clinicians, the best practice workflows, all the things that we know how to do, or try to guide to those best practice and FDA clear technology.
If you've heard of Glucommander before you're often, uh, just think about Glucommander as just the software. But I really want to be clear throughout this talk, the presence. The, the premise is that again, this EGMS system that we have really thinking more holistically and particularly in that center, our team works longitudinally with your glycemic management team.
Once you implement Glucommander to be, uh, engaged with that multidisciplinary team, that's essential for success. Uh, Glucommander is hosted in the cloud, the GL cloud. Uh, we have metrics to get the analytics and reporting again, mentioning that's often a deficit at many institutions trying to improve by.
Realtime tools like glucose surveillance and gluco view as well to better monitor the patients and identify patients at risk. And we provide a continuum of care from entering into the hospital, starting IV Glucommander for those critical patients in the ER, through the ICU, transitioning to SubQ safely Glucommander SubQ.
And we also have an FDA cleared outpatient. So. So, what does this look like for the end user? So if you're in the EMR, this is a Cerner mockup. So when you're in the EMR, um, there's no separate logins. There's no separate place. You have to go for Cerners on the left, you'll see those end pages. There would be a button there for Glucommander on the top and red that Glucommander dashboard, uh, other spots to get to Glucommander information and our cloud-based solution.
This is what appear in the, from the end user, uh, seamless software. Uh, we can certainly spend hours really working through and demonstrating what Glucommander does, but a couple of slides, I thought I'd illustrate. We have an integration, so you can have that lab integration, that blood sugar's pulled in.
So step one, here, you see that two 50 is pulled in. The nurse would step two, hit, uh, uh, continue. And then the insulin infusion rate that would be updated for the patient on IV insulin would appear and just confirm. And Glucommander and change the, uh, pump for that rate. No calculations, no multiple column methods, no multiple steps, no math for our busy, uh, nurses for our, uh, certainly health systems that are dealing with staffing ratio issues, uh, really a seamless solution.
And in step three, having those other alerts as mentioned to you can see that 28 34, that's a countdown for the next blood sugar check, lots of other data, uh, front and center for the nurse to help manage their patients successfully. When you're using Glucommander ideally you'll see these kind of outcomes.
So a simulation for a patient on Glucommander IV gets started timely. None of that red, none of that delays that blood sugars come down nicely into target range. They stay in range while on Glucommander IV, you transition with our transition module to try to minimize their risk for rebound hyperglycemia.
And then in green, on Glucommander SubQ, keeping those patients, uh, in range. Uh, we get patients in target sooner than, uh, usual care DKA. The study here was mild DKA showing five hours, median time to target, uh, using our solution. Multiple sites have shown reductions in severe hypoglycemia. The study referenced to your 98 9 0.8% reduction in severe hypo using IV Glucommander compared to usual care.
If you do this over and over again, you can see the outcomes that would lead to those, uh, costly outcomes that we alluded to earlier. Length of stay reduction, cost of care reduction, and several other outcomes that we've, we, again, we've published and all available on our website. So I, I thought I'd spend a little bit, uh, trying to weave all this together.
With some case examples, I will first start with an IV patient, a critically ill patient. So you have a patient, a typical patient that comes to your ICU. A 75 year old man presents with shortness of breath. Cough fever gets tested for COVID. 19 is negative diagnosed with sepsis, severe pneumonia. Start on antibiotics and pressers monitor in the intensive care unit, blood sugar, 330 would pause and, and reflect yourself how you generally manage this patient.
Um, we know from the guidelines that, uh, IV insulin, but, uh, often we are seeing the IV insulin is generally used just for those hyperglycemia crises, DK and HHS, but this patient would meet criteria for IV insulin. And that's the challenge. What we know. And what we do that implementation gap. So what we know the standards of medical care, continuous IV insulin is the most effective method for achieving glycemic targets.
IV insulin should be administered unvalidated written or computerized protocol. And I think the second paragraph here as insulin therapy should be initiated for treatment, uh, starting at a threshold at greater than 180. This patient meets, uh, criteria for IV insulin. What are your institutional challenges with IV insulin management?
So take a second to pause and see if this list may match, uh, what you're thinking about as well. Um, nurses tend to do really most of the management for IV insulin in the critical care setting and top challenges that we often hear from nursing with usual care, with paper based protocols or that there are calculations involved, multiple steps involved and doing multiple, uh, tasks in the ICU.
Any way to minimize those steps are E. Unable to complete the timely hourly checks without the alerts to warn 'em when that next check is due too many protocols for IV insulin that are in place, different providers tweaking their protocols just a bit. And you have all these various protocols to use.
And know if you're moving in different units in the hospital, uh, protocols that are in place tend to drop the blood sugar too. And there is a subset of critically ill patients that may be getting meal carbohydrates and often no way to, to cover those meals. And then just as patients are getting in control to see the, get the hyperglycemia while they're eating, uh, a meal coverage, when you don't have, uh, ability to cover that on IV insulin.
I mean the main, a question that I ask when you're, when you're seeing this and thinking about usual care and PA protocols, why are your nurses still having to do calculations, still having to do multiple steps around IV insulin? When solutions like a Glucommander exists with the challenges of turnover, staffing, retention, all these things that we're hearing now, more than ever, what are you doing to reduce the burdens and cognitive load of your staff should be an essential question.
All right. So what we do again, we know what the, we see the guidelines. What do we do? We use outdated protocols. We, uh, often see delays in the start of IV insulin. So may recognize that somebody needs it for a variety of reasons. There's delays. It starts, uh, instead of using IV insulin, which again, uh, would be recommended for the patient example here.
I often see patients start on basal insulin instead for the reasons alluded to earlier, the fear of hypoglycemia. Or just, you know, just think it's stress hyperglycemia, that's gonna resolve quickly and it often doesn't. Um, and then we also see patients started on sliding scale, insulin alone, a very reactive approach instead of IV insulin.
Uh, we looked at this, uh, with Grady Memorial hospital a couple years ago. Um, the, the impact of using basal insulins compared to IV Glucommander. So they had a, an approach, uh, not using Glucommander, um, for basal insulin, but they had their, their protocol for basal insulin. And they compared that to IV Glucommander use and looking on the left here as expected.
I mean, time to target. Two to three times longer using basal insulin and on the right here, uh, looking at hypoglycemias from severe, less than 40 to mile, less than 70, and seeing the dramatic, uh, decrease in severe hypoglycemic events by using IV insulin. So we often hear that fear of hypoglycemia, fear of hypoglycemia with IV insulin using basil instead.
And that obviously that fear is not born out here. IV blue command. In fact much safer and much lower, uh, less than 40 than using basal insulin. So as we talk about some of the aspects of Glucommander IV to overcome some of the challenges that we know about some of the things that we do. Um, so Glucommander IV has glucose surveillance, which is a tool to monitor in real time.
Patients proactively identify patients that are not on Glucommander that would benefit from being on treatment. And we have a proven algorithm. Mentioned personalized dosing, no calculations needed. Again, refer to our evidence, um, uh, page on our website, uh, to look through all our evidence over the years.
And that piece about carbohydrate coverage. I mentioned earlier. So we have ability to cover, manage carbohydrate and take while on IV, since a patient that is improving still on IV and able to lead a little bit, just when you get 'em in control, let's keep them in control and make sure we're managing carbohydrates while on IV insulin.
A little deeper illustration of glucose surveillance. Two will mentioned a couple of times. So on the bottom of this page, you see the patients on Glucommander. This is an example of a list of patients that are on a dashboard. You could see in a unit or on insulin. And then right above that, we have these three names, uh, D 50 readmission.
These are patients that are not on Glucommander, but that having multiple readings greater than 180, Uh, a nurse manager, a diabetes educator, a frontline clinician can quickly look at and see how these, this patient blood sugar, 440, 60, 50. Why aren't they on IV insulin? Let's get that started. And this is one of those high reliability strategies.
When you're looking to improve any process, the more high reliability strategies you can do, the greater the impact you're likely to have. So having a tool like glucose surveillance provides that realtime surveillance, active surveillance, and ability to intervene, uh, in real time. We also have a realtime dashboard as, uh, again, shown earlier.
Here's another look at the dashboard with patients they're actively on IV Glucommander. You can see the timers on the right for when that next blood sugars due. We know timely blood sugar check is related to hypoglycemia and the, uh, variability of blood sugars. So here's a status indicator for all patients and can quickly see when the next blood sugars do and nurses can plan and prioritize.
I also wanted to highlight some other, uh, realtime alerts that we have. So you can see in the middle here in red 15, that's the anti gap. So we have an integration pulling in the anti and gap and nurses can be alerted to what that is and, and helps with that communication. Understanding not to prematurely discontinue a patient with, uh, DKA on IV insulin, uh, too soon.
So that's Glucommander solutions to try to overcome those barriers. We've mentioned. There are some numerous process improvements. People improvements, QI solutions. Here's a sample of a few to think about when you're trying to improve glycemic management, other tools. Obviously we have our glucose surveillance, but there's numerous tools in the EMR to try to identify in real time, patients that have hyper or hypo.
Improve ordering, uh, ways that we can work through the EMR to make the ordering more simple one clicks, embedding order sets and certainly metrics. So a lot of sites, um, as we mentioned, don't have data when you do have data. I often see sites don't even share it. So frontline, uh, critical care workers may not even know other rates of hypo hyperglycemia.
And certainly working with people closely engaging stakeholders, create that accountability structure, consider those nurse or pharmacy driven processes. There's a lot published about successful pharmacy driven processes to drive improvement in glycemia. So in this particular case, identified on Google surveillance, nurse driven process was in place at the institution, uh, to start IV insulin.
And, uh, the unit over time has experienced low rates of hypoglycemia and that data is shared with the team regularly, uh, celebrating the wins. So for our last case, uh, talk about SubQ management. So a typical patient, uh, SubQ management of, uh, hyperglycemia. This is a 62 year old male that comes in with type two diabetes presents with a lower extremity infection, cellulitis, blood sugars, high in admission.
So a point of reflection at your institution, what would the management be? What would the insulin management be? Will it be basal bolus? Basal prandial therapy will be oral agents will be basal only sliding scale insulin. Only imagine if I did a, a poll, you might see some varied answers here. And that's a problem, right?
We're trying to standardize care and standardize the best practice. Uh, we should, you should anticipate what, uh, your providers are gonna be writing for these, uh, for these patients and will the insulin doses, if they do get started on standard basals will the insulin doses be changed daily based on their response.
So again, thinking about the implementation gap and SubQ management in the hospital, what we know we have, uh, guidelines standard of care, uh, thresholds for beginning insulin therapy should be around 180. Once insulin is therapy is started that target goal of one 40 to 180. Recommended for the majority of critical ill and noncritical ill, you may go tighter if you can safely do it without significant hypoglycemia.
And the standard management is basal insulin, uh, with, uh, with small amount of correction for patients that are not eating well and 16.7 insulin regimen with basal prandial correction, our basal BS regimen as a preferred treatment for non-critical ill patient. 16.8 at the bottom. I think the key points, uh, sliding scale insulin regimen is really strongly discouraged.
There is some evidence, uh, in the literature that there are patients with mild hyperglycemia, less than 180 can use sliding scale insulin. But we know for the vast majority of patients that remains basal therapy as the standard of care. Won't review all the evidence, but this is based on work 15 years ago.
Dr. AMEZ who's on our scientific advisory board here at Glytec Baso therapy, getting patients in range by day two to three, compared to sliding scale insulin. This helped trigger, uh, one, several other studies, but two the guidelines that are really recommending basals over sliding scale insulin and a simple structure.
What we know a patient has a home insulin regimen, then yes, we'll use that to create a custom dosing. If they don't have a home regimen, then based on the work of, uh, rabbit two, Dr. Amper has other studies. You tend to start around 0.3 or 0.5 units per kilogram per day. And then once you have that total daily dose on the right, you're gonna split it up basil and Blu 15.
And divide that meal time, that bowl with insulin breakfast, lunch, and dinner. So this is what we know, but what do we do? We do sliding scale insulin only for hyperglycemia. Despite the literature, you see many institutions, 30, 40, or higher percentage of their patients that meet indications for basal balls or on sliding scale.
Only no changes to doses after hypo, lack of daily changes to, uh, doses as mentioned insulin stacking risks. You see those short acting insulin. Uh, hour after hour for hyperglycemia, instead of waiting for that effect, four to six hours, no changes of that mealtime dosing for that higher lower meal intake as well, patients on a 60 gram diet, and now they, 90 grams, you go up or eat 30 grams.
You go up on you, go down on that mealtime dosing, uh, things that we do at, uh, ly. So Glucommander SubQ does offer for SubQ patients as well, that realtime tool, the glucose surveillance steps within our software to overcome that clinical inertia you get started on a basal BS regimen. The next day, those doses are just based on how patient's responding and, and really guide to more personalized care guided, starting regimens, the mealtime doses based on the carbohydrates consumed and, uh, and, uh, personalized correction insulin.
So on top of that, uh, so those are some solutions that we offer to counter that we have in our software to counter. Uh, those challenges mentioned certainly a lot of quality improvement solutions as well. Clear aim statements. Can't emphasize that enough. If you're trying to improve, you know, let's be clear on the aim, clear on the data order, set guidance and measure utilization, really working through the mail tribe.
Workflow, that's often a, a high source of hypoglycemia and a good place to work closely with your nursing colleagues. If you get gluco metrics, insulin O metrics measuring how you're doing, uh, using insulin, are you using basal both therapy as in your protocols and getting that feedback and certainly with the people being sure you have champions stakeholders, uh, some institutions have successfully instituted SWAT teams to just look at some, um, outlier diabetes cases.
And then certainly there are successful nurse driven process. So let's reflect back on the case. Started on basal BS with Glucommander SubQ adjustments were made daily to both basal and BS insulin based on the patient's blood sugar and the patient received mealtime, personalized doses and, uh, correction doses, and, uh, stayed in target range throughout the rest of their hospital.
Stay. So there's a lot of, uh, great examples we have from our sites that implement the Glucommander. I thought I would, uh, touch briefly on one of our sites, um, grading Memorial hospital, they published, uh, um, several different articles over the years. Uh, this one on the left showing hypoglycemia reduction over three years of using IV Glucommander and sustaining from their baseline 90 plus percent reductions in severe hypo and the less than 70.
And then on the right, these are some recent, uh, illustrations that they've been able to do at their site. With the change benefits. They've recognized that the GMs Glucommander obviates the major limiting factor of IV insulin, and really addressing that fear of hypoglycemia with having zero Senti Sentinel events with Glucommander IV.
The confidence, the results that they've seen, sharing that data publishing that research, they've be able to expand, uh, to several other areas throughout their hospital and continue the expansion of Glucommander and other institutions have shown and, and touted their, um, the impact of Glucommander Kuya.
Delta mentioned earlier, they went whole house with IV and SubQ a number of years ago and published data showing. Reduction in hypo, hyper and reduction length of stay, and that translated into cost savings. Um, at the time of the study, they showed a 9 million annual cost savings, uh, after going from a largely sliding scale only institution to largely basal bolus and for IV insulin.
When you look at the studies over the years, You know, the initial work on IV insulin for tide control back with the LUN studies work from nice sugar, really showing the importance of more conservative control and see how we compare over time on the right Glucommander studies, showing those, uh, low rates of hypoglycemia when compared to other protocols, um, and really helping overcome that fear of hypoglycemia and managing patients.
So this is a bit of a roadmap. The people process technology, the outcomes, uh, the, the aims that you need to look for, preventing hypo treating hyper driving, optimal utilization. Those are the general ones you can get specific underneath there to really drive glycemic management success. If you're doing any quality improvement project, uh, certainly think through the top 10, if you're having challenges and, uh, and where is where you.
Can improve here at Glytec. We continue to work closely with our partners, uh, around the country. We're in over 300 hospitals health systems around the country. Here's just a sample of some of the health systems that have Glucommander in place. And we continue to work strategically with partners to, um, To really think to the future recently, partly with premier GPO and, uh, with premier Glytec is now the sole supplier of insulin management software in the patient safety solutions category.
We've partnered with Roche and we'll be the first software on their new smart device. Next generation hospital, blood glucose meter called the Cobos post. And we continue to work with other partners to really meet our goals of achieving glycemic management success. So a few key takeaways here, as we wrap up this session, there is this implementation implementation gap.
It's not just for glycemia, certainly many other, uh, states in the hospital. There's what we know and what we do. And how do we overcome that gap? Having a framework for approaching the areas and people process and technology that are limited and maybe able to, uh, to improve having a quality improvement C.
Understanding the motivators, both intrinsic and extrinsic. Uh, in particular, now we have, uh, one of our, our, our biggest extrinsic motivator, the CMS regulations that are gonna be in place. What are your improvement strategies for IV and SubQ glycemic management, putting in place high reliability strategies, smart order set, design, getting those glycemic committees and glycemic champions, physician nursing pharmacy to help lead that change.
And certainly here at Glytec. We advocate the use of. E glycemic management system, like Glucommander to help really overcome that implementation gap. So those are key takeaways. I want to also end, uh, with, um, advertisement for one of our, uh, for our, our conference coming in October T3, time to target. This is our second one of these conferences.
We had an amazing first year, last year. It's a virtual conference. Take out your phone, scan that QR code, or you can certainly visit our, uh, website and we'll drop that, uh, link in the chat. Uh, I think you'll be really excited with the lineup of speakers, national speakers that we're able to bring to this type of conference.
These are really the leaders in glycemic management, um, across the spectrum from nursing. We'll have pharmacy leaders, but you can see a sample here. Of various leaders around the country, Dr. EZ, who I've mentioned really one of our premier leaders in the space, Dr. DIC, outta Nebraska, Dr. Cook. Who's really the go guru of metrics in the country.
Dr. Lo Barbara McClean. And so Cooper, uh, variety of topics, definitely. Uh, or a register today. And, uh, I think I'm doing pretty well on time, so I will, uh, stop there to, uh, be able to get to, uh, questions. And, uh, I will note that all the references in linked are at the end of this talk. And, uh, uh, at some point after this talk will be able to get, um, the slides and the references that you need out to you.
[00:37:59] Kara Joyce: Wonderful. Thank you so much, Dr. Messer. We have been getting a number of questions in during this presentation. If we do not get to your question, we will follow up with you directly via email. And if you have a question that you wanna ask Dr. Messer directly, his contact information is displayed right here on the screen.
So the first question comes from Simon. One of our challenges is provider engagement. Do you have a good framework or approach to getting engagement?
[00:38:29] Jordan Messler: Yeah, great question. Uh, we touched on it, uh, briefly and, uh, I've, I've spent, uh, long time thinking about this topic, uh, presented at this national meetings. Um, the framework that we share there is from Dr. Provos there's others from Harvard. There's a, uh, A great writer, Dan pink, who provides a framework for intrinsic motivation.
Uh, I think you really gotta think about those motivators extrinsic motivators. And, and for that, we obviously have a regulatory, one mentioned often is taught about, uh, talked about in terms of financial motivators. I find those don't always work. So I really lean on. One those intrinsic motivators and getting deliberate strategies to mastery.
How do you help your clinicians learn, uh, understand inpatient, diabetes management, better, uh, maybe offering leadership roles that do you have a director of your hospitalist program for, uh, diabetes management, autonomy, finding ways that you can. Both yes. Standardized practice, um, because you need to standardize to understand variation, uh, but you certainly also be talking to providers to make sure that they have some level of autonomy input into decisions, um, uh, ability to, to, you know, understand the exceptions and really that purpose, you know, engaging, uh, really meeting to.
Talking to providers understanding their wants in the hospital and having that shared purpose for patient safety linked with your mission at your health system and your hospital and understanding, you know, what, what gets providers outta bed and working in the hospital every day. So we've
[00:40:00] Kara Joyce: had a couple of questions come in about integrating what type of interface is needed to integrate this into the EMR.
And at that you shared an example using Cerner is this compatible with epic.
[00:40:15] Jordan Messler: Yeah. So we have, um, uh, Glucommander in, uh, a variety of EMRs around the country. Most commonly with epic, probably over half of our clients have epic and then a good portion of Cerner. Uh we've uh, certainly also have integrations and, uh, implement the Glucommander at other sites like Allscripts and Meditech.
Uh, so certainly examples of those, there's a variety of integrations. You know, certainly that question, we can go into detail offline, but, um, but our, our technical team and a clinical team work closely with sites, uh, to be able to get those lab integrations, the ADT, uh, and there's other integrations that we have, uh, with the Mar in order, uh, to be able to get the information back and forth, uh, seamlessly.
[00:41:01] Kara Joyce: This next question comes from Kathleen. How does this program assist nurses with patients who are using insulin carboration doses?
[00:41:11] Jordan Messler: Yeah. So a great question. Um, so if you're asking specifically for their home regiment and if they're self-managing in the hospital, that would be, uh, potentially outside of Glucommander.
If they're, if. Self management, um, of patients with insulin pumps. However, as mentioned, we have, um, for mealtime dosing, the ability to, uh, understand exactly, you know, what the dose that a patient wants, uh, for, for mealtime and adjust that. Uh, dose down based on the carbs that they eat. We also do have a, an illustrated insulin to carb program, but we do have ability, uh, to have basal insulin to carb regimen.
So we can certainly accommodate, uh, if a patient has an insulin to carb ratio as well.
[00:41:59] Kara Joyce: Jason asks what are some changes that I can make at my institution tomorrow to begin to improve glycemic management?
[00:42:09] Jordan Messler: Yeah. Uh, I I, that's a great question, Jason. I. Hopefully from some of those key takeaways, you got some ideas, um, from the whole talk to use tomorrow. What, what you definitely wanna do tomorrow is really think through that framework and think through your challenges.
Uh, you know, first, just like any good quality improvement project is talk to the frontline, see what's happening, understand what's happening. Uh, if you're trying to improve, improve glycemia, you need to have those foundational things. Do you have a team at your institution? Do you have those champions? Uh, do you have that glycemic management C.
And then be clear on those aims and you can do that, you know, fairly quickly and that's the foundational get started. Um, and then once you're clear on your aims, I would also think small sometimes, uh, the most difficult thing about glycemic management is as recognized it's impacting 40, 50% of our patients in the hospital.
Every unit in the hospital has patients with diabetes hyperglycemia. Uh, but sometimes when you begin, when you're first starting out. Um, you, you might wanna think small, let's just look at one unit or one provider group, uh, that I really wanna focus on initially. And then expand from there.
[00:43:19] Kara Joyce: Lisa asked, have you integrated Glucommander with evident previously CPSI, a computer system for small
[00:43:26] Jordan Messler: hospitals? Uh, yeah. Lisa, I don't know the answer to that one offhand. I'm not familiar with evident, but we can, we can certainly get back to you on that.
[00:43:40] Kara Joyce: Melissa wants to know. Is there a reference list of articles that could be
[00:43:43] Jordan Messler: shared? Um, yeah. You want to, Karen, do you want to, uh, let attendees know how they can get, uh, access to these slides and which will include the references?
[00:43:55] Kara Joyce: Yes, absolutely. So all registered attendees will receive the slide deck in their email.
So keep an eye on your inbox. And in the last couple of pages of the slide deck, you will find the full reference list. Next question from Sandra, can you suggest any hospital protocols on glycemic management that could serve as models to start our own protocol?
[00:44:19] Jordan Messler: Well, um, yeah, I mean the first protocol I recommend is talk to us at, uh Glytec and see how we can get Glucommander at your institution. Um, you know, the list of references in particular, you know, referring to rabbit two and the approach that they did on the non ICU setting for basal bowls, you can find a lot of those verticals in those articles, how, how they managed.
Um, there are examples that I've seen online. I. I don't know which specific ones, but there are a variety of hospitals that, that I've seen publish their protocols. I would refer to the society, hospital medicine, implementation guide, um, as well, they have examples of successful protocols. You can go to hospital medicine, um, website, uh, I think it's hospital medicine.org.
And, you know, you can download their implementation guide as well, which have protocols.
[00:45:11] Kara Joyce: This next one will be our last question. As mentioned all questions that we weren't able to answer, we will be following up with you directly. This is also from Sandra. Where do I find more information on how to obtain Glucommander and pricing?
[00:45:24] Jordan Messler:
Yeah, well, if we, uh, uh, reach out to us, um, I don't care. How do we get, uh, we have everyone's contact information or we can certainly have you, you can go to our website and, uh, ask for more information on our website as well. And we could, uh, definitely follow up with you, Sandra or anyone else, uh, online.
[00:45:49] Kara Joyce: My suggestion would be to look at our website. You can request a demo and find more information. Thank you, everyone for your attention for these fantastic questions, we will be following up with the rest of you and we will be sending out these slides. So keep an eye out. We thank you for joining us and we, we hope to continue to have us on our future webinars.
[00:46:09] Jordan Messler: Thanks everyone.
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