Inpatient Glycemic Control How many professionals does it take to - PowerPoint PPT Presentation

Inpatient Glycemic Control How many professionals does it take to steer the sugar ship away from the rocks? Rachel Brewster, BA, CMSRN, ME-SAFE-A Judy Curry, BPA, RDMS, CPHQ Ruth Littlefield, CNA S

Objectives S The Need to Steer a Sugar Ship S The importance of glycemic control for hospitalized patients S Establishing the Crew of the Ship S Finding the right people to be at the table and to lead the initiative S Jumping on Board or Jumping Over Board (Walking the Plank) S Leading through change, moving the project forward, and staying focused S Knowing the Crew is Accomplishing It’s Mission S Tracking progress and identifying success JC

The Need Potential Harms of Uncontrolled Blood Glucose Levels in Hospitalized Patients with Type 2 Diabetes S Increased risk of infections –sepsis, pneumonia, wound infection in postop patients with one blood glucose level >220 on post-op day one S Decreased neurologic recovery – observational studies show an association between hyperglycemia and worsened outcomes in patients with acute stroke S Higher mortality with acute MI – 1 year mortality rate 19.3% with admission blood glucose <101 compared to 44% with an admission blood glucose >200 S Longer hospitalization S Delayed procedures RB

The Target S Literature review for leading practices for glycemic control in hospitalized patients S Non DKA Patients S Decrease episodes of hyperglycemia S Avoid episodes of hypoglycemia S Have majority (80%) of blood sugars be within the range of 70-180 S January 2016 S <70 2% S 70-180 49% S >180 49% RL/JC

The Crew Finding The Right People to Participate and Lead S Excited and optimistic S Willing to share ideas S Subject matter experts S Open minded S Currently doing the work S Committed to the team S Willing to trial change S Uses critical thinking S Active listener S Committed to the work JC

All Aboard! Jumping on Board or Walking the Plank RB

“The” Captain ALL

Ship Mates Nutritioni Hospitalists Nurses -MSU sts Tim Canham, Rachel Brewster Brooke Reed PA Lindsay Moore Ally Curt Smith, MD Sherman Nurse CMO Educator Kent Clark, MD Natalie Trombley Inpatient Care Leaders Quality Comm Judy Curry Heather Ward, MD - Discharge Chair Nurses -ICU Planner Sonya Conary Catherine Gelsinger Nurse Becky Osborne Managers CNAs Diabetes Educator Nicole Kenney Ruth Littlefield Sue Maxwell S Pam Sprague Taylor Varnum Lisa Sirois RL/JC

How To Avoid The Rocks Engage Insulin d Providers Patients Staff Hypoglycemia Hyperglycemia Data S JC

Embrace the Fish Insulin Providers Patient s Fast Acting Steroids Education Basal Illness Real Time Review Pre Meal Education Consistency Correction New Dx Basal Calculation Optimizatio Outisde Food Feedback n Feedback Orders Used Rule of 15 Real Time Review Insulin Timing Symptoms Documentation Documentation Education Blood Sugars Education Hypo- Correction Staff and Basal Hyper- Steroids S glycemia Data JC

Steering the Ship Gemba Board JC

Anchors Aweigh Any

The Voyage Just Some of the Many Changes Tried! S Hospitalist chart review process S CHO meal menu in grams S CHO in the MAR S Real time chart review S Sliding scale and basal insulin orders S New calculation for basal insulin dose S Red tray delivery of meals S Signs in patient rooms re: guest food S Insulin drip for non DKA ICU patient JC

The Voyage RL

The Voyage Timely Administration of Prandial Coverage Plan Act Educatio Meals on n About Red New Trays Standard Gemba MSU Board Nutrition KPI ICU Study Do RB

The Voyage Simultaneous BS and Insulin Administration Plan Act BS at Move to Meal CNA Time Approach Nurse Trial By Does All Nurse Tasks Study Do RB

The Voyage Delivery of Meals Plan Act Educatio CNA n About Support New Standard Gemba Take BS Board and KPI Deliver Study Do Tray RL

Fleet Collaboration Nutrition Services: Red Trays Nurse Educator: Skills/Knowledge Providers: Order Consistency RL/RB

Beyond the Rocks Overall - Blood Glucose Samples 70-180 Goal 0.9 0.8 0.7 0.6 0.5 0.4 0.3 JC

Beyond the Rocks Overall - Blood Glucose Samples < 70 12 10 8 6 4 2 0 JC

Beyond the Rocks Of the Blood Sugars Greater >180 No Steroids Steroids 100% 80% 60% 40% 20% 0% JC

Beyond the Rocks Total Times Correction Insulin Given in the Month Divided by the Total Number of Patients in the Month 20 18 16 14 12 10 8 6 4 2 0 JC

Beyond the Rocks CHO Coverage Insulin Given Within 30 Minutes 1 0.9 0.8 0.7 0.6 0.5 JC

Beyond the Rocks Correction Insulin Given Within 30 minutes Goal 1 0.8 0.6 0.4 0.2 0 JC

So….How Many? S RL

166 People / 1178 Days In Addition to Workgroup (147) Workgroup (19) S Providers (17) S Nutritionists (2) S Bedside Nurse (60) S Hospitalists (2) S Bedside CNA (39) S Nurse Managers (3) S House Supervisors (6) S Nutrition Services (25) S Diabetes Educator (1) S Inpatient Care Committee (4) S Nurse Educator (1) S Discharge Planners (2) S Quality (1) S aICU Providers (?) S CMO (1) RB S Bedside Nurse (4)

Finding the Treasure Knowing That the Crew Has Accomplished It’s Mission RB

Questions/Comments ALL

References S Glucose Management in Hospitalized Patients, Charles Kodnet, MD; Laurie Anderson, MD; and Katherine Pohlgeers, MD; University of Louisville School of Medicine, Louisville, Kentucky; American Family Physician, Volume 96, Number 10, November 15, 2017 S Diabetes Care; Standards of Medical Care in Diabetes, 2019 S Inpatient Management of Diabetes and Hyperglycemia: Implications for Nutrition Practice and The Food and Nutrition Professional; Journal of the American Dietetic Association, 2007 JC