CLOSING THE QUALITY GAP Key Elements to Improve Care of the Inpatient with DM Hyperglycemia Garnerin

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CLOSING THE QUALITY GAPKey Elements to Improve
Care of the Inpatient with DM /
HyperglycemiaGarnering Institutional Support

• Greg Maynard MD, MS
• Professor of Clinical Medicine and Chief,
  Division of Hospital Medicine
• University of California, San Diego

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Tale of Identical TwinsTom and Harry

• 65 year old twins
• Diabetes on NPH 20 units and OHGs with poor
  control, neither sees MD regularly
• Smokers
• At a Gentlemans Club when both developed chest
  pain. After 6 hours..
• Tom goes to Hospital A
• Harry Hospital A full, so Harry goes
  crosstown to Hospital B

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Tom at Hospital A

• Admitted to CCU, MI confirmed
• Glucose 230 mg/dL
• No infusion started for 18 hours
• Infusion control poor, glycemic excursions when
  Tom eats.
• Recurrent hypoglycemia, treated inconsistently,
  especially with trips to Radiology
• Finally controlled on infusion day 4.

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Tom at Hospital A contd

• Transition to ward Tom on sliding scale
• Recurrent hyperglycemia to 300
• Brief return to unit for CRBSI
• Confusion with various insulin regimens as Tom
  goes from eating to NPO several times.
• No mention of hyperglycemia in discharge summary
• Tom discharged on same meds as admit
• LOS 6 days, EF 35 at 1 month

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Tom 3 years later

• Follows up with Cardiology only (no PCP)
• Glycemic control remains poor
• Recurrent CV events
• Recurrent hospitalizations

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Harry at Hospital B

• Admit CCU, MI confirmed, glu 230 mg / dL
• Infusion started by protocol when glucose gt 140
  mg/dL x 2.
• Glycemic excursions with meals covered w/
  subcutaneous RAA-I per protocol.
• Minor hypoglycemia covered routinely
• Transitioned to ward on basal / bolus regimen,
  TDD of 80 units.
• A1C obtained 10

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Harry at Hospital B contd

• When Harry goes NPO for test, nurses continue
  basal insulin, hold nutritional insulin (as per
  MAR instructions)
• Education on smoking cessation and DM
• Information about DM / glucose control included
  in DC summary.
• Hospitalist arranges for PCP, discharge regimen
  of Glargine 35 units, 10 units RAA-I w/ meals
  prescribed.
• LOS 5 days, EF at 1 month 45

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Harry 3 years later

• Quits smoking
• A1c 6.2
• Not re-hospitalized
• What can you do to make sure all patients with
  hyperglycemia are treated like Harryevery time?

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Focus on the WardsImplementation Gap

• One-third with mean glucose gt 200 mg/dL
• 60-70 of insulin regimens sliding scale only
  (even if horrible control)
• gt10 with hypoglycemic episodes.
• Uneven training amongst staff
• Poor coordination of tray delivery, monitoring,
  and insulin
• Inconsistent transitions
• Patients often confused or angry

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Barriers

• Skepticism of benefits
• Pre-existing orders
• Habits
• Coordination
• Staff turnover
• Competing priorities
• Unpredictable / varied caloric intake
• Varied insulin requirements

• Fear of hypoglycemia
• Time
• Workflow change
• Information / reporting
• Multiple teams and hand-offs
• Ongoing Education needs
• Steroids, etc

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My First Algorithm for Process Improvement
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My Own Journey

• Interest in Inpatient DM / Glycemic Control
• Past failures
• Opportunity to lead efforts at UCSD
• Slow painful improvement.
• then some breakthroughs with PI techniques
• Writing panel AACE / ADA Call to Action
• Society of Hospital Medicine Glycemic Control
  Task Force

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Components of a Glycemic Control Program

• Administrative support
• Multidisciplinary steering committee to promote
  the development of initiatives
• Assessment of current processes, quality of care,
  and barriers to change
• Development and implementation of interventions
• Standardized order sets, protocols, policies.
• Educational programs, Special teams
• Metrics for evaluation

Inpatient Diabetes and Glycemic Control A Call
to Action Conference. Position Statement. AACE,
February 2006. Available at http//www.aace.com/m
eetings/consensus/IIDC/ IDGC0207.pdf. Accessed
October 24, 2006. Garber et al. Endocr Pract.
200612(suppl 3)3-13.
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Society of Hospital Medicine Glycemic Control
Taskforce

• Greg Maynard-UCSD
• David Wesorick Univ of Michigan
• Kevin Larsen-HCMC
• Jeff Schnipper-Brigham and Womens
• Cheryl OMalley-Banner Good Sam
• Case Management, Pharmacy and Nursing
  representatives
• Great feedback / examples Jacqui Thompson,
  Chris Hogness, others

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• Endocrinologists on SHM Task Force
• Representing the ADA
• Andrew J. Ahmann, MDMichelle F. Magee, MD
• Representing AACE
• Richard Hellman, MD, FACP, FACE
• Expert Panel
• Susan Shapiro Braithwaite, MD, FACP, FACEMary
  Ann Emanuele, MD, FACPIrl B. Hirsch, MDRobert
  Rushakoff, MD
• Other Experts Providing Feedback
• Guillermo Umpierrez
• Stephen Clement MD
• Silvio Inzucchi MD

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www.hospitalmedicine.org
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How Do We Close the Gap? Essential Elements

• Institutional support and multidisciplinary teams
  
• Standardized order sets
• Infusion
• Subcutaneous which promote basal / bolus regimens
• Algorithms / protocols / policies
• Address dosing
• Nutritional intake
• Special situations TPN, enteral tube feedings,
  perioperative insulin, steroids
• Safety issues
• Transitions in care and discharge planning
• Metrics How will you know youve made a
  difference?
• Comprehensive educational program

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The Multidisciplinary Team

• Team Leader
• Critical Care
• Wards
• Endocrinologist
• Hospitalist
• Senior Administrator
• Nurse supervisor
• Nurse
• Ward
• ICU
• Pharmacist
• CPOE expert

• Information/data pull
• QI staff representative
• Diabetes Educator
• Health Unit Secretary
• Case manager
• PRN
• Anesthesia
• Surgeon
• ED personnel
• Patient re
• Nutrition/dietary
• Laboratory

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Why Glycemic Control?(Its about more than
infusion insulin glycemic targets!)

• DM / Hyperglycemia Very Common
• Opportunity to identify and intervene
• poorly controlled DM, previously undiagnosed DM,
  stress hyperglycemia (pre-diabetes)
• Hypoglycemia and extreme hyperglycemia
• Safety problem and a Quality problem
• Inpatient Care - Complex w/ unique challenges
• Education alone insufficient, need systems change

Society of Hospital Medicine. http//www.hospitalm
edicine.org/ResourceRoomRedesign/
pdf/GC_Workbook.pdf.
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Hyperglycemia A Common Comorbidity in
Medical-Surgical Patients in a Community Hospital
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62
Normoglycemia
n 2,020 Hyperglycemia Fasting BG ? 126
mg/dl or Random BG ? 200 mg/dl X 2
Known Diabetes
New Hyperglycemia
Umpierrez G et al, J Clin Endocrinol Metabol
87978, 2002
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Hyperglycemia is Common in Hospitalized Patients

• Non critically ill medical/surgical 38
• Intensive care units (ICU) 29 100
• Episode of glucose gt 110 mg/dl 100
• Episode of glucose gt 200 mg/dl 31
• Mean glucose gt 145 mg/dl 39

Umpierrez G et al, J Clin Endocrinol Metabol
87978, 2002 Levetan CS et al, Diabetes Care
21246,1998 Krinsley JS. Mayo Clin Proc.
2003781471-1478 Faglia et al, 66th ADA
Scientific Meeting, 2006
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Insulin Requirements in Health and Illness
Correction Nutritional Prandial Basal
Units
Healthy
Sick/Eating
Sick/NPO
Clement S et al. Diabetes Care. 2004
27553591. Reprinted with permission.
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Drugs Promoting Hyperglycemia

• COMMONLY ASSOCIATED
• Steroids
• Catecholamines
• Tacrolimus
• Cyclosporine
• Gatifloxacin
• TPN

• SIGNIFICANT but LESS PROMINENT
• Oral contraceptive pills
• Thiazides
• Atypical antipsychotics
• Calcium-channel blocking agents
• Protease inhibitors

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The Other Reason Rational Use of Insulin and
Other Agents Is Important in Hospitals
Iatrogenic Hypoglycemia

• JCAHO considers insulin to be one of the 5
  highest-risk medicines in the inpatient setting
• Catastrophic damage can occur
• Frequent source of adverse drug effects usually
  1 or 2 at UCSD

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Why Glycemic Control? (continued)

• Huge Implementation Gap
• Public reporting, regulatory guidelines etc.
• Can be cost effective
• Inpatient hyperglycemia is very strongly
  associated with poor outcomes
• Improved glycemic control is associated with
  improved outcomes

Society of Hospital Medicine. http//www.hospitalm
edicine.org/ResourceRoomRedesign/
pdf/GC_Workbook.pdf.
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JCAHOs Certificate of Distinction for Inpatient
Diabetes Care

• Specific staff education requirements
• Written blood glucose monitoring protocols
• Plans for the treatment of hypoglycemia and
  hyperglycemia
• Data collection of incidence of hypoglycemia
• Patient education on self-management of diabetes
• An identified program champion or program
  champion team.

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Business Case

• Improved coding better reimbursement
• Diagnosis ? Uncontrolled or ? Controlled
• (? with complications)Diabetes
  type ? 1 ? 2 ? Gestational or ? Secondary to
  another causeSpecify or ?
  Stress/situational hyperglycemia
• Incremental Billing
• Improved outcomes Improved bottom line

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The Multidisciplinary Team Asks

• What?
• Is the right thing to do?
• Will make the system more effective?
• Where?
• Are the processes to improve?
• Do we start? (dissect and understand the
  processes)
• How?
• You cannot destroy productivity
• You must devote as much attention to fitting
  changes into clinical work flow as you do to the
  evidence-based guideline

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Institutional Assessment

• Institutional Support
• Multidisciplinary team
• Reliable data flow / metrics
• Standardized order sets, protocols and algorithms
  for subcutaneous insulin
• Intensive insulin infusion order set/ protocol

• Nutritional dietary system
• Diabetes self-management
• Hypoglycemia, insulin safety and safety culture
  issues
• Transitions in care
• Educational issues

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Looking into the gap Early Evidence
What to measure?
How to measure?

• Iatrogenic hypoglycemia
• Glycemic control Extreme hyperglycemia
• Insulin use patterns
• frequency of sliding scale only
• number of different order sets

• Anecdotes about insulin use
• Sample active inpatients
• Keep ICU and ward separate
• Define your exclusion criteria
• Build a data collection tool

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Small Sample Data ExampleUse to gain
institutional support

• Basal insulin is being used in insulin
  regimens less than half the time. A third of our
  monitored patient-days have a mean glucose of
  more than 180 mg/dL. One of the 5 days we monitor
  patients includes at least one hypoglycemic
  event, and almost 1 of 3 days incorporates either
  a hypoglycemic event or an unsafe extreme
  hyperglycemic event of more than 300 mg/dL.