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Glycemic Control at Southwest Washington Medical Center

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The strongest predictor of clinical excellence: ... Pharmacy. Nutrition. Review literature and best practices. Networking with leading institutions ... – PowerPoint PPT presentation

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Title: Glycemic Control at Southwest Washington Medical Center


1
Glycemic Control at Southwest Washington Medical
Center
  • Implementing a Quality Improvement Blueprint
  • Chris Hogness, MD, for the SWMC Glycemic Control
    Team

2
Trying to move from guidelines to the care of
specific patients without making a mess
Heifetz, Leadership Without Easy Answers
(Cambridge Harvard University Press, 1994)
3
Accomplishments from spring 2005 to the present
  • Team culture
  • High level institutional support
  • Metrics
  • Standardized order sets
  • Physician and staff training
  • Progress towards specific goals
  • Regional networking

4
TEAM Approach to the Treatment of the
Hospitalized Diabetic Patient
Pharmacist
Physician
Primary Care Nurse
Dietitian
Endocrinologist
5
Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence
caregivers feel comfortable speaking up if they
perceive a problem with patient care
of respondents within an ICU reporting good
teamwork climate
Health Services Research, 200641(4 Part
II)1599.
6
Where to begin?
  • Small multidisciplinary group
  • Physicians
  • Nursing
  • Pharmacy
  • Nutrition
  • Review literature and best practices
  • Networking with leading institutions
  • Assess current practices
  • Pick a glycemic control project

7
Garnering high level institutional support
  • Hospital Executive Team presentation March 2006
  • Evidence and local application
  • Quality Committee of Hospital Board of Trustees
    presentation May 2006
  • Board of Trustees adopts glycemic control as SWMC
    Quality Goal June 2006
  • Hospital Foundation funding Sept 2006

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Multidisciplinary committee membership
  • Physician champion
  • Medical staff
  • Pharmacy
  • Nursing
  • Nutrition
  • Laboratory
  • Information Systems
  • Food Services
  • Quality Care Resources
  • Education
  • Administration

10
Multidisciplinary committee function
  • Coordination and evaluation of inpatient glycemic
    control activities
  • Protocol implementation
  • Staff education
  • Compilation and review of data
  • Monthly meetings

11
Steering committee
  • Smaller group provides administrative support
  • Membership
  • Key executive leaders
  • Directors of pharmacy, nursing, nutrition
  • Physician champion
  • Lead pharmacist/CDE for glycemic control
  • Meets every other month
  • Review outcomes, financial/staffing support,
    reporting to hospital board of trustees

12
Glycemic Control Team daily management of
patients
  • 1.4 FTE Pharmacy 8 hrs/day, 7 days/week
  • 1.4 FTE CDE 8 hrs/day, 7 days/week
  • Physician back-up call rotation
  • Clerical support

13
Metrics
  • Format
  • Glucometer based
  • Patient centered
  • Uses
  • Internal review/evaluation
  • Glycemic control committee(s)
  • Nurse unit meetings
  • Physician hospitalist groups
  • External comparisons
  • Regional
  • National

14
Glycemic control at SWMC 2005
15
Summary by Location (Cont.)
16
Summary by Location (Cont.)
17
Metrics currently tracked
  • Average blood glucose level by unit
  • Percent of glucometer readings in goal range
  • Critical care 70-150 mg/dl
  • Non-Critical care 70-180 mg/dl
  • Percent of patient-monitored days in control
  • No more than 1 reading outside 70-180 mg/dl for
    patients with at least 2 readings over a 24 hr
    day
  • Number of patients with severe hypoglycemia
  • Glucose lt 40 mg/dl

18
Specific Aims
  • Non-critical care units
  • 80 of patient-monitored days in control (no more
    than 1 value outside 70-180 mg/dl goal range)
  • Critical care units
  • 80 of glucose levels in 70-150 mg/dl goal range
  • Investigate all severe hypoglycemia episodes and
    decrease incidence
  • Increase percent of insulin-treated patients
    basal insulin to 80
  • Shorten surgical length of stay, decrease
    infection rates, decrease mortality

19
Standardized insulin order sets and protocols
  • Critical care insulin infusion
  • August 2005 4-column protocol pilot
  • March 2006 6-column revision
  • Non-critical care insulin infusion
  • Fall 2006 4-column protocol pilot
  • Spring 2007 full implementation
  • Subcutaneous insulin order set
  • Pilot Fall 2005
  • Multiple revisions since
  • Sliding scale eliminated

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3 South Adult Insulin Infusion PILOT (backer)
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24
Education, education, education
  • Physicians
  • Nurses
  • Pharmacists
  • Patients
  • Hospital Administration
  • Board of Trustees

25
Education Physicians
  • Three hospital grand-rounds
  • Fall 2005, Summer 2006, Fall 2006
  • Individual presentations to each of four internal
    medicine hospitalist groups
  • Presentations to medical staff departments
  • Surgery, Anesthesia, Cardiology, Ob-Gyn Dept
    mtgs.
  • All-staff Quarterly meetings
  • Medical executive committee

26
Education Nurses
  • 3 hour didactic Caring for the Diabetic and
    Hyperglycemic Patient
  • Presenters Physician, pharmacist, CDE, nurse
    educator
  • 25 nurses per class
  • 614 nurses trained February-March 2007
  • Funded by hospital foundation
  • Case review at monthly nursing unit meetings
  • 20 question required annual Web-In-Service

27
Education pharmacists
  • Written didactic material distributed to 5
    pharmacists on glycemic control team
  • On-the-job training working with physicians
    managing in-patient cases
  • Rotation through outpatient diabetes clinic
  • Protocols written for cross-covering night
    pharmacists

28
Pharmacy Team

29
Education patients
  • Certified Diabetic Educators see pts with
  • Hemoglobin A1C gt 8
  • DKA
  • New diagnosis DM
  • Newly begun on insulin
  • Nurses begin patient self-administering insulin
    as soon as possible in hospital stay
  • Patients enrolled in diabetic education classes
    for follow-up after discharge

30
Focus on perioperative care
  • Surgeons request pharmacy assistance this is
    too important to leave to us
  • Anesthesia department receptive
  • Small group including pharmacist,
    anesthesiologist champion, hospitalist
    review/modify perioperative processes

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33
Holding the gains over time
  • Percent of glucometer values in specific ranges
    for different units
  • Percent of patient-monitored days in control
  • Number of cases of severe hypoglycemia on
    specific units
  • Percent of insulin treated patients receiving a
    basal insulin
  • Length of stay for surgical and critical care
    patients

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44
Increase in appropriate insulin prescribing on
wards
45
Length of stay in ICU decreases for diabetics…
46
…while ICU length of stay increases slightly for
all patients
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48
Portland-Vancouver Regional Inpatient Glycemic
Control Collaborative
  • September 2006 Nine hospitals attend inaugural
    meeting at SWMC
  • Quarterly meetings December 2006, March 2007,
    June 2007
  • Consensus on regional metrics for transparent
    data-sharing in the region
  • Shared experience protocols, education,
    literature and conference information

49
  • Questions?
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