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Multidisciplinary Approach to Inpatient Blood Glucose Management. Presented by : CAPT Christine Chamberlain, PharmD, BCPS, CDE. NIH Clinical Research Center. Introduction. 1,500 studies currently in progress. Most Phase 1 & 2 trials. - PowerPoint PPT Presentation
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Presented by:
CAPT Christine Chamberlain, PharmD, BCPS, CDE
Multidisciplinary Approach to Inpatient Blood Glucose Management
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NIH Clinical Research Center
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Background about NIH Clinical Research Center, supported by Mark O. Hatfield of Oregon who recently passed away
It was named in honor of Sen. Mark O. Hatfield of Oregon, who supported medical research throughout his congressional career. The facility houses inpatient units, day hospitals, and research labs and connects to the original Warren Grant Magnuson Clinical Center. The 870,000-square-foot Hatfield Building has 240 inpatient beds and 82 day-hospital stations. The highly flexible facility can be easily adapted to allow more inpatient beds and fewer day-hospital
Introduction
1,500 studies currently in progress. Most Phase 1 & 2 trials.
240 inpatient beds, 82 day hospital stations, and outpatient clinics.
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Objectives
List important factors that were considered in the design of blood glucose management service (BGMS)
Explain the design of electronic medical record to support the service
Implement new strategies for managing inpatients requiring insulin efficiently in similar environments
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Introduction
All patients seen at NIH are on a clinical research protocol
Some investigational drugs may affect glucose or insulin action
Some research protocols require steroids
Minimizing serious adverse events of glycemia related to protocol
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Our goal is to minimize serious adverse events related to glycemia control during clinical trial
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Introduction
Patients come from all 50 states and other countries as often we are studying rare diseases
Many foreign languages
Many without insurance
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I am sure your institution faces similar challenges related to native language and no insurance
We have a computerized physician order entry system since the 1970s but most recently upgraded to Allscripts sunrise clinical manager in 2004 (pharmcacy system a few years later) and Scriptpro for outpatient pharmacy in 2010
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Perils of Hyperglycemia
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n engl j med 355;18 www.nejm.org november 2, 2006
Who, What, When, Where, How
Our goal is to not let glycemia control be the cause of a problem for a patient
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Reasons for Formation of Blood Glucose Management Service
No consistency
Changing management guidelines
New drugs to use in controlling blood glucose
Late endocrine consults
Delay in implementing consult recommendations
Discharge planning
Disjointed patient education
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Fellows changed weekly; Attending changed monthly; used regimens familiar with; some more aggressive than others
Literature showing that euglycemia improved outcomes but we were slow to adopt treatment plans
Debate with ICU
Introduction of lantus and detemir, and rapid acting insulins
Patients would come in on byetta
Discharge planning did not occur until day of discharge, communication and consultation not done until day of discharge
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Blood Glucose Management Service
Members
Attending
Fellows
Pharmacist
Dietitian
Nurse Practitioner
Nurse
Social Worker as needed
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The diabetes educators had a dream to not be called at the last minute to counsel a patient on diabetes at discharge to intervene sooner and better BUT we needed a champion!
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BGMS Roles
Attending Physician
Champion
Expert
Training
Liaison
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Organized the service and delineated functions
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BGMS Roles
Fellow
Initial visit and history
Orders
On-call
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Would present new patients and for all patients on service, he/she would devise an insulin plan that would be agreed upon by the entire team
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BGMS Roles
Dietitian
Patient teaching
Participation in daily rounds
Determination of diet/TPN
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BGMS Roles
Nurse
Ambassador
Daily visits with patient
Participate in daily meetings, report
Documentation in electronic record
Discharge teaching with patients
Staff training
Back up on call Fellow
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Clinical nurse specialist Kathy Feigenbaum
We established the term ambassador the person who would glean information about the patient on a daily basis and report to the BGMS staff each ambassador was assigned a patient care unit/or units once we expanded and this person was the point of contact during the day for any issues presented by the patients nurse (change in NPO status etc.). The fellow was contacted if a orders needed to be changed or patient needed to be seen.
What is not on this slide is that she created and managed the call schedule and did most of the staff training
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BGMS Roles
Nurse Practitioner
Ambassador
Daily visits with patient
Participate in daily meetings, report
Documentation in electronic record
Discharge teaching with patients
Staff training
Back up on call Fellow
Facilitate order entry
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She brought many years of experience dealing with severely insulin resistant patients, she was also a Spanish speaking liaison
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BGMS Roles
Pharmacist
Ambassador
Daily visits with patient
Participate in daily meetings, report
Documentation in electronic record
Discharge teaching with patients
Staff training
Back up on call Fellow
Medication Profile review
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Unlike my colleagues, I was not a diabetes educator so, One of my first goals was to become a CDE
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Mission Statement
Multidisciplinary team consult service
Provide around the clock responsibility for blood glucose management for referred patients.
Manage only inpatients receiving insulin
Team will participate in multidisciplinary rounds each working day and a fellow during weekends
Team interdisciplinary notes will be recorded daily in the EMR
Insulin orders will be entered in the EMR rather than a recommendation in a note
Resources: laptops, pager, conference room, supervisor support
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We needed administration support we were not asking for a lot of resources, but relied on many people to devote extra time to this effort and did require support by various supervisors from nursing, pharmacy and dietary
Since evidence-based medicine strongly suggests that near-normal glycemia for hospitalized patients decreases morbidity and mortality, and since proper, modern intensive insulin management requires a multidisciplinary team approach, an NIH Blood Glucose Management Service (BGMS) has been established
Managed insulin orders only, followed patients only on insulin
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BGMS Meeting
Report
Discussion
Orders
Discharge planning
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Ambassador presented patient, endocrine fellow would formulate a plan, the group would discuss the plan and when everyone agreed, orders would be placed in the electronic medical record and reviewed by the entire team and discharge planning discussed
Punctuality and efficiency was continuously stressed as well as quality improvement how can we make it better
PIE - punctuality, improvement, efficiency
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Birth of BGMS
January 8, 2007
Piloted on one unit initially
Medical executive committee endorsement
Hospital wide at 7 months
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We started on one unit and work on smoothing out the wrinkles, the dog and pony show was continued and the concept needed to be sold to the medical executive committee in order to go hospital wide
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Tracking
Census form
Occurrences
Daily Rounds log
Monthly on-call schedule
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Justify your existence:
Track average daily census (how many patients we followed per month)
Medication or documentation occurrences
Record who attended daily rounds
This was used to justify the consult services utility and track a reduction in medication errors or occurrences. We could not use parameters such days in hospital or infection rate as these were dictated by the individual protocol but these are areas that could be measured
Blood glucose values outside of goals is a potential tracking tool at the time this was started, we had no mechanism since most tests were point of care (fingersticks on the individual unit) but this could be a future goals when meter data is incorporated into hospital system and technology such as theradoc could be used.
We could not use traditional metrics
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Selling the Concept
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Initially started on one unit then slowly expanded to other units as we made improvements along the way. Our biggest advocates over time were the nurses they started recommending the service to other teams
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Bumps in the Road
Selling the concept
Finding the data
Primary team physicians changing orders
Communication between BGMS and primary team
Transfers to the ICU (transition of care)
Misinterpretation of insulin order
No resources for diabetes supplies (glucometer, strips)
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About 7 months after our initiation, management did question cost/effectiveness of our service, they even solicited input for other institutions on how they provided this type of care - they were all supportive of this approach
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Documentation
Flowsheet (Eclipsys electronic medical record)
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Ann McNemar was a key figure in development, her a nursing background was a significant asset
We wanted all the information in one place insulin dose, blood glucose level etc.
One issue was double documentation needed by nursing staff (had to record doses on the MAR and on this flow sheet)
Also changing the insulin name (sub heading under basal insulin and insulin standard meal dose)
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Flowsheet continued
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Initially our BGMS plan was written on the flowsheet (separate line at the end of the flowsheet), but the primary team often did not see our notes so we asked our IT expert to devise a BGMS consult note
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Checklist for Expansion
BGMS team pager
Appropriate education for each patient care unit
Sufficient beta-testing of the EMR systems, including:
The BG flowsheet- worklist link and
System for recording daily BGMS progress notes
Stamp for the BGMS fellow to place a note in each patients medical record indicating the service is following that patient, and where progress notes can be found (On service note)
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During team meetings we viewed blood glucose levels in realtime by having to computers connected to the network and electronic medical record and projected on a screen for viewing in a conference room. Orders were entered and all team members reviewed order entry.
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Documentation
Consult Note (structured note)
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The stamp was soon replaced by a consult structured note which Ann McNemar helped create our vision> It stated that the BGMS service would write all insulin orders until one of the parameters listed occurred. It communicated to the primary team that we would take over the responsibility of writing insulin orders thus reducing the time to implementation
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Documentation
Consult Note (structured note)
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Initially a consult was placed under endocrine consult and the provider had to specify BGMS.
We eventually received our own consult order through perserverence
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Bumps in the Road
Selling the concept
Finding the data
Primary team physicians changing orders or putting them in hold status
Communication between BGMS and primary team
Transfers to the ICU
Misinterpretation of insulin order
No meter when discharged
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About 7 months after our initiation, management did question cost/effectiveness of our service, they even solicited input for other institutions on how they provided this type of care
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Documentation
Consult Note (structured note)
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Consult note was devised with the ability to pull in data such as BBGM results, lab values, copy forward option for summary information
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Documentation
Consult Note (structured note)
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Documentation
Consult Note (structured note)
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Documentation
Consult Note (structured note)
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BGMS Meeting - Efficiency
Report
Discussion
Orders
Discharge planning
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Ambassador presented patient, endocrine fellow would formulate a plan, the group would discuss the plan and when everyone agreed, orders would be placed in the electronic medical record and reviewed by the entire team and discharge planning discussed
Punctuality and efficiency was continuously stressed as well as quality improvement how can we make it better
PIE - punctuality, improvement, efficiency
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Standardized Script for Rounds
We are following Mr/Mrs ________ whose primary diagnosis underlying their hospitalization is _______.
Our present blood glucose management orders for him/her are ________.
Issues today that may have influenced the BGs you can see on the flowsheet include _____ (and examples may be infections, alterations in his/her diet, procedures, new medications like glucocorticoids).
Upcoming plans for his/her hospitalization that may effect his/her blood glucose control include ____ (and examples may include alterations in his/her diet, procedures, new medications like glucocorticoids, plans for discharge).
State pertinent lab values for that day
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This became the standardized script for the ambassadors for rounds. Goal was to keep our meetings to 1 hour or less and stay focused
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Quote for the Day
Quoting Lennon and McCartney, I have to admit its getting better, a little better all the time.
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Efficiency, mission, keeping on track, improvements
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Discharge planning
Prepare for home regimen
Prepare for insulin pump or adjust setting if admitted on pump
Transition to outpatient
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We had difficulty with transition of care to outpatient and having a fellow follow the patient
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Discharge planning patient education
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We standardized patient education, one of our goals was group education, however we were never able to achieve that goal but did use the tools we created for the group education to educate individual patients in a consistent manner
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Trials and Tribulations
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And as Dave most eloquently put it seemed at times we were like salmon swimming upstream
Most difficult obstacle was expanding the service
Second was transition to outpatient care who would follow the patient after discharge. We devised a plan to have the endocrine fellow initiating the BGMS consult to follow the patient as an outpatient in our diabetes or endocrine clinics
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Bumps in the Road
Selling the concept
Finding data
Primary team physicians changing orders or putting them in hold status
Communication between BGMS and primary team
Transfers to the ICU
Misinterpretation of insulin order
No meter when discharged
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Initally we saw medication errors including missed doses, wrong dose, unclear orders and lack of communitcation with the BGMS about changes in patient status. Initially some nurses were uncomfortable with the high insulin doses and we provided education and reassurance. We learned how to write better orders and we established rules for insulin dosing
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Medication Occurrences
Feigenbaum et al. The Clinical Center's Blood Glucose Management Service : A Story in Quality Integrated Care Volume 38, Number 2, March/April 2012
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Insulin Basic Concepts
Established rules for initial insulin dosing
Created treatment plans specific to glycemia issue
Created Standard operating procedures
Created insulin ordering templates
Insulin drip
High concentration insulin
Insulin subcutaneous pump
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I will now cover the rules or concepts we established
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Inpatient Glycemia Goals
Pre-meal goal
Critically ill 140-180 mg/dl
Non critically ill pre-meal
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