Tak­ing con­trol

Ar­ray of IT helps drive Illi­nois hos­pi­tal’s pro­gram to man­age glu­cose lev­els

Modern Healthcare - - Special Feature -

In­ad­e­quate glu­cose con­trol can re­sult in hos­pi­tal-associated in­fec­tions and other com­pli­ca­tions that can lead to in­creased lengths of stay and non­re­im­bursable read­mis­sions within 30 days. By us­ing Six Sigma method­olo­gies to re­design pro­cesses, ed­u­cat­ing physi­cians, staff and pa­tients, and em­bed­ding ev­i­dence-based pro­to­cols in our com­put­er­ized physi­cian-or­der en­try sys­tem, Decatur (Ill.) Me­mo­rial Hos­pi­tal has made proac­tive man­age­ment of in­pa­tient di­a­betes the rule rather than the ex­cep­tion.

For at least 60 years, the use of a slid­ing scale to re­ac­tively man­age in­sulin has been passed down by physi­cians from one gen­er­a­tion to the next. It pre­scribes the amount of in­sulin based on the glu­cose read­ing—a re­ac­tive ap­proach that can re­sult in glycemic swings. Cur­rent best prac­tice points to an­tic­i­pa­tory phys­i­o­logic in­sulin dos­ing, pre­scribed as a basal/nu­tri­tional/cor­rec­tional reg­i­men. Be­fore launch­ing our glu­cose con­trol ini­tia­tive, a year’s worth of data showed that 55% of Decatur’s in­pa­tients were be­ing man­aged solely us­ing slid­ing scale and only 72% of pa­tients main­tained glu­cose read­ings be­low 180 through­out their stay.

When asked when their pa­tients’ blood sugar had been checked, nurses typ­i­cally an­swered 15 to 30 min­utes af­ter meal­time. Ac­cord­ing to the data, how­ever, up to 70% of the time the checks had oc­curred be­tween 31 min­utes and two hours af­ter meals.

To launch our ini­tia­tive, we es­tab­lished a 23-per­son, mul­ti­dis­ci­plinary glycemic con­trol team that in­cluded our pa­tient-safety and reg­u­la­tory of­fi­cer, the CMO, a Six Sigma Black Belt and rep­re­sen­ta­tives from di­etary, ed­u­ca­tion, clin­i­cal in­for­mat­ics, phar­macy, lab and ad­min­is­tra­tion.

Map­ping out the base­line pro­cesses re­vealed many re­lated ac­tiv­i­ties that were en­tirely un­con­nected. Af­ter anal­y­sis, the team cre­ated a new, con­nected glu­cose con­trol process map. It con­nected nurs­ing, phar­macy, food de­liv­ery and pa­tient-care el­e­ments with a new treat­ment pro­to­col and pa­tient ed­u­ca­tion.

At Decatur, pa­tients may or­der food when­ever they want, with­out their nurse know­ing about it. To elim­i­nate these chal­lenges, in the new process, nu­tri­tion ser­vices takes the or­der, re­views the car­bo­hy­drate count and no­ti­fies the nurse when the tray is de­liv­ered. The nurse takes a glu­cose read­ing be­fore the meal and, if nec­es­sary, ad­min­is­ters cor­rec­tional in­sulin within 15 to 30 min­utes of the first bite. When fin­ished, the pa­tient calls the nurse, who cal­cu­lates carbs based on what was eaten and gives cor­rec­tional in­sulin as needed.

Af­ter re­view­ing ex­haus­tive re­sources from the So­ci­ety of Hos­pi­tal Medicine, the team en­listed a va­ri­ety of IT to hard­wire the ev­i­dence, in­clud­ing CPOE, elec­tronic nurs­ing doc­u­men­ta­tion, our phar­macy in­for­ma­tion sys­tem, a glu­cose mon­i­tor­ing sys­tem, room ser­vice soft­ware and re­port­ing tools.

We used CPOE to de­liver clin­i­cal de­ci­sion sup­port and en­sure the right in­for­ma­tion was given to the right per­son via the right chan­nel at the right time to achieve the right out­come. The new CPOE-based process en­ables the physi­cian to com­plete an ev­i­dence-based or­der in only three clicks. A re­lated screen pulls in the re­sults of the last four fin­ger­sticks and en­ables the physi­cian to ad­just the dose or start a new reg­i­men.

Af­ter pi­lot­ing the new pro­to­col with the hos­pi­tal­ist team, ad­di­tional nurs­ing units came on board ev­ery few weeks un­til it was in use hos­pi­tal-wide. To mea­sure im­prove­ment, the team looked at 75 pa­tients who were di­a­betic or hy­po­glycemic. For all 75 pa­tients, glu­cose lev­els be­low 180 were main­tained by 81.3% of the pa­tients, an im­prove­ment over the base­line of 72%. And glu­cose level checks im­proved from only 20% oc­cur­ring within 30 min­utes of meal­time to more than 80%.

Based on early re­sults and user feed­back, we con­tin­ued to make im­prove­ments in our process by:

Re­fin­ing the way car­bo­hy­drate counts are printed on meal tick­ets;

Tweak­ing the pro­to­col and CPOE or­der form to im­prove the work­flow;

En­cour­ag­ing sur­geons to re­quest a med­i­cal con­sult when they are con­cerned about their pa­tients’ glu­cose re­sults.

For the next phase, the team plans to roll out its glu­cose-con­trol pro­gram to pri­ma­rycare physi­cians and in­cor­po­rate it into Decatur’s pa­tient-cen­tered med­i­cal home pro­ject. Decatur is ap­ply­ing for Joint Com­mis­sion Disease Spe­cific Cer­ti­fi­ca­tion in In­pa­tient Di­a­betes Care and reg­u­larly con­ducts site vis­its so peers can see the power of clin­i­cal de­ci­sion sup­port with CPOE.

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