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