Education Nurses,

Mid-level Providers, Physicians,

Ancillary Staff

Michelle Magee, MD

Anita Manley, RN, CDE

Sara Hohn, RN,MS,CDE, CNS, BC-ADM

EducationInitial & ongoing education• Nursing• Mid-level providers • Physicians• Ancillary services, including pharmacists,

nutritionists, clerical staff, medical assistants

Patient education: diabetes survival skills

Educating the adult learnerEmpowerment• Enable to manage glucose using insulin therapy & to know when to proactively seek helpExperience• Interactive provision of clear information

Reflection• Allows understanding of meaning, value, & consequencesInsight• Newly seeing meanings, patterns, relationships, or possibilitiesChange• Behavior, attitude & understanding

Expanding the “Team”Staff education

Champion Training Course

Anita Manley RN CDE

October 12, 2007

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 DC planning

• Metrics: How will you know you’ve made a difference?• Comprehensive Educational Program

– Nurses– Dieticians– C.N.A.– Physicians– Pharmacists

Hyperglycemia in hospital patients at SWMC

• 12/05 - Multidisciplinary Glycemic Control Committee meets for the first time (MGCC)

• 03/06 - MGCC presents GC to the Executive Team• 05/06 - MGCC presents to the Quality Committee of

the SWMC Board• 06/06 - SWMC Board endorses GC as a quality goal• 07/06 – Presentation to Internal medicine, surgery, obgyn,

anesthesia, oncology, hospitalist groups• 09/06 - Foundation provides funding• 10/06 - The Glycemic Team starts working• 02/07 – Nurses training begins and Physician academic

detailing begins, • 04/07 – Clinical Dietitians education• To present - continuing New employee training• Future – webinservice .

Comprehensive Education

““If you think education is expensive - try If you think education is expensive - try ignorance”ignorance”Derek Bok – Past president, Harvard UniversityDerek Bok – Past president, Harvard University

700 nurses by the end of March 2007

Objectives

• Describe the benefits of improved blood glucose control in the hospital

• Discuss your role in improving patient blood glucose levels in the hospital

• Describe the difference between basal, nutritional, and correction dose insulin.

• Identify the needs of and your responsibility to a newly diagnosed patient with diabetes prior to discharge.

Speakers

• A physician champion presented the glycemic goals and why SWMC has embraced them.

• A glycemic control team pharmacist presented the piece on insulin and the insulin order sets for both subcutaneous and IV delivery.

• A glycemic control team CDE presented the survival skills and nutrition education for patients newly diagnosed.

How did we accomplish this?

• Mandatory for most nurses (a shorter version was offered to the ED)

• 25 Three hour classes were scheduled throughout Feb and March.

• A monthly class is offered for new hires and for those who did not make one of the original classes

Results so far

• Approximately 550 nurses were educated in February and March

• An additional 125 have attended the new hire sessions held monthly since March

• We continue to present monthly to new hires and to those stragglers who missed out for various reasons

Doctor to DoctorPhysician education

• Presentations to all committees:– Internal medicine– Surgery– Cardiology– Intensivist and Hospitalist– Pulmonology– ENT– OBGYN– Oncology– Pediatrics

• Individual 1:1 academic detailing for those requesting or needing more detail

Education and the snow ball effect

The More we understand the more we expect……

• Education has enhanced communication between patient care staff, providers and the GCT

• Use of rapid cycle P.D.S.A. (plan,do, study,act) allows changes in ordersets to be made quickly in response to staff feedback

• The nursing education was and is still being revised in response to order set changes and staff feedback.

Areas for improvement

• Increase the use of basal insulin

• Post discharge planning and follow up

• Glucometrics specific to providers/groups ordering insulin.

Holding the Gains

• WebInservice – Mandatory for Nurses, Pharmacists and Dietitians

• Tutorial Covers:– Types of diabetes– Hospital hyperglycemia and patient outcomes– SWMC blood glucose targets– Insulin terms, action, delivery and safety– Hypoglycemia– Glycemic control team services– Discharging the patient with diabetes

Passing the Testis linked to Annual Pay for

Performance • 17 multiple choice questions related to the

glycemic module• Staff can access web inservice anytime• They have 10 months to pass all the modules • Failed test can be retaken until passed• Changes can be made easily to accommodate

changes is practice or focus.

Contact information

Anita Manley

Diabetes, Endocrine and Nutrition Center

At Southwest Washington Med Center

360 993-5215

amanley@swmedctr.com

Inpatient Diabetes Management-the Oregon ExperienceFrom a CNS Perspective

Sara Hohn RN, MS, CDE, CNS, BC-ADM

Seize Opportunities

• There has been great momentum in the inpatient arena at OHSU at times

• There are other times movement has been slower

• The point is to accept the lulls, but always look for opportunities to get things moving in a good direction again

Challenges We Face Today

• Less resources

• More complicated patients

• Length of stay decreased

• Better treatments requiring more care at the bedside

• Less staff nursing time for learning

A Very Positive Time Was Had...

• When cardiac surgery protocol was developed a few years ago

• Since that time wound infections have decreased and are meeting benchmark

• Prior to this protocol, infection rate was too high

Oregon Health and Science University Cardiac Surgery

Protocol• Piloted in August, 2004 only in cardiac surgery

population.• Audits started immediately.• Each chart when audited was followed by an

email to the nurse as to what they did not do right or correct work was reinforced

• Multidisciplinary group met within 2 weeks of start date and 20 situations were brought up that might merit changes in the protocol

Process Developed

• Case scenarios with complex questions to make nurses think hard

• Endocrinologist involvement at all in-services which conveyed evidence based data as to why this was very important to initiate

• Much discussion about nurses fear of hypoglycemia vs. adverse effects of hyperglycemia

Survey For Nurses Re: Cardiac Surgery Protocol

• Five in-services were done during summer 2004 prior to pilot launch in fall

• At each in-service, the nurses were taught about the protocol but approximately 70 changes were made during the in-services due to nursing input

• This made the protocol much more user friendly and then resulted in higher nursing commitment

Change in Insulin Drip on Non-ICU Units

• OHSU historically has been progressive by having insulin drips on non-ICU units over the past ten years

• Both providers and nurses have complained more recently that the drip was not able to take care of various levels of insulin sensitivity

• It became obvious a new drip was needed on non-ICU units

Change in Insulin Drip on Non-ICU units (cont’d)

• There currently is an attempt by endocrine services to improve the insulin drip we currently are using on non-ICU units

• No new drip is being added

• Goal is to improve consistency in protocols

• Any focus on a protocol can be a time for nursing in particular to speak out on their workloads and issues

Change in Insulin Drip on Non-ICU units (cont’d)

• This drip will not be more work for the nurses

• They are voicing safety concerns to validate their complaint, without really understanding the real question at hand which is safety

Change in Insulin Drip on Non-ICU units (Cont’d)

• The cardiac surgery protocol has been very successful over the last few years and so it was decided the floor protocol needed to utilize the column method as well

• Continuity of care across ICU to non-ICU units is the goal

Quality Executive Committee Meeting

• Most key members are in support of tight glycemic control

• Nursing executive wants teaching done in a safe manner and wants as few protocols as possible

• Charge given to head of quality to create a workgroup for moving drip forward and discussing staffing issues, etc

Result of Quality Exec Committee

Meeting• Additional key group forming

– Head of Quality leading this group– Also involved will be:

• Head of nursing education • Diabetes education manager• CNSs and Nurse Practice Education Coordinators• Endocrine MDs and Diabetes CNS• Surgeons• Hospitalists

What is Helping To Move Things Forward at OHSU

• JACHO interest, including the new credentialing process for diabetes care in the hospital

• Data extensive showing tight control in hospital reduces complications and therefore saves hospitals money in the long run

• Support from endocrinologists in Diabetes Center

• Interest coming from surgeons and other doctors

New Protocol to Be Piloted Carefully

• Step down cardiac unit which is used to using cardiac surgery intensive protocol is going to study the drip with all the nurses and give feedback to endocrine. Next step is to pilot it on surgery unit after changes made by step down unit

• Issue split out to two things:– New drip is needed (old one not working anymore)– Staffing Issues/ Need for more Education

We Need to get More Creative With Nurse Education

• Online competencies

• Short face to face meetings if possible

• Video streaming

• Electora

• Posters

Inpatient Position Statement from AADE

• This will be done in the next year

• Position statements coordinated by Professional Practice Committee

• Role of diabetes educator in the hospital will be clarified in this statement

• Inpatient specialty practice group on AADE website

Physician Education

Eliminating inpatient sliding scale insulinA reeducation project with medical house staff

• Systematic program to reeducate on how to manage inpatient hyperglycemia without SSI

• General medicine with diabetes or BG > 140• Two house officers/24hr period for all subjects• Rounded with Endo twice daily for two weeks• 88 patients identified in 8 wks; 16 house MDs• Basal-bolus intensive Rx• 98 historical control patients

Baldwin, et al. Diabetes Care, 28: 1008. 2005

Eliminating inpatient sliding scale insulinA reeducation project with medical house staff

Measures of glycemic control results:

study control pmean gluc + SD (mg/dl) 150 + 37 200 + 51 <0.01

gluc < 60 mg/dl (%) 3.60 1.40 =0.01

low BG requiring IV D50 (%) 26 30 NS

gluc > 250 mg/dl (%) 6.5 20.5 <0.01

glucose 80-140 mg/dl (%) 43.8 22 <0.01

glucose 80-180 mg/dl (%) 65.1 43.1 <0.01

Baldwin, et al. Diabetes Care, 28: 1008. 2005

Eliminating inpatient sliding scale insulinA reeducation project with medical house staff

• A1c guided change in therapy• Used admit A1c and hospital BGs to guide

change in DM Rx regimen

Results:

study control p

A1c obtained (%) 99 32 <0.01

Mean A1c (%) 8.7 10.2 NS

DM Rx changed (%) 80 32 <0.01

1 yr f/u in 34 patients, A1c down from 10.1 to 8% p <0.01

Baldwin, et al. Diabetes Care, 28: 1008. 2005

Hospital Physician Insulin Rx Education Initiative

• 907 bed urban tertiary care teaching hospital; ~ 30 units (~1/2 med/surg)• Medicine and Surgery physicians - attendings (staff and private) - housestaff• In-services; grand rounds; medicine and surgery

housestaff noon conferences/teaching conferences

• Academic detailing: 14 high volume internists; & 5 high volume nephrologists

Pre-launch Letter to Attending Physicians

• Introducing order set• Rationale for glycemic control in the hospital• Targets for glucose for hospital• Insert type of order set to be implemented• Insert date will start utilization of orders • Signed by hospital VPMA/Chief Medical Officer

Attach:• Order set• AACE Consensus Statement on Hospital

Management

Education impacts outcomes: Glucometrics

0%

5%

10%

15%

20%

25%

30%

35%

FY 2005Qtr 1

FY 2005Qtr 2

FY 2005Qtr 3

FY 2005Qtr 4

FY 2006Qtr 1

FY 2006Qtr 2

% o

f D

ays

% first am day 2 BG >180mg/dL

% patient days med/surg BG any time >180mg/dL

% patient days with 1 or more BG <41mg/dL

P < 0.01

P < 0.01

P < 0.01

Magee, Beck et al. Insulin Congress 2006 Abstract #130

Hospital Physician Insulin Rx Education Initiative FY 05- Q2 06

Indicator (%) Relative improvement

Basal Insulin Use 21.3%

Uncontrolled Diabetes 19.1%

1st am day 2 BG > 180mg/dl 35.9%

Pt days BG > 180mg/dl 13.9%

Pt days BG < 40mg/dl - 5.9%*

* % severe hypoglycemia went from 4.9 to 4.7% of patient days

Physician “Glycemic” Control Report Card

• Rehabilitation Hospital

• 10 staff physicians

• In-serviced on rationale and strategies for targeted glycemic control in the hospital

• Subcutaneous insulin order set implemented

• MD report cards

Distribution of BG ranges by MD

0

10

20

30

40

50

60

70

80

90

0-39 40-60 61-79 80-180 >180

MD A

MD B

MD C

MD D

% o

f va

lues

Blood glucose range (mg/dl)

Physician Report Card

Blood Glucose Measures 1/1-2/28/07

MD ABG range Total BGs % total BGs # BGs # cases

0-39 0 0.0

40-60 2 0.7

61-79 12 3.9

80-180 255 83.8

>180 35 11.5 304 34

Strategies for ongoing education

• Communication/Marketing

• Insulin Rx Updates

• New staff education

• Enduring education tools

Enduring Education Materials

• Web & Intranet based CME modules

IV insulin

SQ insulin

DKA & HHS

Peri-operative management

• Pocket book

Diabetes Survival Skills Education (JCAHO expectations; ADA Certification)

Content areas - What is diabetes?

- Fingerstick BG monitoring - BG targets - Insulin self-administration - Hypoglycemia prevention, recognition & Rx

- Hyperglycemia recognition - Sick Day Guidelines

- When to call the doctor

Discussion

amanley@swmedctr.com

hohns@ohsu.edu

Michelle.F.Magee@Medstar.net