inpatient glycemic management

8/5/2015

1

Robert J. Rushakoff, MD

Medical Director, Inpatient DiabetesProfessor of Medicine

Division of Endocrinology and MetabolismUniversity of California, San FranciscoSan Francisco, CA 94115

[email protected]

Disclosures

Conflict of Interest (COI) and Financial

Relationship Disclosures:

–none

Inpatient Glycemic Management:How We Get Others To Follow Our Lead

August 5th, 2015New Orleans, LA

Objectives1) State current inpatient glycemic control goals

2) Discuss several strategies to improve insulin safety

3) Describe several ways to decrease clinical inertia in

acute care

4) State innovative ways to educate health care

professionals in the hospital setting using technology

"Each blind man perceived the elephant as something different: a

rope, a wall, tree trunks, a fan, a snake, a spear..."

8/5/2015

2

EducationNurses

Physicians

Students

Patient Education

TransitionsOutpatient to Inpatient

Inpatient to Inpatient

Inpatient to Outpatient

Data Collection

Medical Errors

Glucometrics

Diabetes Management

Order Entry

Smart Orders

Dosing Calculators

Jargon

CQI

Patient Assessment of Skills, Education

Diabetes Assessment Form

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Page 1 of 6

Coordination of Outpatient Care

Home care services

Outpatient diabetes classes

Medical Errors

JCAHO

ICU ProtocolsPeriopManagement

Secondary Diagnosis

Insulin Administration

• Order Written

• Order Sent to

Pharmacy

• Order Entry by

Pharmacist

• Drug Preparation by

pharmacy

• Insulin delivery to unit

• Medication

Administration

• Documentation

Inpatient Diabetes Goals

Who Cares

Just get patient

home

Sliding Scales are

fine

Avoid that scary hypoglycemia


Normal glucoses

for everyone

A high glucose

means failure

Sliding Scales are

banned

Some

hypoglycemia is

acceptable


Appropriate Glucose

Control Based on

physiology and

outcome studies

Target Glucose Levels

Alive

No DKA or

Hyperosmolar

Coma


No hypo- or

hyperglycemia

•Prevent fluid and electrolyte

abnormalities secondary to

osmotic diuresis

•Improve WBC function

•Improve gastric emptying

•Decrease surgical complications

•Earlier hospital dischange

•Decreased post-MI mortality

•Decreased post-CABG

morbidity and mortality


8/5/2015

3

Normal

Glucoses

Decreased Morbidity and

Mortality


Problems With

High Glucoses

Glucose and Post-CABG: Morbidity and Mortality

Diabetes and Coronary Artery Bypass Surgery

An examination of perioperative glycemic control and outcomes

• Retrospective review of 291 patients surviving 24 h post-op

• 40% with retinopathy, nephropathy, or neuropathy

Inpatient complications:

For each 1 mmol/l (18 mg/dL) increase in post-op day 1 over 6.1 mmol/l (110 mg/dL), a 17% increased risk of complications

McAlister FA et al.

Diabetes Care. 2003; 26:1518-1524.

High Blood Glucose Levels Associated With Increased Mortality in ICU

• Retrospective review of 259,040 critically ill patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati

• Hyperglycemia was an independent predictor of

mortality starting at 111 mg/dL

• Effect was greatest with acute myocardial

infarction, unstable angina, and stroke

– Raised MI risk from 1.7 to 6 times

– Raised stroke risk from 1.8 to 29 times

– Raised unstable angina from 1.4 to 3 times

Falciglia M et al. Crit Care Med. 2009; 37:3001-3009.

• A significant but weaker effect was seen in patients with sepsis, pneumonia, and pulmonary embolism

• Hyperglycemia was not found to be associated with mortality in diseases such as COPD and hepatic failure, hip fractures

• In diabetes patients, the increase in mortality risk was not seen until mean glucose was >146 mg/dL

Hyperglycemia–related mortality in critically ill patients varies with admission diagnosis

Falciglia M et al. Crit

Care Med. 2009; 37:3001-3009.

Intervention

Studies

8/5/2015

4

Decreased InfectionsInsulin infusion improves neutrophil function

in diabetic cardiac surgery patients

Perioperative IV insulin infusion

Neutrophil phagocytic activity

% baseline

Control 47

Insulin 75

Rassias AJ et al.

Anesth Analg. 1999; 88:1011-

1016.

Decreased InfectionsGlucose control lowers the risk of wound

infection in diabetics after open-heart operations

Perioperative IV insulin infusion

Protocol to maintain glucoses <200 mg/dL

Incidence of Deep Wound Infections (%)

1997 1999

Routine Control 2.4 2.0“Tight” Control 1.5 0.8

Zerr KJ et al. Ann Thorac Surg. 1997;63:356-361. Furnary AP et al. Ann Thorac Surg. 1999;67:352-360.

Furnary AP et al. J Thorac Cardiovasc Surg. 2003;125:1007-1021.

Decreased Morbidity and MortalityIntensive Insulin Therapy in Critically Ill Patients

• Patients (all) on mechanical ventilation in ICU

• Randomly assigned to IV insulin maintaining glucoses between 80-

110 mg/dL or conventional treatment (IV insulin if glucose >215

mg/dL then maintain glucose between 180-200)

Van den Berghe G et al. N Engl J Med. 2001;345:1359-1367.

% given insulin 24-hour dose AM glucose

Intensive 99 71 units 103

Conventional 39 33 units 153

12 month mortality

Intensive 4.6%

Conventional 8.6%

Main effect on patients

in ICU >5 days

NICE-SUGAR

• 6104 adults who were expected to require treatment in the ICU

on 3 or more consecutive days randomized to intensive blood

glucose control (target range, 81 to 108 mg/dL) or conventional

blood glucose control (<180 mg/dL)

• Primary endpoint death from any cause within 90 days after

randomization

• Baseline characteristics similar

The NICE-SUGAR Study Investigators. N Engl J Med. 2009;360:1283-1297.

Data on Blood Glucose Level, According to Treatment

Group

The NICE-SUGAR Study Investigators. N Engl J Med. 2009;360:1283-1297.

Probability of Survival and Odds Ratios for Death, According to Treatment Group

Problems

With Low

Glucoses

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5

Hypoglycemia and Mortality in Insulin-treated vs on–Insulin-treated AMI Patients

Kosiborod M, et al. JAMA. 2009;301(15):1556-1564.

Hypoglycemia

No hypoglycemia

P=.92P<.001

Mo

rta

lity

, %

10.4

18.4

9.2 10.2

0

10

20

No Insulin Treatment Insulin Treatment

Hypoglycemia was a predictor of

higher mortality in patients nottreated with insulin, but not

in patients treated with insulin

Hazard Ratio for Death According to the

Occurrence of Hypoglycemia on 1 Day or

More Than 1 Day and Receipt or Nonreceipt of

Insulin Therapy at the Time of the First Hypoglycemic

Episode.

The NICE-SUGAR Study Investigators. N Engl J Med 2012;367:1108-1118

2015 Inpatient Glucose Goals

Organization ICU Non-ICU Pre-prandial Non-ICU Maximum

AACE/ACE 140-180 mg/dl <140 mg/dl 180 mg/dl

ADA 140-180 mg/dl <140 mg/dl 180 mg/dl

ACP 140-200 mg/dl Avoid <140 mg/dl

Endocrine Society <140 mg/dl 180 mg/dl

Society of Critical

Care Medicine100-150 mg/dl

UCSF 100-160 mg/dl 100-180 mg/dl

Blood Glucose Levels During Isulin Treatment

Days of Therapy

Blo

od g

luco

se (

mg/d

L)

100

120

140

160

180

200

220

240

A dm it 1 2 3 4 5 6 7 8 9 10

SSRI

Lantus + glulisine

Mean Blood Glucose Levels During Insulin Therapy

* p<0.01

¶ p<0.05

¶

* * *¶ ¶ ¶

Day 3: P=0.06

Umpierrez GE Et al. Diabetes Care. 2007;30:2181–2186.

How to Obtain “Tight” Control

�Bedside glucose monitoring

� IV insulin drips

�Diabetes Flow sheets

�Discourage the use of traditional

Sliding Scale insulin

INSULIN

SLIDING

SCALE

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6

INSULIN

SLIDING

SCALE

Roller Coaster Effect of Insulin Sliding Scale

Mr. And Mrs. XXXXX are admitted

for “Giants” fever.

Mr. XXXXX has Type 2 diabetes and

takes a total of 75 Units insulin per

day (2 shots). Glucoses at home are

“poorly controlled.”

Mrs. XXXXX also has Type 2 diabetes

but she has good control taking about

25 units of Lispro premeal and 40

Units glargine at night.

Fingerstick qid with regular insulin SQ

coverage:

FSBG Action

< 50 1 amp D50 iv and call HO

51-80 give juice and repeat in 0.5-1 hr

81-150 no coverage

151-200 2U regular insulin SQ





>400 12U regular insulin SQ, call HO

INSULIN

SLIDING

SCALE

8/5/2015

7

Jane Jeffrie Seley

DNP, MPH, GNP, BC-ADM, CDE, CDTC

Diabetes Nurse PractitionerInpatient Glycemic Control TeamNew York Presbyterian Hospital Weill Cornell Medical College New York, New York

[email protected]

Disclosures

Presenter: Jane Jeffrie Seley

Attended Advisory Board Meeting:

-Novo Nordisk March 2015

-Bayer Diabetes Care April 2015

-Sanofi Diabetes April 2015

Improving Insulin Safety

Creating and Implementing

Comprehensive Insulin Order Sets

Why Computerized Order Sets?

• Reduces insulin dosing errors: Auto-calculates safe dose

• Simplifies & promotes weight based dosing: Auto-populates weight into dosing algorithm

• Reduces insulin TYPE errors: basal, prandial and correction insulins are separated40

Why Computerized Order Sets (Cont.)? • Reduces clinical inertia: Takes fear out of

dosing insulin by automating process

• Reduces omission of doses and improper timing of BGM & insulin: e.g. RN gets

medication due reminder, Prescriber & RN get reminder of need for basal insulin for Type 1

patients

41

Secret to Success With Comprehensive

Pre-Selected Matters

Secret to Success: Pre-Checked Orders

8/5/2015

8

Step One

Which Order Set

Do I Choose?

Descriptions Next To Each Order Set

Why wasn’t poor PO intake ordered?

NPO Aspart Only Order Set

for short-term NPOReduced Fear of Hypos:

Correction Starts at >150 mg/dL

Very Low Dose Aspart-Glargine Order Set

Diabetes Meal Plan**

47

Defaults to 4 servings (60gm Carb) per meal**All diabetes and/or hyperglycemia pts placed on Diabetes Meal Plan

A1c*

*A1c can be used to diagnose diabetes, evaluate glycemic control PTAJust check box

Type of Diabetes

48

Bedside BGM

Defaults to ac & bedtime for prandial & q6 hrs for NPO

8/5/2015

9

49

NPO: no auto-basal for type 2

Very Low Dose .10 u/kg

Low Dose .15 u/kg

Med Dose .20 u/kg

High Dose .30 u/kg

Hypoglycemia Treatment

50

Diabetes Education

Diabetes Survival Skills

Pt Education: Focus on Survival Skills

Diabetes Teaching Resources

Consistent Carbohydrate Menu

Lists Serving Sizes & Grams! ! ! ! ! ! ! ! ! ! !

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!

!

!

!

!

!

!

!

!

!

!

!

!

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!

!

!

!

!

!

Graham Crackers (3 crackers) . . . . . . . . .

Plain Rice Cake (1 cake) . . . . . . . . . . . . . . . . . .

Pudding:

Vanilla (½ cup) . . . . . . . . . . . . . . . . . . . . . .. . . . .

Chocolate (½ cup) . . . . . . . . . . . . . . . . . . . . . .

Rice Pudding (½ cup) . . . . . . . . . . . . . .

Ice Cream:

Vanilla (½ cup) . . . . . . . . . . . . . . . . . . .. . . . . . .

Chocolate (½ cup) . . . . . . . . . . . . . . . .. . . . . . .

Jello/Gelatin:

Sugar Free Strawberry (~½ cup)………………..

Beverages

Skim, 2% or whole milk (8 oz). . . ……... .

Lactose Free milk (8 oz) . . . . . . . . . . . . . . . . . . .

Vanilla Soy milk (8 oz) . . . . . . . . . . . . . . . . . . . . .

Regular or Decaf Coffee/Tea (8 oz). . . . . . . . . . . . .

Diet Ginger Ale (8 oz) . . . . . . . . . . . . . . . .

!

!Condiments/Salad Dressing:

Smart Balance Butter Spread (1 tsp).. . . . . . . . .

Peanut Butter (1½ Tbsp) .. . . . . . . . . . . . . . . .. . . . .

Sugar Free Jelly (1 Tbsp) . . . . . . . . . . . . .

Sugar Free Syrup (2 Tbsp) . . . . . . . . . . . . . . . . . . . .

Lemon Juice (1 packet) . . . . . . . . . . . . . . .

Ketchup (1 Tbsp) . . . . . . . . . . . . . . . . . . . . .

Fat-Free Mayo (1 Tbsp) . . . . . . . . . . . . . . . ..

Mustard (1 packet) . . . . . . . . . . . . . . . . . . . .

Fat-Free Italian (1 Tbsp) . . . . . . . . . . . . . . . . . .. . . .

Creamy French (1 Tbsp) . . . . . . . . . . . . . . . . .. . .

.

!

Sample!Food!Label!!!

!Step 3!

Carbohydrate Grams

Carbohydrate Servings

5 – 10 ½

11 – 19 1

20 – 24 1 ½

25 – 34 2

35 – 44 2 ½

45 – 49 3

50 – 55 3 ½

56 – 64 4

17

7

22

24

24

27

32

2

11

13

18

0

0

0

4

6

3

0

2

1

0

1

2

1

½

1½

1½

1½

2

2

0

1

1

1

0

0

0

0

½

0

0

0

0

0

0

0

Step!1!

Step!2!

8/5/2015

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Teaching Patients to Use Insulin Pen Diabetes Education

Documentation

Diabetes Champions

• Meets Monthly (1 hr)

& Annually (8 hr)

• Email reminders sent to

all RNs, NPs, RDs

• Created TEAM WEB

with educational

resources for pts &

professionals

Developing & Implementing

Glycemic Control Guidelines

Adult Inpatient

Glycemic

Management

Guideline

Pocket Card

Page 1

Insulin Titration Algorithm

60

WHICH INSULIN NEEDS ADJUSTMENT:

If AM fasting BG is

too high or low:Adjust Glargine

If pre-lunch, pre-dinner or

bedtime is too high or low:Adjust Aspart

HOW TO ADJUST:

If BG is less than 50:

If BG is less than 70:

Deduct 50%

Deduct 20%

If BG is 70-100: Deduct 10%

If BG is 180-250:

If BG is >250:

Add 10%

Add 20%

8/5/2015

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Inpatient Guideline Pocket Card (P2) Inpatient Guideline Pocket Card (P3)

Inpatient Guideline

Pocket Card (P4)

Data VISPattern Management Tool

Online Mandatory Education

by Discipline:Dietitians

NursesPharmacists

Prescribers (NPs, PAs)

References• American Diabetes Association (2015). Standards of Medical Care In Diabetes-

2015. Diabetes Care: 38(1):1-86.

• Draznin, B., Gilden, J., et al (2013). Pathways to quality inpatient management of

hyperglycemia and diabetes: A call to action. Diabetes Care; 36(7):1807-14.

• Flory, J.H., Aleman, J.O., Furst, J., & Seley, J.J. (2014). Basal Insulin Use in the

Non-Critical Care Setting: Is Fasting Hypoglycemia Inevitable or Preventable? J.

Diabetes Sci. Technology, J Diabetes Sci Technol; 8(2):427-428.

• Rodriguez, A., Magee, M. et al (2014). Best Practices for Interdisciplinary Care

Management by Hospital Glycemic Teams: Results of a Society of Hospital Medicine Survey Among 19 US Hospitals. Diabetes Spectrum; 27(3), 197-205.

• Rushakoff, R., et al (2014). Using a Mentoring Approach to implement an Inpatient

Glycemic Control Program in Unites States Hospitals. Healthcare; 2 (2014). Pp 205-

210.

8/5/2015

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References (Cont.)

• Ryan, D., Swift, C., (2014). The Mealtime Challenge: Nutrition and Glycemic

Control In the Hospital. Diabetes Spectrum; 27 (3). Pp 163-168.

• Mendez, C. Umpierrez, G.E. (2014). Pharmacotherapy for hyperglycemia in

Noncritically Ill Hospitalized Patients. Diabetes Spectrum; 27 (3). Pp 180-188.

• Seley, J.J. (2015, In Press). Diabetes Care in the Inpatient Setting, in Complete

Nurse's Guide to Diabetes Care (3rd ed.), Childs, B.P., Cypress, M., & Spollett, G. (Eds): American Diabetes Association, Alexandria, VA.

• Umpierrez GE, Hellman R et al (2012). Management of hyperglycemia in

hospitalized patients in non-critical care setting: an endocrine society clinical

practice guideline. Endocrine Society. J Clin Enddocrinol Metab. Jan;97(1):16-

38.

UCSF Inpatient Diabetes

• Infrastructure

– 1989: Bedside Glucose Monitoring

– 1990: IV insulin order set

– Mid 1990s SQ Insulin Order sets

– 1999: intranet education

– 2004: Mandatory use of New insulin order sets

– 2004: New mandatory nursing (online) and Physician

education (online and small group case based)

– 2012: Inpatient EMR for orders (EPIC)

Insulin Order Forms• Adult

– DKA– Adult SQ Insulin – Patient

eating

– Adult SQ Insulin – NPO, TPN, Tube Feeding

– IV insulin – ICU protocol– IV insulin – Med-Surgical Unit

protocol

– Adult Insulin pump• Patient waver form

– Adult SQ insulin algorithm for NPO patients**

– CV Surgery Specific orders• PREO-OP Pathway**

• OB-GYN

– SQ Insulin – Patient eating

– IV Insulin form - delivery

– Pump Form• Pump waiver form

• Pediatrics

– SQ Insulin – Patient eating

– Pump Form• Pump waiver

– DKA

– IV insulin

Therapeutic Inertia

• Glucoses Better

• Low rate of hypoglycemia

• Nevertheless, our audits continued to show inappropriate initial insulin orders and therapeutic inertia for both attending staff and housestaff, with required insulin order changes not being made on a daily basis.

Therapeutic Inertia

• Physician Education

• Daily High Glucose Report– Nurse to check in on patients with very high glucoses

• Diabetes team for patients with high glucoses– Physician

– Nurse

– Pharmacist

• Diabetes Team for All Patients– Physician

– Nurse

– Pharmacist

General Resident Education

• residents may gain confidence about their knowledge and feel more at ease with

inpatient glucose management, but significant improvements in management

have generally not occurred.

8/5/2015

13

Education by Example

• David Baldwin, et al showed that

having an endocrinologist round with

a member of the medical team

improved both insulin order-writing

and glucose levels

UCSF Intervention limitations

• Physician Education

– Still not all residents get training

– Residents not taking care of patients

– Hospitalists (turnover)

• Nursing

– NPs managing patients

Order set

Adult SQ Insulin – Patient eating: set premeal dose Premeal Dosing

Postmeal Dosing (based on amount consumed)

Adult SQ Insulin – Patient eating: CHO Counting Premeal Dosing CHO dependent

Postmeal Dosing (based on CHO consumed)

Adult SQ Insulin – NPO, TPN Q4h nutrition and correction

Nutrition dose timed to cycle TPN, correction q4h

Adult SQ Insulin –Tube Feeding Q4h nutrition and correction

Nutrition dose timed to cycle feedings, correction q4h

Adult Insulin Pump

IV Insulin protocol: ICU Specific initial rate for CVS/DKA/other

IV insulin protocol: Medical/surgical units Specific initial rate for CVS/DKA/other

DKA

Big Brother

• Daily Reports:

– 2 or more glucoses>225

– Glucose <60

– On insulin pump

– Dx type 1 DM

How to communicate with teams

• Impossible to figure out who is actually taking care of patient

• Pager – to tell them to read email (but which pager)

• Email – no one actually reads emails

• Sticky notes

• Endocrine notes (people don’t actually read other notes)

8/5/2015

14

Inpatient Hyperglycemia

The virtual Inpatient Glucose Management Service

8/5/2015

15

10 Day

Audits of

Patients Per

Day with 2 or

More

Glucoses ≥

225 mg/dl

(for specific

units)

Before

vGMS

After

vGMS% of Patient in

Each Glucose

Range Among

Patients on

SQ Insulin

Premeal

Protocol

8/5/2015

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% of Patient in Each Glucose Range By

Days on SQ Insulin Premeal Protocol

Date # Months vGMS

active

Total # individual

patients on list

during month

% of patients

on list for

only 1 day

% of patients on

list for > 1 day

# consecutive

days on list (for

patients on list

for >1day)

# consecutive

days on list (for

all patients on

list)

10/2012 0 (baseline) 272 20 80 4.06 3.45

5/2013 1 month 257 21 79 3.62 3.07

10/2013 5 months 242 17 83 3.39 2.8

5/2014 1 year 248 31 69 3.25 2.55

4/2015 2 years 220 38 62 3.01 2.13

Changes in number of Days

patients on high glucose list

“I know that for my interns, the feedback really drives their own improvements because they want to avoid getting a "Rushakoff note" in the chart the next

morning. And it works as a perfect "just-in-time" teaching mechanism to inform appropriate responses to high blood sugars for inpatients.”

Criteria Used for No Note

• Followed by endocrinology consult team

• Random High:

– Glucoses were fine before

– No new meds (eg glucocorticoids)

– No pattern

– Would be dangerous to change orders based on the two higher numbers


• New Orders Already Written

– Appear appropriate

– Shows understanding how to adjust

• On IV insulin infusion

• Change of Medications

– Single glucocorticoid pulse

– Glucocorticoid discontinued


• One time issue

– Received Dextrose with medication (though may

put in note to avoid the dextrose)

• Procedure

– Glucoses before fine and would expect ok after

• New orders written (often day of admit)

– Cannot yet assess effect

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The numbers

• Number of vGMS notes in past 2 years:

3400

• Time to complete task:

30-45 minutes

• Change in number of Formal Endocrinology Consults:

none

• Physicians– Robert Rushakoff

– Umesh Masharani

– Melissa Weinberg

– Sarah Kim

– Aaron Neinstein

– Bonnie Kimmel

– Saleh Adi

– Stephen Gitelman

– Jan Hirsch

– Kathryn Rouine-

Rapp

– David Robinowitz

– Michael Hwa

– Heather Nye

– Steve Pantilat

• Pharmacists– Heidemarie

Windham

– Lisa Kroon

– Kethen So

– Thomas Bookwalter

– Anna Seto

– Yali Brennan

• Administration– Rosanne

Rappazini

– Jennifer Pacholuk

– Joy Pao

– Janice Hull

� Nurses� Mary Sullivan

� Pauline Chin

� Marlene Bedrich

� Craig Johnson

� Molly Killion

� Jeanne Buchanan

� Noraliza Salazar

� Lynn Dow

� Byanqa Robinson

� Dietary� Marian Devereaux

� Ami Bhow

PEOPLE CHANGING INPATIENT DM MANAGEMENT AT UCSF

Community Hospital Training

Annenberg Project

Rushakoff RJ, Sullivan MM, Seley JJ, Sadhu A, O'Malley CW, Manchester C, Peterson E, Rogers KM. Using a Mentoring Approach to Implement an Inpatient Glycemic Control Program in United States

Hospitals. Health Care: The Journal of Delivery Science and Innovation Volume 2, Issue 3, September

2014, Pages 205–210

Physicians

• Robert J. Rushakoff, MDDirector Inpatient Diabetes, UCSF

• Cheryl W. O’Malley, MDProgram Director, Internal Medicine Banner Good Samaritan

Medical, Phoenix, Arizona

• Kendall M. Rogers, MDChief, Hospital Medicine University of New Mexico Health Sciences Center

Albuquerque, New Mexico

• Archana Sadhu, MD Director, Inpatient Diabetes Program, The Methodist Hospital System Houston,

Texas

Diabetes Educators

• Carol Manchester, MSN, ACNS, BC-ADM, CDEUniversity of Minnesota Medical Center, Minneapolis, Minnesota

• Jane Jeffrie Seley, DNP, MPH, BC-ADM, CDENew York Presbyterian/Weill Cornell Medical Center

• Mary M. Sullivan, RN, DNP, ANP-BC, CDEUniversity of California, San Francisco

• Eric D. Peterson, EdM, FACMEAnnenberg Center for Health Sciences at Eisenhower

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Site Visit• Faculty team visits each site

– 1 physician (inpatient endocrinologist or hospitalist)

– 1 nurse with inpatient glycemic control experience

• Team Meeting– Review experience, goals, barriers

– Refine the team project

– who they need to involve– Data collection to characterize their current performance

– Common barriers that they are likely to face and strategies that have been used by other institutions to overcome them

– Implementation and measurement that they may want to consider to evaluate both process and outcome

• Presentation to other stakeholder groups– Physician or nursing staff forums

Web Conferences

• 3 Web conferences planned

– #1 Sites share their project plans

– #2 Sites present interim progress and challenges

– #3 Sites present data generated from their project

• Primarily intended as a tactic to keep sites

“on task” and to facilitate interaction between sites

Annenberg Center Diabetes Project-Hospital B-

• Community, non-teaching; No Endocrinology

• Lots of forms – main was self adjusting SS

• Many MD groups, hospitalist group

• No education, Meal timing

Annenberg Center Diabetes Project-Hospital B-

• Lots of forms – main was self adjusting SS– SS form gone; BB mainly used (CHO based postmeal for meals on

demand)

• Many MD groups, hospitalist group– Hospitalist contract dispute

• No education– Case studies – CDs, in person for specific populations

• Meals– Refreshment centers closed

– Still get meals on demand• CDE Involvement

– Assist with insulin orders– Call MDs for consistently high numbers

Annenberg Center Diabetes Project Annenberg Center Diabetes Project

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inpatient glycemic management

Documents