Education Nurses, Midlevel Providers, Physicians, Ancillary Staff

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Education Nurses, Mid-level Providers,
Physicians, Ancillary Staff

• Michelle Magee, MD
• Anita Manley, RN, CDE
• Sara Hohn, RN,MS,CDE, CNS, BC-ADM

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Education

• Initial ongoing education
• Nursing
• Mid-level providers
• Physicians
• Ancillary services, including pharmacists,
  nutritionists, clerical staff, medical assistants
• Patient education diabetes survival skills

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Educating the adult learner

• Empowerment
• Enable to manage glucose using insulin therapy
• to know when to proactively seek help
• Experience
• Interactive provision of clear information
• Reflection
• Allows understanding of meaning, value,
  consequences
• Insight
• Newly seeing meanings, patterns, relationships,
  
• or possibilities
• Change
• Behavior, attitude understanding

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Expanding the TeamStaff education

• Champion Training Course
• Anita Manley RN CDE
• October 12, 2007

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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 youve made a
  difference?
• Comprehensive Educational Program
• Nurses
• Dieticians
• C.N.A.
• Physicians
• Pharmacists

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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 .

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Comprehensive Education

• If you think education is expensive - try
  ignoranceDerek Bok Past president, Harvard
  University

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700 nurses by the end of March 2007
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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.

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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.

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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

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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

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Doctor to DoctorPhysician education

• Presentations to all committees
• Internal medicine
• Surgery
• Cardiology
• Intensivist and Hospitalist
• Pulmonology
• ENT
• OBGYN
• Oncology
• Pediatrics
• Individual 11 academic detailing for those
  requesting or needing more detail

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Education and the snow ball effect
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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.

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Areas for improvement

• Increase the use of basal insulin
• Post discharge planning and follow up
• Glucometrics specific to providers/groups
  ordering insulin.

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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

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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.

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Contact information

• Anita Manley
• Diabetes, Endocrine and Nutrition Center
• At Southwest Washington Med Center
• 360 993-5215
• amanley_at_swmedctr.com

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Inpatient Diabetes Management-the Oregon
ExperienceFrom a CNS Perspective

• Sara Hohn RN, MS, CDE, CNS, BC-ADM

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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

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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

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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

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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

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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

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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

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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

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Change in Insulin Drip on Non-ICU units (contd)

• 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

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Change in Insulin Drip on Non-ICU units (contd)

• 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

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Change in Insulin Drip on Non-ICU units (Contd)

• 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

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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

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Result of Quality Exec CommitteeMeeting

• 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

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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

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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

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We Need to get More Creative With Nurse Education

• Online competencies
• Short face to face meetings if possible
• Video streaming
• Electora
• Posters

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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

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Physician Education
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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 gt 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
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Eliminating inpatient sliding scale insulinA
reeducation project with medical house staff

• Measures of glycemic control results
• study
  control p
• mean gluc SD (mg/dl) 150 37 200
  51 lt0.01
• gluc lt 60 mg/dl () 3.60
  1.40 0.01
• low BG requiring IV D50 () 26
  30 NS
• gluc gt 250 mg/dl () 6.5
  20.5 lt0.01
• glucose 80-140 mg/dl () 43.8
  22 lt0.01
• glucose 80-180 mg/dl () 65.1
  43.1 lt0.01

Baldwin, et al. Diabetes Care, 28 1008. 2005
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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
  lt0.01
• Mean A1c () 8.7 10.2
  NS
• DM Rx changed () 80 32
  lt0.01
• 1 yr f/u in 34 patients, A1c down from 10.1 to 8
  p lt0.01

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

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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

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Education impacts outcomes Glucometrics
Magee, Beck et al. Insulin Congress 2006 Abstract
130
P lt 0.01
P lt 0.01
P lt 0.01
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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 gt 180mg/dl 35.9
• Pt days BG gt 180mg/dl 13.9
• Pt days BG lt 40mg/dl - 5.9
• severe hypoglycemia went from 4.9 to 4.7 of
  patient days

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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

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Distribution of BG ranges by MD
of values
Blood glucose range (mg/dl)
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Physician Report Card

• Blood Glucose Measures 1/1-2/28/07
• MD A
• BG 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
• gt180 35 11.5
  304 34

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Strategies for ongoing education

• Communication/Marketing
• Insulin Rx Updates
• New staff education
• Enduring education tools

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Enduring Education Materials

• Web Intranet based CME modules
• IV insulin
• SQ insulin
• DKA HHS
• Peri-operative management
• Pocket book

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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

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Discussion

• amanley_at_swmedctr.com
• hohns_at_ohsu.edu
• Michelle.F.Magee_at_Medstar.net