Michael Poulin Maine Medical Center Portland, Maine

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Michael PoulinMaine Medical CenterPortland,
Maine
Michael Poulin is a Supervisor, Systems Analyst
with Maine Medical Center and has 24 years
experience in healthcare. Michael has been
involved in numerous Pharmacy and Hospital system
application implementations from a configuration
and analytical viewpoint. Michael has build a
variety of medication management related order
sets including the Insulin Comprehensive Linked
Set, highlighted here, today.
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Electronic Insulin Order Set SCM Implementation
Process and Demonstration

• Michael Poulin
• Supervisor, Systems Analyst
• Maine Medical Center

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History of Glycemic Management Project at MMC

• Initial CSSP (Clinical Services Strategic
  Planning) Proposal written by John Devlin, MD
  which is funded for three (3) years beginning
  FY2008
• 4 Hours MD
• 20 Hours Project Manager
• 20 Hours CDE
• Year 1 Getting Insulin Right
• Year 2 Coordinate w/Outpatient
• Year 3 MaineHealth

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History of Glycemic Management Project at MMC
(continued)

• Gathered Clinicians and reviewed evidence based
  practice to create guidelines.
• Used CTICU/R1 and SCU as base for creating new
  Insulin Management Tool
• CTICU/R1 using insulin with tight glycemic
  control (80 mg/dL to 120 mg/dL)
• SCU using Insulin Drips (Yale Protocol)
• Vascular initiative is folded into project

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Year 1 Getting Insulin Right

• Focus Groups
• Nutrition Services - CHO diet orders
• Develop insulin order set in SCM
• Clinical Decision Support Tools
• Subcutaneous Insulin
• Intravenous Insulin
• Transition from IV to SC Insulin
• Hyperglycemic Emergencies (DKA, Hyperosmolar
  Hyperglycemia)
• Hypoglycemia
• Enteral Tube Feeding (ETF)
• Total Parental Nutrition (TPN)
• Patient on Glucocorticoids
• Perioperative Glycemic Management
• Other Diabetes Medications (Oral/Injectable)
  Contraindications
• Patient Education Survival Skills Steps To
  Discharge
• Hypoglycemia protocol
• Education RN, MD/DO, Pharm
• Roll out

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Project Team

• Many disciplines involved in team
• Physicians, PAs, NPs, Nurses, CNAs,
  Pharmacists, Dieticians, Lab, and IS.
• Team met weekly to review clinical content and to
  refine processes.
• Ad hoc meetings to review subsets of info, when
  needed.
• IS Analyst worked with team to translate the
  desired clinical practice into an electronic
  process.

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Project Issues/Challenges

• Changes in Clinical Practice
• Introduction of Basal, Prandial, and Correctional
  dosing methodology. Simultaneously need to
  eliminate Sliding Scale practice.
• Nutrition orders change from Calorie Counting per
  day to Carbohydrates per meal.

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Project Issues/Challenges

• Converting data into electronic process
• Complex ordering algorithms require much
  analysis to assure appropriate processing of
  data.
• Revised electronic flowsheet to document
  administration of insulin and quest to
  incorporate Glucometer test results into
  flowsheet
• No prior experience from which to base creation
  of electronic process
• System limitations encountered - not always able
  to accommodate request of team.

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Project Issues/Challenges

• Resource Coordination
• Resource Timelines
• Largest initiative to date utilizing SCM software

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Stop Sliding Scale Dosing(current practice using
SCM)
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Basal, Prandial and Correctional
Dosing..thinking like the Pancreas..

• Releases a continual, low level amount of insulin
  
• providing BASAL
• Burst of insulin in response to the rise in
  glucose after a meal
• NUTRITIONAL or prandial
• Pancreas responds to and corrects a rise in blood
  glucose from other sources
• CORRECTIONAL

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A sample Visio diagram representing one of the
many algorithms used in the programming the SCM
Order Set for Glycemic Management
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The result of all those Visio diagrams 907
pages of programming (those sheets you see
below have info on BOTH sides!)
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In Summary

• Order Set configured in SCM based upon input from
  Glycemic Management team
• Programming done in SCM to support the algorithms
  derived from the Visio diagrams resulting in
  approximately 55,000 lines of code (or 907
  pages!)

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BMI Example 22 and the order set automatically
fills in appropriate BMI Range field (lt25)
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Glycemic Control Algorithm You may select a
different BMI range as needed for patient
3 Choices are BMIlt25 (TDD lt40), BMI 25-30 (TDD
40-80), BMIgt30 (TDD gt80)
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Glycemic Control Algorithm Target
glucose 90-130 mg/dl or 120-180 mg/dl
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HELP? These notes give support and clear
explanation
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Glycemic Control Algorithm? BMI done? glucose
target doneNext Nutrition Status selection
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Next selection IV to SC transition day? Answer
Yes or No
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CHECK HERE to use recommended orders
Form fields are locked and turn gray
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Hemoglobin A1c
Hemoglobin A1c result is displayed (within 6
months) If result is older than 60 days or there
is no result then a lab is ordered (as seen above)
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Diet Order
Any existing diet order will be shown here
Diet order has been pre-selected based on your
earlier selection
Nutrition Consult is automatically ordered
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IV Insulin selection
Note the Calculator icon see next slide for
functionality
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Basal dosing
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Basal dosing
Choose your Rx agent
hover mouse over choice to read support
information
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You may type or calculate the Glargine dose here
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Dose calculator is activated with click on icon
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Basal is now set at 15 units
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Nutritional factors

• The next screen choices are pre-selected for
  breakfast, lunch and dinner

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Prandial- Breakfast
The appropriate item is checked based on BMI and
previous selections
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Prandial- Lunch
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Prandial- Dinner
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Correctional
hover mouse to read support information
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Meals
Bedtime
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Hypoglycemia protocol
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Nurse to physician orders
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When you want themOral agents
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Click insulin algorithm to view selection summary
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Click OK to process
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Submit and you are finished
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A section of the Orders tab once order set has
been submitted.
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Documentation Form for Prandial Dose (SCM eMAR)
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SCM Glucose Management Flowsheet indicating
documentation of Prandial Dose of Insulin
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and more selections available on Glucose
Management Flowsheet
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