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Pharmacist Glycemic Control Team Associated with Improved At a Glance Original Research Practical Implications p e128 Author Information p e134 Full text and PDF www.ajmc.com Web exclusive Pharmacist Glycemic Control Team Associated With Improved Perioperative Glycemic and Utilization Outcomes David M. Mosen, PhD, MPH; Karen S. Mularski, MD; Richard A. Mularski, MD, MSHS, MCR; Ariel K. Hill, AB; and Elizabeth Shuster, MS atients with diabetes and stress hyperglycemia are frequently hospitalized for surgical procedures,1 and ABSTRACT recent estimates indicate that 30% to 50% of US inpa- Objectives: Perioperative hyperglycemia is a risk factor for P 1,2 tients have diabetes and/or hyperglycemia. Multiple studies increased surgical morbidity and mortality. Pharmacy-led manage- have documented the risks of perioperative hyperglycemia, ment teams may improve glycemic control and postoperative out- including poor surgical outcomes and higher readmission comes. We sought to determine whether a pharmacist-led glycemic control team is associated with improved glycemic control and rates.1-4 However, improved glycemic control leads to reduc- reduced postdischarge utilization and medical costs. tions in hospital complications, length of stay, and mortality.1,5-7 Study Design: Retrospective, observational study. Multiple professional societies, agencies, and task forces have issued guidelines recommending methods to achieve Methods: We assessed patient-level outcomes during a 12-month pre-intervention period and compared them at years 1 and 2 post safe and effective glycemic control in hospitalized patients.8-12 implementation at a tertiary care multi-specialty medical center. Although the optimal target glucose range for hospitalized The patients were noncritically ill postoperative surgical patients patients continues to evolve based on results of recent clini- followed 72 hours post surgery (days 1-3). Measurements were cal trials,10,13,14 achieving moderate glycemic control is also proportion of patients with good glycemic control (capillary blood beneficial to surgical patients.15-17 Surgical populations—as glucose [CBG] 70-180 mg/dL) (day 1), hypoglycemia (CBG <70 mg/dL) (days 1-3), 90-day postdischarge utilization, and 6-month opposed to medically ill patient populations—seem to be at per patient per month (PPPM) medical costs. lower risk for hypoglycemia and are able to derive benefit Results: Glycemic control significantly improved in year 1 (odds from inpatient glucose control.9,18-21 ratio [OR], 2.24; 95% CI, 1.85-2.72) and year 2 (OR, 2.19; 95% Despite the potential benefits of improved glucose con- CI, 1.81-2.66) post implementation; hypoglycemia declined trol for surgery patients, patients admitted to hospitals for significantly in year 1 (OR, 0.38; 95% CI, 0.31-0.46) and year 2 any cause, including surgical services, may not receive op- (OR, 0.31; 95% CI, 0.25-0.38). In addition, postdischarge hospital timal glycemic management. The challenges to creating and readmissions declined in year 1 (OR, 0.69; 95% CI, 0.56-0.86) implementing a perioperative glycemic control program are and year 2 (OR, 0.67; 95% CI, 0.54-0.84) post implementation, and emergency department utilization declined in year 1 (OR, numerous and well-recognized.8,13,22 The clinical expertise 0.71; 95% CI, 0.60-0.84) and year 2 (OR, 0.72; 95% CI, 0.60- necessary for prescribing and adjusting appropriate insulin 0.85) post intervention. Finally, PPPM costs declined significantly regimens in patients with rapidly changing needs may not in year 1 (beta coefficient = –208.8) and year 2 (beta coefficient = be readily available to all surgical patients.23,24 Patient safety –283.5) post implementation. advocates predict that expanding the roles of nonphysician Conclusions: The intervention was associated with improved glyce- health professionals (eg, pharmacists) will be central to the mic control outcomes, reduced utilization, and lowered postdis- success of new healthcare delivery models in optimizing charge medical costs. quality and providing timely evidence-based care.25 Am J Pharm Benefits. 2015;7(5):e127-e134 In an effort to improve care in our dysglycemic surgical population, we created a dedicated glycemic control team (GCT) responsible for writing insulin orders and coordinat- ing all aspects of glucose control perioperatively.21 The objec- tive of this implementation research analysis was to evaluate the effectiveness of the GCT with respect to: a) inpatient glycemic control; and b) post surgical outcomes, including www.ajmc.com Vol. 7, No. 5 • The American Journal of Pharmacy Benefits e127 n Mosen • Mularski • Mularski • Hill • Shuster to the intensive care unit from the operation room. PRACTICAL IMPLICATIONS Our evaluation population is thus congruent with Implementation of a pharmacist-led glycemic control team was associated the GCT’s target population (ie, noncardiovascular, with improved glycemic control and utilization outcomes in a population of noncritically ill, postoperative patients with glycemic noncritically ill surgical patients. control opportunities). n Good glycemic control improved in years 1 and 2 post implementation. n Hypoglycemia declined in year 1 post implementation. Exclusion Criteria n Postdischarge hospital admissions, emergency department utilization, and Cardiovascular surgery patients and critically ill per patient per month medical costs declined in years 1 and 2 post imple- patients were excluded from the evaluation analysis. mentation. Description of GCT Intervention The development and implementation of the wound infection and all-cause hospital readmissions, GCT pharmacist program and protocol for management postdischarge emergency department (ED) utilization, of hyperglycemia has been described previously. The and postdischarge medical costs. Glycemic control in the glycemic control team was deployed in January 2009. As perioperative setting at our hospital had been managed at described by Mularski and colleagues (2012) 21: the discretion of each patient’s individual surgeon and/or anesthesiologist, and approaches to glucose control were “The GCT protocol was created by a pharmacy clinical highly variable in the management of perioperative hyper- coordinator who worked closely with physicians experi- enced in diabetes management from the Endocrinology, glycemia when it was identified. Hospitalist, and Surgery Departments. The protocol was designed to direct the safe and appropriate use of intrave- METHODS nous (IV) and subcutaneous insulin in surgical and medi- This study was reviewed and approved by the Kaiser cal patients with diabetes or risk of developing hospital Permanente Northwest (KPNW) Center for Health Re- hyperglycemia. Important components of the protocol search Institutional Review Board. included recommendations on when to begin and discon- tinue IV insulin, how to transition from IV therapy, how Setting to calculate subcutaneous insulin doses, how to adjust in- We developed and implemented a GCT at Kaiser Sunny- sulin doses, when to resume oral agents, how to manage side Medical Center (KSMC) in Clackamas, Oregon. KSMC is patients on tube feedings and total parental nutritional, a tertiary care hospital and part of KPNW, a nonprofit health and discharge planning. The GCT protocol allows the maintenance organization with about 485,000 members in GCT pharmacist to provide comprehensive inpatient gly- cemic management. In addition to writing and adjusting southwest Washington and the Portland, Oregon, metro- daily insulin orders, the GCT can also order relevant labs politan area. KPNW’s regional EpicCare-based electronic (glycated hemoglobin [A1C]), place consultation requests medical record (EMR) provides highly sensitive integrated for a registered dietician and/or diabetes educator, and via data on patient membership, demographics, primary care verbal collaboration with clinicians place discharge orders assignment, and clinical data (including weight and height, for insulin and diabetic supplies.” laboratory results, and healthcare utilization). Trained inpatient pharmacists were available, on a Inclusion Criteria consultation basis, 7 days a week, to any surgical patient The study population included all surgical inpatients ad- requiring perioperative glycemic control management. mitted to the post anesthesia care unit (PACU) who also had 2 or more point-of-care test (POCT) glucose measurements Position Duties and Work Flow during the 24-hour period (day 1) following the index PACU The GCT was usually consulted in the immediate post admission. To assess hypoglycemia and hyperglycemia, we anesthesia phase upon recognition of stress hyperglyce- measured POCT glucose measurements during days 1 to 3 mia or for ongoing management of known diabetes. Re- following the PACU admission date. By identifying patients garding day-to-day work flow, Mularski (2012) notes21: using PACU admission, we included all surgical patients being admitted to the hospital, except for 2 groups: cardio- “After reviewing the patient’s chart and meeting with the vascular surgery patients and critically ill surgical patients, patient’s nurse, the GCT pharmacist enters insulin orders into the EMR order entry system. All of the following are since in our hospital, those patients are admitted directly e128 The American Journal of Pharmacy Benefits • September/October 2015 www.ajmc.com Glycemic Control Team Associated With Better Outcomes available to the GCT pharmacist: the POCT glucose results, appropriate adjustments to ordered insulin regimens as laboratory test values, electronic medication
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