Second Edition THE GLYCEMIC CONTROL IMPROVING GLYCEMIC CONTROL, PREVENTING IMPLEMENTATION GUIDE: HYPOGLYCEMIA AND Editors: OPTIMIZING CARE OF Greg Maynard, MD, MSc, SFHM (Lead Editor) THE INPATIENT WITH Karrie Berg, DO, MA Kristen Kulasa, MD HYPERGLYCEMIA Cheryl O’Malley, MD, FACP, FHM Kendall M. Rogers, MD, CPE, FACP, SFHM AND DIABETES 1 Improving Acute Coronary Syndrome Care for Hospitalized Patients Section 1: Essential First Steps Copyright ©2015 by Society of Hospital Medicine. All rights reserved. No part of this publication may be reproduced, stored in retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written consent. For more information or to obtain additional copies contact SHM at: Phone: 800-843-3360 Website: www.hospitalmedicine.org/gc 2 Improving Acute Coronary Syndrome Care for Hospitalized Patients Table of Contents Executive Summary ......................................................................................................................9 How to Use This Guide ................................................................................................................11 Section I: Take First Steps ..........................................................................................................12 A. Assess the Current State of Glycemic Management at a High Level ..................................... 14 B. Obtain Institutional Support ..................................................................................... 18 C. Form an Interdisciplinary Team ................................................................................ 19 D. Establish Team Rules ............................................................................................ 21 E. Define Scope, Priorities and General Goals of ourY Efforts ................................................ 22 F. Review the Framework for QI and QI Tools ................................................................... 23 G. Conclusion ......................................................................................................... 23 Section II: Identify Best Practices for Management of the Hospitalized Patient .....................24 with Diabetes/Hyperglycemia A. Background ........................................................................................................ 25 B. Monitoring Glucose Levels and HbA1c ........................................................................ 25 C. Glycemic Targets ................................................................................................. 26 D. Methods To Achieve Control .................................................................................... 27 1. Subcutaneous Insulin ............................................................................................................................. 27 2. Insulin Infusion and transition to Subcutaneous .................................................................................... 28 E. Transition to the Outpatient Setting ............................................................................ 28 F. Conclusion ......................................................................................................... 28 Section III: Assess Current State of Glycemic Management ....................................................30 A. Performing a Comprehensive Local Assessment of Current Care Processes ........................... 31 B. Current Glycemic Performance ................................................................................. 31 C. Electronic Medical Record (EMR) Review .................................................................... 33 D. Process Flow Mapping: A Critical QI Tool ..................................................................... 33 E. Individual Glycemic Control Process Assessment Items ................................................... 36 F. External Assessment Tools ...................................................................................... 42 3 Table of Contents (continued) Section IV: Choose Metrics and Develop a Data Collection Plan for Your ...............................43 Glycemic Control Program A. Introduction ........................................................................................................ 44 B. Process Measures ................................................................................................ 44 C. Other Measures ................................................................................................... 45 D. Outcome Measures and Glucometrics Introduction ......................................................... 45 E. Measuring Glycemic Control: Glucometrics .................................................................. 46 1. Defining the Target Patient Population ................................................................................................... 46 2. Which Glucose Values to Include and Exclude ....................................................................................... 47 3. Units of Analysis .................................................................................................................................... 48 4. Glucometric Measures ........................................................................................................................... 50 5. Regulatory Measures ............................................................................................................................. 52 F. External Sources to Obtain Glucometrics and Benchmarking .............................................. 53 G. Effective Presentation of Data .................................................................................. 57 H. Conclusion ......................................................................................................... 59 Section V.1: Overview - Designing and Implementing Protocols for ........................................62 Optimal Inpatient Glycemic Control A. Five Key Principles for Effective Implementation and Clinical Decision Support ...................... 63 B. Layering Interventions to Reinforce the Protocol and the Hierarchy of Reliability ..................... 66 C. Action-Oriented Learning: Plan–Do–Study–Act .............................................................. 69 Section V.2: Inpatient Glycemic Management Teams — Traits of High-Performing Teams ....72 A. Team Design (Make-up) ......................................................................................... 73 B. Five Important Characteristics for an Effective Inpatient Management Team ........................... 73 C. Team Extenders ................................................................................................... 75 D. Day-to-Day Management ........................................................................................ 76 Section V.3: Subcutaneous Insulin Order Sets and Protocols: ..................................................78 Effective Design and Implementation Strategies A. Identifying and Incorporating Key Concepts and Best Practices ........................................... 79 B. Standardize the Monitoring of Blood Glucose Values and Glycosylated Hemoglobin .................. 80 C. Establish a Target Range for Blood Glucose in Non-Critical Care Areas ................................. 80 D. Prompt Clinicians to Consider Discontinuing Oral Agents ................................................. 81 E. Incorporate Nutritional Management .......................................................................... 81 F. Access Diabetes Education and Appropriate Consultation ................................................. 81 G. Prescribe Physiologic (‘‘Basal-Nutritional-Correction Dose’’) Insulin Regimens ...................... 81 H. Special Situations ................................................................................................ 86 I. Plan for Discharge and Provide Guidance for the Transition ............................................... 87 J. Pulling It All Together: Make Sure Your Protocol/Order Set Is Easy to Use and Widely Utilized ..... 87 K. Monitor the Use and Effectiveness of Your Protocols and Order Sets .................................... 91 L. Conclusion ......................................................................................................... 91 4 Improving Glycemic Control Table of Contents (continued) Section V.4: Designing and Implementing Insulin Infusion Protocols and Order Sets ............93 A. Preparing to Implement an IIP .................................................................................. 93 B. Elements of an Optimal Insulin Infusion Protocol ........................................................... 96 C. Implementation: Addressing Safety Issues ................................................................... 99 D. Implementation: Educating And Engaging Nursing and Physician Staff.................................101 E. Implementation: Addressing Common Clinical Situations ................................................102 F. Assessing the Impact of Your Efforts: Follow-Up and Follow-Through ..................................103 G. Conclusion ........................................................................................................104 Section V.5: Design and Implement a DKA Protocol and Order Set ........................................106 A. Diagnosis 106 B. Monitoring ........................................................................................................106